Crash of a Mitsubishi MU-2B-35 Marquise in San Juan: 2 killed

Date & Time: Apr 15, 2002 at 1500 LT
Type of aircraft:
Operator:
Registration:
N45BS
Flight Type:
Survivors:
No
Site:
Schedule:
Christiansted - San Juan
MSN:
558
YOM:
1972
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
10583
Captain / Total hours on type:
768.00
Aircraft flight hours:
7236
Circumstances:
The flight departed VFR, and when near the destination airport, was advised by air traffic control to hold VFR over the "plaza" and to make left 360 degree orbits. Several witnesses reported light rain was occurring at the time of the accident; there was no lightning or thunder. One witness located where the airplane came to rest reported observing the airplane emerge from the base of the clouds in a 45-degree left wing low and 20 degrees nose low attitude. He momentarily lost sight of the airplane but then noted it rolled to a wings level attitude. He also reported hearing the engine(s) "cutting in an out." Another witness located approximately 1/4 mile north of the accident site observed the airplane flying eastbound beneath the clouds in a right wing and nose low attitude, he also reported hearing the engine(s) sounding like they were "cutting in and out." A pilot-rated witness located an estimated 1,000 feet from where the airplane came to rest estimated that the ceiling was at 300 feet and there was light drizzle. He observed the airplane in a 45-degree angle of bank to the right and in a slight nose low attitude. He stated that the airplane continued in that attitude before he lost sight of the airplane at 250 feet. The airplane impacted trees then a concrete wall while in a nose and right wing low attitude. The airplane then traveled through automobile hoists/lifts which were covered by corrugated metal, and came to rest adjacent to a building of an automobile facility. Impact and a post crash fire destroyed the airplane, along with a building and several vehicles parked at the facility. Examination of the airplane revealed the flaps were symmetrically retracted and landing gears were retracted. No evidence of preimpact failure or malfunction was noted to the flight controls. Examination of the engines revealed no evidence of preimpact failure or malfunction; impact and fire damage precluded testing of several engine accessories from both engines. Examination of the propellers revealed no evidence of preimpact failure or malfunction. Parallel slash marks were noted in several of the corrugated metal panels that covered the hoists/lifts, the slashes were noted 25 and 21 inches between them. According to the airplane manufacturer, the 25 inch distance between the propeller slashes corresponds to an airspeed of 123 knots. Additionally, the power-off stall speed at the airplanes calculated weight with the flaps retracted and 48 degree angle of bank was calculated to be 122 knots. Review of NTSB plotted radar data revealed that the pilot performed one 360-degree orbit to the left with varying angles of left bank and while flying initially at 1,300 feet, climbing to near 1,500 feet, then descending to approximately 800 feet. The airplane continued in the left turn and between 1502:10 and 1502:27, the calibrated airspeed decreased from 160 to 100 knots. At 1502:27, the bank angle was 48 degrees, and the angle of attack was 26 degrees. Between 1502:30 and 1502:35, the true heading changed indicating a bank to the right. The last plotted altitude was 200 feet, which occurred at 1502:35. A NTSB weather study indicated that at the area and altitude the airplane was operating, NWS VIP level 1 to 2 echoes (light to moderate intensity) were noted. Additionally, the terminal aerodrome forecast (TAF) for the destination airport indicated that temporarily between 1400 and 1800 (the flight departed at approximately 1436 and the accident occurred at approximately 1503), visibility 5 miles with moderate rain showers, scattered clouds at 1,500 feet, and a broken ceiling at 3,000 feet.
Probable cause:
The failure of the pilot to maintain airspeed (Vs) while maneuvering following inadvertent encounter with clouds resulting in an inadvertent stall and uncontrolled descent and subsequent in-flight collision with trees, a wall, and a building.
Final Report:

Crash of a Boeing 767-2J6ER in Busan: 129 killed

Date & Time: Apr 15, 2002 at 1121 LT
Type of aircraft:
Operator:
Registration:
B-2552
Survivors:
Yes
Schedule:
Beijing - Busan
MSN:
23308
YOM:
1985
Flight number:
CA129
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
155
Pax fatalities:
Other fatalities:
Total fatalities:
129
Captain / Total flying hours:
6497
Captain / Total hours on type:
6287.00
Copilot / Total flying hours:
5295
Copilot / Total hours on type:
1215
Aircraft flight hours:
39541
Aircraft flight cycles:
14308
Circumstances:
On April 15, 2002, about 11:21:17, Air China flight 129, a Boeing 767-200ER, operated by Air China International (Air China hereinafter), en route from Beijing, China to Busan, Korea, crashed during a circling approach, on Mt. Dotdae located 4.6 km north of runway 18R threshold at Busan/Gimhae International Airport (Gimhae airport hereinafter), at an elevation of 204 meters. The flight was a regularly scheduled international passenger service flight operating under instrument flight rules (IFR) within Korean airspace, according to the provisions of the Korean Aviation Act and Convention on International Civil Aviation. One captain, one first officer and one second officer, eight flight attendants, and 155 passengers were on board at the time of the accident. The aircraft was completely destroyed by impact forces and a post crash fire. Of the 166 persons on board, 37 persons including the captain and two flight attendants survived, while the remaining 129 occupants including two copilots were killed.
Probable cause:
3.1 Findings Related to Probable Causes:
1. The flight crew of flight 129 performed the circling approach, not being aware of the weather minima of widebody aircraft (B767-200) for landing, and in the approach briefing, did not include the missed approach, etc., among the items specified in Air China’s operations and training manuals.
2. The flight crew exercised poor crew resource management and lost situational awareness during the circling approach to runway 18R, which led them to fly outside of the circling approach area, delaying the base turn, contrary to the captain’s intention to make a timely base turn.
3. The flight crew did not execute a missed approach when they lost sight of the runway during the circling approach to runway 18R, which led them to strike high terrain (mountain) near the airport.
4. When the first officer advised the captain to execute a missed approach about 5 seconds before impact, the captain did not react, nor did the first officer initiate the missed approach himself.
Final Report:

Crash of a Swearingen SA227AC Metro III in Palma de Majorca: 2 killed

Date & Time: Apr 12, 2002 at 0506 LT
Type of aircraft:
Operator:
Registration:
EC-GKR
Flight Type:
Survivors:
No
Schedule:
Madrid - Palma de Mallorca
MSN:
AC-620
YOM:
1985
Flight number:
TDC306
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3897
Captain / Total hours on type:
2162.00
Copilot / Total flying hours:
697
Copilot / Total hours on type:
487
Aircraft flight hours:
29726
Circumstances:
The twin engine aircraft departed Madrid-Barajas Airport at 0338LT on a cargo flight to Palma de Mallorca, carrying two pilots and a load of 1,340 kilos consisting of various goods. On a night approach to Palm Airport runway 24L, the crew completed a last turn when the aircraft stalled and struck the runway surface. Out of control, it veered to the right, collided with a lightning system and came to rest upside down in a grassy area. The aircraft was destroyed and both pilots were killed.
Probable cause:
The accident is considered to have occurred as a result of the aircraft performing a very close turn maneuver performed at night, at low altitude and descending in a non-standard approach, not in accordance with normal procedures and company procedures. The crew could not control the descending aircraft due to a possible start of loss of lift, slip on the turn, or both.
Final Report:

Crash of a Cessna 402B in Nassau

Date & Time: Apr 3, 2002 at 1210 LT
Type of aircraft:
Registration:
N768WC
Survivors:
Yes
Schedule:
Nassau - Bimini
MSN:
402B-1066
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On April 3, 2002, about 1210 eastern standard time, a Cessna 402B, N768WC, registered to and operated by Southstream Aviation, Inc., was ditched in Coral Harbor Lake, southwest of the Nassau International Airport, Nassau, Bahamas. Visual meteorological conditions prevailed at the time and a VFR flight plan was filed for the 14 CFR Part 91 personal flight to Bimini, Bahamas. The airplane was substantially damaged and the commercial-rated pilot and a passenger were not injured. The flight originated about 6 minutes earlier from the Nassau International Airport. According to the passenger who is a U.S. certificated pilot, the airplane was fueled before takeoff. He checked the fuel tanks for contaminants after fueling; none were found. The flight departed from runway 14, then when turning on course to Bimini, the left engine sputtered. The pilot reduced then increased power from the left engine which then quit. He noted at that time the manifold and fuel pressure indications were decreasing. The pilot then turned back towards the Nassau airport to return when the right engine quit. Unable to return to the airport, the pilot ditched the airplane in the lake; the airplane remained upright in the approximately 1-4 feet deep water. Both occupants exited the airplane unaided. The accident site was located approximately 2.6 nautical miles southwest of the Nassau International Airport.

Crash of an Antonov AN-32 in Cafunfo

Date & Time: Apr 2, 2002
Type of aircraft:
Operator:
Registration:
ER-AEQ
Flight Type:
Survivors:
Yes
Schedule:
Luanda - Cafunfo
MSN:
16 03
YOM:
1988
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
2855
Aircraft flight cycles:
1213
Circumstances:
On approach to Cafunfo Airport, the encountered strong crosswinds. On short final, the aircraft was too low and struck the ground short of runway threshold. On impact, the undercarriage were torn off. The aircraft slid on its belly for few dozen metres then lost its empennage and left wing before coming to rest. All 15 occupants escaped uninjured.

Crash of a Boeing 307 Stratoliner in Seattle

Date & Time: Mar 28, 2002 at 1310 LT
Type of aircraft:
Operator:
Registration:
NC19903
Flight Type:
Survivors:
Yes
Schedule:
Seattle - Seattle
MSN:
2003
YOM:
1940
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15000
Captain / Total hours on type:
62.00
Aircraft flight hours:
20577
Circumstances:
The crew had originally planned to practice landings at an airport about 20 minutes away, then stop, refuel the airplane, and subsequently return to the original departure airport. Prior to the flight, the crew discussed fuel endurance, which was calculated to be 2 hours based on the captain's knowledge of the airplane's fuel consumption, and the quantity of fuel indicated on the gauges. The fuel tanks were not dipped. The flight was made at 1,500 feet msl. Upon reaching the practice airport, the crew conducted one full stop landing, then taxied back for takeoff. During takeoff, an engine had a momentary overspeed, and the crew decided to return to the original departure airport without refueling. Approaching the original departure airport, the airplane had to delay landing for about 7 minutes for a manual gear extension. Upon completion, it turned back toward the airport, and was about 6 miles from the runway when fuel pressure for one of the engines dropped. The boost pumps were turned on; however, the engine lost power. A low fuel pressure light then illuminated for another engine. The captain called for the flight engineer to switch fuel feed to another tank, but the flight engineer responded, "we're out of fuel." The remaining engines subsequently lost power, and the captain ditched the airplane into a bay. The time from first takeoff until ditching was 1 hour, 19 minutes. The airplane had flown 39 hours since restoration, and exact fuel capacities, fuel flow calculations and unusable fuel amounts had not been established. A dipping chart had been prepared, with one person in the cockpit and one person with a yardstick putting fuel in a main tank in 25-gallon increments. However, the data had not been verified, and dipping was not considered to be part of the pre-flight inspection.
Probable cause:
Loss of all engine power due to fuel exhaustion that resulted from the flight crew's failure to accurately determine onboard fuel during the pre-flight inspection. A factor contributing to the accident was a lack of adequate crew communication regarding the fuel status.
Final Report:

Crash of a Mitsubishi MU-300 Diamond in Anderson

Date & Time: Mar 25, 2002 at 0901 LT
Type of aircraft:
Registration:
N617BG
Survivors:
Yes
Schedule:
Memphis – Anderson
MSN:
067
YOM:
1983
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10500
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
1575
Copilot / Total hours on type:
275
Aircraft flight hours:
4078
Circumstances:
The MU-300 on-demand passenger charter flight sustained substantial damage during a landing overrun on a snow/ice contaminated runway. The captain, who was also the company chief pilot and check airman, was the flying pilot, and the first officer was the non flying pilot. Instrument meteorological conditions prevailed at the time of the accident. Area weather reporting stations reported the presence of freezing rain and snow for a time period beginning several hours before the accident. The captain did not obtain the destination airport weather observation until the flight was approximately 30 nautical miles from the airport. The flight received radar vectors for a instrument landing system approach to runway 30 (5,401 feet by 100 feet, grooved asphalt). The company's training manual states the MU-300's intermediate and final approach speeds as 140 knots indicated airspeed (KIAS) and Vref, respectively. Vref was reported by the flight crew as 106 KIAS. During the approach, the tower controller (LC) gave the option for the flight to circle to land or continue straight in to runway 30. LC advised that the winds were from 050-070 degrees at 10 knots gusting to 20 knots, and runway braking action was reported as fair to poor by a snow plow. Radar data indicates that the airplane had a ground speed in excess of 200 knots between the final approach fix and runway threshold and a full-scale localizer deviation 5.5 nm from the localizer antenna. The company did not have stabilized approach criteria establishing when a missed approach or go-around is to be executed. The captain stated that he was unaware that there was 0.7 percent downslope on runway 30. The company provided a page from their airport directory which did not indicate a slope present for runway 30. The publisher of the airport directory provided a page valid at the time of the accident showing a 0.7 percent runway slope. Runway slope is used in the determination of runway performance for transport category aircraft such as the MU-300. The airplane operating manual states that MU-300 landing performance on ice or snow covered runways has not been determined. The airplane was equipped with a cockpit voice recorder with a remote cockpit erasure control. Readout of the cockpit voice recorder indicated a repetitive thumping noise consistent with manual erasure. No notices to airman pertaining to runway conditions were issued by the airport prior to the accident.
Probable cause:
Missed approach not executed and flight to a destination alternate not performed by the flight crew. The tail wind and snow/ice covered runway were contributing factors.
Final Report:

Crash of a Cessna 340 in Denver: 4 killed

Date & Time: Mar 24, 2002 at 1631 LT
Type of aircraft:
Operator:
Registration:
N341DM
Flight Type:
Survivors:
No
Schedule:
Aspen – Gunnison – Denver
MSN:
340-0347
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3563
Captain / Total hours on type:
560.00
Aircraft flight hours:
3977
Circumstances:
The pilot was flying a three leg IFR cross-country, and was on an ILS approach in IMC weather conditions for his final stop. Radar data indicated that the pilot had crossed the final approach fix inbound and was approximately 3 nm from the runway threshold when he transmitted that he had "lost an engine." Radar data indicates that the airplane turned left approximately 180 degrees, and radar contact was lost. A witness said "the airplane appeared to gain a slight amount of altitude before banking sharply to the left and nose diving into the ground just over the crest of the hill." Postimpact fuel consumption calculations suggest that there should have been 50 to 60 gallons of fuel onboard at the time of the accident. Displaced rubber O-ring seals on two Rulon seals in the left fuel valve and hydraulic pressure/deflection tests performed on an exemplar fuel valve suggest that the fuel selector valve was in the auxiliary position at the time of impact. The airplane's Owner's Manual states: "The fuel selector valve handles should be turned to LEFT MAIN for the left engine and RIGHT MAIN for the right engine, during takeoff, landing, and all emergency operations." No preimpact engine or airframe anomalies, which might have affected the airplane's performance, were identified.
Probable cause:
The pilot not following procedures/directives (flying a landing approach with the left fuel selector in the auxiliary position). Contributing factors were the loss of the left engine power due to fuel starvation, the pilot's failure to maintain aircraft control, and the subsequent inadvertent stall into terrain.
Final Report:

Crash of a Boeing 727-30C in Belo Horizonte

Date & Time: Mar 18, 2002 at 2218 LT
Type of aircraft:
Operator:
Registration:
PP-VLV
Flight Type:
Survivors:
Yes
Schedule:
Salvador - Belo Horizonte
MSN:
19009
YOM:
1967
Flight number:
VLO9051
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown on runway 16 at Belo Horizonte-Tancredo Neves-Confins Airport, the three engine aircraft went out of control, veered off runway at high speed, lost its undercarriage and came to rest. All three crew members evacuated safely while the aircraft was damaged beyond repair.

Crash of a Piper PA-31P Pressurized Navajo in Anderson: 2 killed

Date & Time: Mar 17, 2002 at 2306 LT
Type of aircraft:
Registration:
N125TT
Flight Type:
Survivors:
No
Schedule:
LaGrange – Anderson
MSN:
31-7400187
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1011
Aircraft flight hours:
3991
Circumstances:
The airplane was destroyed by impact forces and fire, when it impacted the ground about 3.7 miles from the destination airport. The airplane had been cleared for an ILS approach to the airport. No anomalies were found during the on-scene examination of the airframe, engine or gyroscopic flight instruments that could be associated with a pre-existing condition. The minimum descent altitude for the approach is 243 feet above ground level. The inbound course for the instrument approach is 298 degrees magnetic. The radar data shows that the airplane headed in a northerly direction prior to commencing a left turn onto the inbound course of the instrument approach. The last radar return, was received prior to the airplane reaching the locator outer marker for the approach. Altitude returns show the airplane descending from a pressure altitude of 4,000 feet to a pressure altitude of 2,800 feet. The 2,800-foot return was the final return received. The wreckage path was distributed on a magnetic heading of approximately 145 degrees. The weather reporting station located at the destination airport recorded a 100 foot overcast ceiling with 1 statute mile of visibility about 20 minutes prior to the accident. The current weather was available to the pilot via the Automated Weather Observing System at the destination airport. No communications were received from the airplane after controllers authorized the pilot to change to the destination airport's advisory frequency.
Probable cause:
The pilots failure to maintain control of the airplane during the instrument approach. The low overcast ceiling and the pilot's in-flight decision to execute the instrument approach in below minimum weather conditions were factors.
Final Report: