Crash of a Learjet 25C in Lexington: 1 killed

Date & Time: Aug 30, 2002 at 1307 LT
Type of aircraft:
Registration:
N45CP
Flight Type:
Survivors:
Yes
Schedule:
Marco Island - Lexington
MSN:
25-073
YOM:
1972
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2681
Captain / Total hours on type:
436.00
Copilot / Total flying hours:
1363
Copilot / Total hours on type:
60
Aircraft flight hours:
7514
Circumstances:
Shortly before landing, the crew confirmed that the hydraulic and emergency air pressures were "good", and that the circuit breakers on the "right and left" were in. In addition, the first officer reported "arming one and two." The airplane landed 1,000 - 1,500 feet from the landing threshold of runway 04, which was 7,003 feet in length. The captain utilized aerodynamic braking during part of the landing roll. About 3 seconds after touchdown, the first officer stated, "they're not deployed, they're armed only." About 6 seconds after touchdown, there was an increase in engine rpm. Shortly after that, there was an expletive from the captain. One and a half seconds later, there was another expletive. Slightly less than 2 seconds later, the captain told the first officer to "brake me," and 2.7 seconds after that, stated "emergency brake." About 4 seconds later, there was a "clunk", followed by a decrease in engine rpm 1 second later. Immediately after that, the captain stated, "we're going off the end." The airplane subsequently dropped off an embankment at the end of the runway, impacted and descended through a localizer tower, then impacted the ground and slid across a highway. The airplane had been fitted with a conversion that included thrust reversers. An examination of the wreckage revealed that the thrust reversers were out of the stowed position, but not deployed. The drag chute was also not deployed. Brake calipers were tested with compressed air, and operated normally. Brake disc pads were measured, and found to be within limits. According to an excerpt from the conversion maintenance manual, reverser deployment was hydraulically actuated and electrically controlled. There was also an accumulator which allowed deploy/stow cycling in the event of hydraulic system failure. Interlocks were provided so that the reverser doors could not be deployed until the control panel ARM switch was on, the main throttle levers were in idle position, and the airplane was on the ground with the squat switches engaged. The previous crew reported no mechanical anomalies. Runway elevation rose by approximately 35 feet during the first 2/3 of its length, then decreased until it was 8 feet lower at its departure end. Winds were reported as being from 050 degrees true at 7 knots. At the airplane's projected landing weight, without the use of thrust reversers, the estimated landing distance was about 2,850 feet with the anti-skid operative, and 3,400 feet with the anti-skid inoperative.
Probable cause:
The captain's addition of forward thrust during the landing rollout, which resulted in a lack of braking effectiveness and a subsequent runway overrun. A factor was the captain's inability to deploy the thrust reversers for undetermined reasons.
Final Report:

Crash of a Fokker 100 in Campinas

Date & Time: Aug 30, 2002 at 1205 LT
Type of aircraft:
Operator:
Registration:
PT-MRL
Survivors:
Yes
Schedule:
Salvador – São Paulo
MSN:
11441
YOM:
1993
Flight number:
JJ3499
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
33
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6500
Captain / Total hours on type:
3600.00
Copilot / Total flying hours:
4300
Copilot / Total hours on type:
145
Circumstances:
The aircraft departed Salvador-Deputado Luís Eduardo Magalhães Airport at 0846LT on a schedule service JJ3499 to São Paulo-Guarulhos Airport, carrying 33 passengers and five crew members. En route, while cruising at an altitude of 35,000 feet, the crew encountered technical problems with the primary hydraulic system. He contacted ATC and was cleared to divert to Campinas-Viracopos Airport for an emergency landing. On approach, the crew was unable to lower the undercarriage that remained blocked in their wheel well. The crew elected to lower the gear manually and several troubleshootings were unsuccessful. The decision was taken to complete a belly landing on runway 33. After touchdown, the aircraft slid for few dozen metres and eventually came to rest. All 38 occupants evacuated safely and the aircraft was damaged beyond repair. It was later transferred to the TAM Museum.
Probable cause:
A loss of hydraulic fluids occurred on a hose separating a fitting from a pump on the right engine, causing the malfunction of the primary hydraulic system and resulting in the degradation of the mechanical system of the landing gear control command.
Final Report:

Crash of a PZL-Mielec AN-28 in Ayan: 16 killed

Date & Time: Aug 29, 2002 at 1856 LT
Type of aircraft:
Operator:
Registration:
RA-28932
Survivors:
No
Schedule:
Khabarovsk – Poliny Osipenko – Ayan
MSN:
1AJ008-19
YOM:
1990
Flight number:
VTK359
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
16
Circumstances:
The aircraft was completing a flight from Khabarovsk to Ayan with an intermediate stop in Poliny Osipenko, carrying 14 passengers and two pilots. Before takeoff from Poliny Osipenko, the crew was informed about weather conditions at Ayan with a visibility up to 5 km. But while approaching the destination, the crew realized that weather conditions deteriorated rapidly with poor visibility due to low stratus and fog. The crew initiated the descent prematurely and after the first turn, the aircraft was already at an insufficient altitude of 800 metres instead of the required 950 metres. At a speed of 283 km/h, the aircraft descended too low and deviated to the right of the approach pattern by 2,3 km when it entered an area of low stratus at an altitude of 320 metres. In a visibility reduced to 50 metres, the crew lost visual contact with the ground but the captain decided to continue the approach. At a height of 188 metres, the aircraft impacted a hill (226 metres high) located near the shore of the Okhotsk Sea. The aircraft was destroyed by impact forces and a post crash fire and all 16 occupants were killed.
Probable cause:
Controlled flight into terrain following after the crew initiated the descent prematurely and failed to follow the published procedures. The following contributing factors were identified:
- The approach was continued in below minima weather conditions,
- Failure of the crew to get a current weather report for Ayan and the alternate airport,
- The decision of the captain to continue the approach at decision height without any visual contact with the ground and his failure to initiate a go-around procedure,
- Failure of the crew to follow the established approach pattern,
- Failure of the meteorological observer to issue updated weather bulletin,
- Absence of radio navigational aids at Ayan Airport,
- Lack of interaction between ATC and meteorological observer at Ayan Airport when aircraft are approaching in adverse weather conditions.

Crash of an Airbus A320-231 in Phoenix

Date & Time: Aug 28, 2002 at 1843 LT
Type of aircraft:
Operator:
Registration:
N635AW
Survivors:
Yes
Schedule:
Houston - Phoenix
MSN:
092
YOM:
1990
Flight number:
AWE794
Crew on board:
5
Crew fatalities:
Pax on board:
154
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19500
Captain / Total hours on type:
7000.00
Copilot / Total flying hours:
11000
Copilot / Total hours on type:
800
Aircraft flight hours:
40084
Aircraft flight cycles:
18530
Circumstances:
After an asymmetrical deployment of the thrust reversers during landing rollout deceleration, the captain failed to maintain directional control of the airplane and it veered off the runway, collapsing the nose gear and damaging the forward fuselage. Several days before the flight the #1 thrust reverser had been rendered inoperative and mechanically locked in the stowed position by maintenance personnel. In accordance with approved minimum equipment list (MEL) procedures, the airplane was allowed to continue in service with a conspicuous placard noting the inoperative status of the #1 reverser placed next to the engine's thrust lever. When this crew picked up the airplane at the departure airport, the inbound crew briefed the captain on the status of the #1 thrust reverser. The captain was the flying pilot for this leg of the flight and the airplane touched down on the centerline of the runway about 1,200 feet beyond its threshold. The captain moved both thrust levers into the reverse position and the airplane began yawing right. In an effort at maintaining directional control, the captain then moved the #1 thrust lever out of reverse and inadvertently moved it to the Take-Off/Go-Around (TOGA) position, while leaving the #2 thrust lever in the full reverse position. The thrust asymmetry created by the left engine at TOGA power with the right engine in full reverse greatly increased the right yaw forces, and they were not adequately compensated for by the crew's application of rudder and brake inputs. Upon veering off the side of the runway onto the dirt infield, the nose gear strut collapsed. The airplane slid to a stop in a nose down pitch attitude, about 7,650 feet from the threshold. There was no fire. Company procedures required the flying pilot (the captain) to give an approach and landing briefing to the non flying pilot (first officer). The captain did not brief the first officer regarding the thrust reverser's MEL'd status, nor was he specifically required to do so by the company operations manual. Also, the first officer did not remind the captain of its status, nor was there a specific requirement to do so. The operations manual did state that the approach briefing should include, among other things, "the landing flap setting...target airspeed...autobrake level (if desired) consistent with runway length, desired stopping distance, and any special problems." The airline's crew resource management procedures tasked the non flying pilot to be supportive of the flying pilot and backup his performance if pertinent items were omitted from the approach briefing. The maintenance, repair history, and functionality of various components associated with the airplane's directional control systems were evaluated, including the brake system, the nose landing gear strut and wheels, the brakes, the antiskid system, the thrust levers and reversers, and the throttle control unit. No discrepancies were found regarding these components.
Probable cause:
The captain's failure to maintain directional control and his inadvertent application of asymmetrical engine thrust while attempting to move the #1 thrust lever out of reverse. A factor in the accident was the crew's inadequate coordination and crew resource management.
Final Report:

Crash of a Douglas C-54E-15-DO Skymaster in Diavik

Date & Time: Aug 28, 2002 at 1650 LT
Type of aircraft:
Operator:
Registration:
C-GQIC
Flight Type:
Survivors:
Yes
Schedule:
Yellowknife – Diavik
MSN:
27343
YOM:
1944
Flight number:
BFL928
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Diavik Airport, the four engine aircraft was too low. This caused the undercarriage to struck the ground about one metre short of runway 10 threshold. On impact, the undercarriage were torn off and the aircraft slid on the runway for almost 300 metres then lost its right wing and rotated to the right before coming to rest, bursting into flames. Both pilots escaped with minor injuries and the aircraft was destroyed.

Crash of a De Havilland DHC-2 Beaver near Aleknagik: 1 killed

Date & Time: Aug 28, 2002 at 1600 LT
Type of aircraft:
Registration:
N4478
Survivors:
Yes
Schedule:
Dillingham - Lake Nerka
MSN:
1653
YOM:
1966
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
26300
Captain / Total hours on type:
200.00
Aircraft flight hours:
8847
Circumstances:
The amphibious float-equipped airplane was returning to a lodge located on a remote lake after picking up supplies. The airplane departed from a paved runway on an airport. En route to the destination lake, the pilot noted the airplane would not attain its normal cruise airspeed and attitude. Believing the airplane was tail heavy, the pilot asked the aft cabin passenger to move forward. Upon touchdown on the lake, the airplane nosed down into the water. As the airplane nosed down, the supplies, which were not secured in the aft cabin, came forward, and pinned the pilot and front seat passenger against the instrument panel. The passenger in the aft cabin lifted as many of the supplies off the pilot and front seat passenger as he could, before he had to exit the sinking airplane. Both the pilot and front seat passenger exited the submerged airplane under their own power, but the pilot did not reach the surface. An autopsy of the pilot disclosed that he had drowned. A postaccident inspection of the airplane revealed the wheels had not been retracted after takeoff on the runway, consequently the airplane landed on the lake with the wheels fully extended. The front seat passenger said that the pilot did not use a checklist prior to landing.
Probable cause:
The pilot's failure to use a checklist to ensure the airplane was in the proper landing configuration, which precipitated an inadvertent water landing on amphibious floats with the wheels extended. A factor contributing to the accident was the pilot's failure to secure the cargo in the aft cabin.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Kasshabog Lake: 1 killed

Date & Time: Aug 24, 2002 at 1308 LT
Type of aircraft:
Registration:
C-GUNE
Survivors:
Yes
Schedule:
Holinshead Lake - Kasshabog Lake
MSN:
1403
YOM:
1959
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft was en route from Holinshead Lake to Kasshabog Lake when the pilot encountered deteriorating weather conditions. As the flight progressed, the ceiling became increasingly lower until it was nearly at tree top level. Shortly thereafter, the pilot located a cabin at the destination outpost camp. On final approach to the camp, the aircraft struck the water while in a turn, tearing off one float and it eventually sank. The pilot and four passengers exited the aircraft and attempted to swim ashore. While swimming, one of the passengers went missing and was not located. Ontario Provincial Police divers were dispatched to search for the missing passenger. Three people were slightly injured and one seriously.

Crash of a De Havilland DHC-6 Twin Otter 300 in Pokhara: 18 killed

Date & Time: Aug 22, 2002 at 1005 LT
Operator:
Registration:
9N-AFR
Survivors:
No
Site:
Schedule:
Jomsom - Pokhara
MSN:
762
YOM:
1981
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
18
Circumstances:
The twin engine aircraft departed Jomsom Airport at 0941LT for a 25-minutes flight to Pokhara, carrying three crew members and 15 passengers, 13 Germans, one American and one British. While descending to Pokhara Airport, the crew encountered poor weather conditions with low clouds. At an altitude of 4,600 feet, the aircraft struck the slope of a mountain located 6 km southwest of the airport, near the village of Kristi Nachnechaur. The aircraft was totally destroyed by impact forces and all 18 occupants were killed. There was no fire.
Probable cause:
Controlled flight into terrain after the crew descended too low in poor visibility without maintaining visual clearance with the ground.

Crash of a Piper PA-31-350 Navajo Chieftain in Sanderson: 1 killed

Date & Time: Aug 16, 2002 at 1135 LT
Registration:
N680HP
Flight Type:
Survivors:
No
Site:
Schedule:
Charleston - Charleston
MSN:
31-8052205
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5720
Aircraft flight hours:
4493
Circumstances:
The pilot completed a flight without incident, and seemed in good spirits before departing, by himself, on the return flight. The second flight also progressed without a incident until cleared from 8,000 feet msl to 5,000 feet msl, which the pilot acknowledged. Visual meteorological conditions prevailed at the time, and radar data depicted the airplane initiate and maintain a 500-foot per-minute descent until radar contact was lost at approximately 400 feet agl. The pilot made no mention of difficulties while en route or during the descent. The airplane impacted trees at the top of a ridge in an approximate level attitude, and came to rest approximately 1,450 feet beyond, at the bottom of a ravine. Examination of the wreckage revealed no preimpact failures or malfunctions. The pilot had been diagnosed with Crohn's disease (a chronic recurrent gastrointestinal disease, with no clear surgical cure) for approximately 35 years, which required him to undergo several surgeries more than 20 years before the accident. The pilot received a letter from the FAA on June 11, 1998, stating he was eligible for a first-class medical certificate. In the letter there was no requirement for a follow up gastroenterological review, but the pilot was reminded he was prohibited from operating an aircraft if new symptoms or adverse changes occurred, or anytime medication was required. His condition seemed to be stable until approximately 5 months prior to the accident. During this time frame, he experienced weight loss and blood loss, was prescribed several different medications to include intravenous meperidine, received 3 units of blood, and had a peripherally inserted central catheter placed. On the pilot's airmen medical application dated the month prior to the accident, the pilot reported he did not currently use any medications, and did not note any changes to his health. A toxicological test conducted after the accident identified meperidine in the pilot's tissue.
Probable cause:
Physiological impairment or incapacitation likely related to the pilot's recent exacerbation of Crohn's disease. A factor in the accident was the pilot's decision to conduct the flight in his current medical condition.
Final Report:

Crash of a Cessna 550 Citation S/II in Big Bear Lake

Date & Time: Aug 13, 2002 at 1120 LT
Type of aircraft:
Registration:
N50BK
Survivors:
Yes
Schedule:
Las Vegas – Big Bear Lake
MSN:
550-0031
YOM:
1985
Flight number:
CFI850
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3900
Captain / Total hours on type:
800.00
Copilot / Total flying hours:
2800
Aircraft flight hours:
5776
Circumstances:
On a final approach to runway 26 the flight crew was advised by a flight instructor in the traffic pattern that a wind shear condition existed about one-quarter of the way down the approach end of the runway, which the flight crew acknowledged. On a three mile final approach the flight crew was advised by the instructor that the automated weather observation system (AWOS) was reporting the winds were 060 degrees at 8 knots, and that he was changing runways to runway 08. The flight crew did not acknowledge this transmission. The captain said that after landing smoothly in the touchdown zone on Runway 26, he applied normal braking without any response. He maintained brake pedal pressure and activated the engine thrust reversers without any response. The copilot said he considered the approach normal and that the captain did all he could to stop the airplane, first applying the brakes and then pulling up on the thrust reversers twice, with no sensation of slowing at all. Considering the double malfunction and the mountainous terrain surrounding the airport, the captain elected not to go around. The aircraft subsequently overran the end of the 5,860 foot runway (5,260 feet usable due to the 600 displaced threshold), went through the airport boundary fence, across the perimeter road, and came to rest upright in a dry lakebed approximately 400 feet from the departure end of the runway. With the aircraft on fire, the five passengers and two crew members safely egressed the aircraft without injuries before it was consumed. Witnesses to the landing reported the aircraft touched down at midfield, was too fast, porpoised, and was bouncing trying to get the gear on the runway. Passengers recalled a very hard landing, being thrown about the cabin, and that the speed was excessive. One passenger stated there was a hard bang and a series of smaller bangs during the landing. Federal Aviation Regulations allowed 3,150 feet of runway for a full stop landing. Under the weather conditions reported just after the mishap, and using the anticipated landing weight from the load manifest (12,172.5 pounds), the FAA approved Cessna Flight Manual does not provide landing distance information. Post-accident examination and testing of various wheel brake and antiskid/power brake components revealed no anomalies which would have precluded normal operations.
Probable cause:
The pilot's failure to obtain the proper touchdown point which resulted in an overrun. Contributing factors were the pilot's improper in-flight planning, improper use of performance data, the tailwind condition, failure to perform a go-around, and the pilot-induced porpoising condition.
Final Report: