Crash of an Antonov AN-32 in Luzamba

Date & Time: Dec 11, 2001
Type of aircraft:
Operator:
Registration:
D2-FEO
Flight Type:
Survivors:
Yes
Schedule:
Luanda - Luzamba
MSN:
18 10
YOM:
1989
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Luzamba Airport, the aircraft was unable to stop within the remaining distance, overran and came to a halt. All six occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Beechcraft 200C Super King Air in Mount Gambier: 1 killed

Date & Time: Dec 10, 2001 at 2336 LT
Operator:
Registration:
VH-FMN
Flight Type:
Survivors:
Yes
Schedule:
Adelaide - Mount Gambier - Adelaide
MSN:
BL-47
YOM:
1982
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
13730
Captain / Total hours on type:
372.00
Aircraft flight hours:
10907
Circumstances:
The Raytheon Beech 200C Super King Air, registered VH-FMN, departed Adelaide at 2240 hours Central Summer Time (CSuT) under the Instrument Flight Rules for Mount Gambier, South Australia. The ambulance aircraft was being positioned from Adelaide to Mount Gambier to transport a patient from Mount Gambier to Sydney for a medical procedure, for which time constraints applied. The pilot intended to refuel the aircraft at Mount Gambier. The planned flight time to Mount Gambier was 52 minutes. On board were the pilot and one medical crewmember. The medical crewmember was seated in a rear-facing seat behind the pilot. On departure from Adelaide, the pilot climbed the aircraft to an altitude of 21,000 ft above mean sea level for the flight to Mount Gambier. At approximately 2308, the pilot requested and received from Air Traffic Services (ATS) the latest weather report for Mount Gambier aerodrome, including the altimeter sub-scale pressure reading of 1012 millibars. At approximately 2312, the pilot commenced descent to Mount Gambier. At approximately 2324, the aircraft descended through about 8,200 ft and below ATS radar coverage. At approximately 2326, the pilot made a radio transmission on the Mount Gambier Mandatory Broadcast Zone (MBZ) frequency advising that the aircraft was 26 NM north, inbound, had left 5,000 ft on descent and was estimating the Mount Gambier circuit at 2335. At about 2327, the pilot started a series of radio transmissions to activate the Mount Gambier aerodrome pilot activated lighting (PAL).2 At approximately 2329, the pilot made a radio transmission advising that the aircraft was 19 NM north and maintaining 4,000 ft. About 3 minutes later, he made another series of transmissions to activate the Mount Gambier PAL. At approximately 2333, the pilot reported to ATS that he was in the circuit at Mount Gambier and would report after landing. Witnesses located in the vicinity of the aircraft’s flight path reported that the aircraft was flying lower than normal for aircraft arriving from the northwest. At approximately 2336 (56 minutes after departure), the aircraft impacted the ground at a position 3.1 NM from the threshold of runway (RWY) 18. The pilot sustained fatal injuries and the medical crewmember sustained serious injuries, but egressed unaided.
Probable cause:
The following factors were identified:
- Dark night conditions existed in the area surrounding the approach path of the aircraft.
- For reasons which could not be ascertained, the pilot did not comply with the requirements of the published instrument approach procedures.
- The aircraft was flown at an altitude insufficient to ensure terrain clearance.
Final Report:

Crash of a Dassault Falcon 100 in Lawrence

Date & Time: Dec 9, 2001 at 1645 LT
Type of aircraft:
Operator:
Registration:
N202DN
Flight Type:
Survivors:
Yes
Schedule:
Madison - Lawrence
MSN:
202
YOM:
1984
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10500
Captain / Total hours on type:
1200.00
Copilot / Total flying hours:
1229
Copilot / Total hours on type:
22
Aircraft flight hours:
5421
Circumstances:
The pilot said that the copilot was flying a visual approach to runway 15 at the Lawrence Municipal Airport, Lawrence, Kansas. The pilot said, "With gear down and full flaps at approximately 15 to 20 feet above the runway and 115 KTS, the nose abruptly dropped and there was no elevator effectiveness with the yoke pulled back to the mechanical stop." The pilot said, "After landing, I noticed that the stabilizer trim indicated full nose down in the cockpit and, upon exterior inspection, the stab was in that position." The copilot said, "I made my turn to base and proceeded to make my turn to final. No problems with the controllability were noted at this time. The turn to final was made and the airplane was lined up with the runway on final approach with normal glide path. My altitude was dropping normally and my airspeed was approximately 140 knots." The copilot said, "When it got time to pull the power back to idle for landing our airspeed was approximately 110 knots and power was reduced. At that point in time the nose of the aircraft seemed to pitch over towards the runway and increase speed. I pulled back on the yoke to raise the nose and at that same instance the pilot recognized the pitch over and pulled back on the yoke at the same time. The yoke did not seem to pull all of the way to its full extent of travel and felt to mechanically stop at about 3/4 the way travel. Even with both pilot's pulling on the yoke it seemed unresponsive and failed to raise the nose back to a proper landing attitude. The aircraft hit the runway very hard and came to a stop on the runway." A preliminary inspection of the airplane showed the stabilizer positioned at 4 degrees nose down. An examination of the airplane's systems revealed no anomalies.
Probable cause:
The copilot's failure to maintain aircraft control during the landing. Factors relating to this accident were the copilot's improper in-flight decision not to execute a go-around, the copilot not performing a go-around, the inadequate crew coordination prior to landing between the pilot and copilot, and the improperly set stabilizer trim.
Final Report:

Crash of a PZL-Mielec AN-2R in Zagreb

Date & Time: Dec 6, 2001 at 1820 LT
Type of aircraft:
Operator:
Registration:
9A-BKA
Flight Type:
Survivors:
Yes
Schedule:
Slavonski Brod – Zagreb
MSN:
1G167-05
YOM:
1976
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a training flight from Zagreb to Slavonski Brod and back. After touchdown at Zagreb-Pleso Airport, the single engine airplane went out of control, nosed down and came to rest. All three occupants were rescued, among them one was slightly injured. The aircraft was damaged beyond repair.
Probable cause:
It was reported that the loss of control after landing was the consequence of the brakes lock.

Crash of a Dornier DO328-110 in Bremen

Date & Time: Dec 2, 2001 at 1833 LT
Type of aircraft:
Operator:
Registration:
D-CATS
Flight Type:
Survivors:
Yes
Schedule:
Braunschweig - Bremen
MSN:
3009
YOM:
1994
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6000
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
1900
Copilot / Total hours on type:
1000
Aircraft flight hours:
10340
Aircraft flight cycles:
9837
Circumstances:
Following an uneventful ferry flight from Braunschweig, the crew was cleared to land on runway 27 at Bremen-Neuenland Airport. After touchdown, the crew started the braking procedure and activated the reverse thrust systems on both engines. At a speed of 60 knots, the aircraft deviated to the right so the captain applied left rudder. The aircraft turn 15° to the left so the captain applied right rudder when the aircraft turned 135° to the right. This turn was so abrupt that it caused the left main gear to collapse. The aircraft rolled for about 1,150 metres before coming to rest. All three crew members evacuated uninjured while the aircraft was damaged beyond repair.
Probable cause:
The accident is due to the fact that the speed display in the cockpit became unusable during the tailwind landing in reverse thrust operation. The following contributing factors were identified:
- The crew failed to comply with published procedures as the reverse thrust systems were not deactivated when the speed of 60 knots was reached during the deceleration manoeuvre,
- The aircraft became unstable while its speed was decreasing during reverse thrust operation,
- The aircraft was oversteered,
- No references either in the AFM or in the AOM on an influence on the speed display by the reverse thrust operation in connection with tail wind up to the permissible value were given,
- In Chapter 05 of the AFM no references to a limited controllability in reverse thrust operation with tail wind was given,
- The information given in Chapter 10 of the AOM for using the thrust reverser in chapter 05 of the AFM was not included.
Final Report:

Crash of a Cessna 208B Grand Caravan in Bessemer: 2 killed

Date & Time: Dec 1, 2001 at 0143 LT
Type of aircraft:
Registration:
N499BA
Flight Type:
Survivors:
No
Schedule:
Little Rock - Bessemer
MSN:
208B-0689
YOM:
1998
Flight number:
FCI600
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5773
Captain / Total hours on type:
990.00
Copilot / Total flying hours:
1675
Aircraft flight hours:
4867
Circumstances:
The flight departed from Little Rock, Arkansas, about 2356 cst, and approximately 49 minutes after takeoff, the FAA approved un-augmented Automated Weather Observing System (AWOS-3) installed at the destination airport began reporting the visibility as 1/4 statute mile; the visibility continued to be reported as that value for several hours after the accident. Title 14 CFR Part 135.225 indicates no pilot may begin an instrument approach procedure to an airport with an approved weather reporting facility unless the latest weather report issued by that weather reporting facility indicates that weather conditions are at or above the authorized IFR landing minimums for that airport. The listed minimums for the ILS approach to runway 05 was in part 3/4 mile visibility. A METAR taken at the destination airport approximately 2 minutes after the accident indicated overcast clouds existed at 100 feet, the temperature and dew point were 4 and 2 degrees Celsius, respectively, and the altimeter setting was 30.16 inHg. No precipitation was present across Arkansas, Mississippi, or Alabama, and no radar echoes were noted along the accident airplane's route of flight. The freezing level near the departure and destination airports at the nominal time of 0600 (4 hours 17 minutes after the accident) was 12000 and 14,500 feet mean sea level, respectively. A witness at the airport reported the fog was the thickest he had seen since working at the airport for the previous year. The flight was cleared for an ILS approach to runway 05, and the pilot was advised frequency change was approved. The witness waiting at the airport reported hearing a sound he associated with a shotgun report. Radar data indicated that between 0138:47, and 0142:11, the airplane was flying on a northeasterly heading and descended from 2,400 feet msl, to 900 feet msl. At 0142:11, the airplane was located .43 nautical mile from the approach end of runway 05. The next recorded radar target 24 seconds later indicated 1,000 feet msl, and was .20 nautical mile from the approach end of runway 05. The touchdown zone elevation for runway 05 is 700 feet msl. The airplane crashed in a wooded area located approximately 342 degrees and .37 nautical mile from the approach end of runway 05; the wreckage was located approximately 4 hours after the accident. Examination of trees revealed evidence the airplane was banked to the left approximately 24 degrees, and the descent angle from the trees to the ground was calculated to be approximately 22 degrees. All components necessary to sustain flight were either attached to the airplane or in close proximity to the main wreckage. There was no evidence of post crash fire and a strong odor of fuel was noted at the scene upon NTSB arrival. A 8-inch diameter pine tree located near the initial ground impact sight exhibited black paint transfer and a smooth cut surface that measured approximately 46 inches in length. The bottom portion of the cut was located 4 feet above ground level. The flap actuator was found nearly retracted; examination of the components of the flap system revealed no evidence of preimpact failure or malfunction. Examination of the flight control system for roll, pitch, and yaw revealed no evidence of preimpact failure or malfunction. Examination of the engine and engine components with TSB of Canada oversight revealed no evidence of preimpact failure of the engine or engine components. Examination of the propeller with FAA oversight revealed no evidence of preimpact failure or malfunction. Examination of the components of the autopilot system, selected avionics and flight instruments from the airplane with FAA oversight revealed no evidence of preimpact failure or malfunction. The pilot's attitude indicator had been replaced on October 14, 2001, and according to FAA personnel, the mechanic and facility that performed the installation did not have the necessary equipment to perform the operational checks required to return the airplane to service. The FAA flight checked the ILS approach to runway 05 two times after the accident and reported no discrepancies.
Probable cause:
The poor in-flight planning by the pilot-in-command for his initiation of the ILS approach to runway 05 with weather conditions below minimums for the approach contrary to the federal aviation regulations, and the failure of the pilot to maintain control of the airplane during a missed approach resulting in the in-flight collision with trees then terrain.
Final Report:

Crash of a BAe 3101 Jetstream 31 in Skien

Date & Time: Nov 30, 2001 at 1828 LT
Type of aircraft:
Operator:
Registration:
SE-LGA
Survivors:
Yes
Schedule:
Bergen - Skien
MSN:
636
YOM:
1984
Flight number:
EXC204
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6590
Captain / Total hours on type:
600.00
Copilot / Total flying hours:
1700
Copilot / Total hours on type:
390
Aircraft flight hours:
14074
Aircraft flight cycles:
16666
Circumstances:
The aircraft was on its way to Skien with a crew of two and 11 passengers. During the flight, ice was observed on the aircraft’s wings, but the ice was considered to be too thin to be removed. During descent towards runway 19 at Geiteryggen the aircraft’s ground proximity warning system (GPWS) sounded a total of three times. The aircraft was then in clouds and the crew did not have visual contact with the ground. The warnings, combined with somewhat poorly functioning crew coordination, resulted in the crew forgetting to actuate the system for removing ice from the wings. The subsequent landing at 1828 hrs was unusually hard, and several of the passengers thought that the aircraft fell the last few metres onto the runway. The hard landing caused permanent deformation of the left wing so that the left-hand landing gear was knocked out of position, and the left propeller grounded on the runway. The crew lost directional control and the aircraft skewed to the left and ran off the runway. The aircraft then hit a gravel bank 371 metres from the touchdown point. The collision with the gravel bank was so hard that the crew and several of the passengers were injured and the aircraft was a total loss. It was dark, light rain and 4 °C at Geiteryggen when the accident occurred. The wind was stated to be 120° 10 kt. The investigation shows that it is probable that ice on the wings was the initiating factor for the accident. The AIBN has not formed an opinion on whether the ice resulted in the high sink rate after the first officer reduced the power output of the engines, or whether the aircraft stalled before it hit the runway. Investigation has to a large extend focused on the crew composition and training. A systematic investigation of the organisation has also taken place. In the opinion of the AIBN, the company has principally based its operations on minimum standards, and this has resulted in a number of weaknesses in organisation, procedures and quality assurance. These conditions have indirectly led to the company operating the route Skien – Bergen with a crew that, at times, did not maintain the standard that is expected for scheduled passenger flights. The investigation has also revealed that procedures for de-icing of the aircraft wings could be improved.
Probable cause:
Significant investigation results:
a) The decision was made to wait to remove the ice from the wings because, according to the SOP, it should only be removed if it had been “typically half an inch on the leading edge”. This postponement was a contributory factor in the ice being forgotten.
b) At times, the relationship between the flight crew members was very tense during the approach to Skien. This led to a breakdown in crew coordination.
c) Among the consequences of the warnings from the GPWS was a very high workload for the crew. In combination with the defective crew coordination, this contributed to the ice on the wings being forgotten.
d) It is probable that the aircraft hit the runway with great force because the wings were contaminated with ice. The AIBN is not forming a final opinion on whether the wings stalled, whether the aircraft developed a high sink rate due to ice accretion or whether the hard landing was due to a combination of the two explanatory models.
e) The company could only provide documentary evidence to show that the Commander had attended an absolute minimum of training after being employed within the company. Parts of the mandatory training had taken place by means of self-study without any form of formal verification of achievement of results.
f) The company’s operation was largely based on minimum solutions. This reduced the safety margins within company operations.
g) The company’s quality system contributed little to ensuring ‘Safe Operational Practices’ in the company.
h) Authority inspection of the company was deficient.
Final Report:

Crash of a Cessna 208B Grand Caravan near Quepos: 3 killed

Date & Time: Nov 29, 2001 at 1148 LT
Type of aircraft:
Operator:
Registration:
HP-1405APP
Survivors:
Yes
Site:
Schedule:
San José – Quepos – Puerto Jiménez
MSN:
208B-0788
YOM:
1999
Flight number:
LRS1625
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
5000
Copilot / Total flying hours:
800
Aircraft flight hours:
1955
Circumstances:
The single engine airplane departed San José Airport on a schedule flight to Puerto Jiménez with an intermediate stop in Quepos, carrying six passengers (3 Americans, 2 Germans and one Dutch) and two pilots. While descending in clouds to Quepos Airport, the aircraft collided with trees and crashed on the slope of a wooded mountain located about 13 km from Quepos Airport. Both pilots and one passenger were killed while five other passengers were seriously injured. The aircraft was totally destroyed by impact forces.
Probable cause:
Collision with terrain after the captain failed to ensure that the vertical, horizontal and lateral separation was sufficient to fly over the mountains while descending under VMC conditions. Also the crew failed to take appropriate corrective actions to prevent the aircraft to continue the descent until it impacted ground, resulting in a controlled flight into terrain. The following contributin factors were identified:
- Momentary loss of situational awareness on the part of the flight crew,
- Inadequate supervision by the pilot-in-command,
- Non-compliance with standard operating procedures published by the operator,
- Use of flight procedures neither written down in manuals nor approved by the authority,
- Violation of safety rules,
- Non-application of visual flight rules by the flight crew,
- Shortcomings in the crew resources management,
- Adverse weather conditions.
Final Report:

Crash of a Swearingen SA226TC Metro II in Bahía Blanca

Date & Time: Nov 27, 2001 at 0538 LT
Type of aircraft:
Operator:
Registration:
LV-WSD
Flight Type:
Survivors:
Yes
Schedule:
Buenos Aires – Bahía Blanca
MSN:
TC-237E
YOM:
1977
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8200
Captain / Total hours on type:
929.00
Copilot / Total flying hours:
2000
Copilot / Total hours on type:
40
Circumstances:
Following an uneventful flight from Buenos Aires-Ezeiza-Ministro Pistarini Airport, the crew started a night approach to Bahía Blanca-Comandante Espora Airport. The approach and landing on runway 34R were considered as normal. After touchdown, the crew started the braking procedure and the aircraft rolled for a distance of 1,200 metres when it started to deviate to the right. It veered off runway, rolled for 150 metres then lost its nose gear and came to a halt. All three occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The aircraft veered off runway after landing due to the possible combination of the following factors:
- A possible (but not confirmed) failure or malfunction of the left engine reverse thrust system,
- Crosswind close to the maximums specified in the flight manual,
- Lack of corrective actions on part of the crew who failed to identify a possible failure,
- Inappropriate use of the nosewheel steering system.
Final Report:

Crash of a Boeing 747-246F in Port Harcourt: 1 killed

Date & Time: Nov 27, 2001 at 0156 LT
Type of aircraft:
Operator:
Registration:
9G-MKI
Flight Type:
Survivors:
Yes
Schedule:
Luxembourg – Port Harcourt – Johannesburg
MSN:
22063
YOM:
1980
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
80500
Aircraft flight cycles:
17600
Circumstances:
The aircraft departed Luxembourg-Findel Airport on a cargo flight to Johannesburg with an intermediate stop in Port Harcourt, carrying nine passengers, four crew members and a load consisting of almost 60 tons of electronics. On a night approach to Port Harcourt Airport, the copilot who was the pilot-in-command failed to comply with the company published procedures and carried a non-standard autopilot approach, tracking a localizer radial inbound and descending using the vertical speed mode as reference. On short final, the crew failed to realize his altitude was insufficient when the aircraft struck the ground 700 metres short of runway. The undercarriage was torn off and the aircraft slid for few dozen metres before coming to rest with its front section that broke away, bursting into flames. A crew member was killed, seven occupants were injured and five escaped uninjured. The aircraft was partially destroyed by fire.
Probable cause:
Wrong approach configuration on part of the flying crew which resulted in a controlled flight into terrain after the crew failed to comply with several published procedures. It was determined that the copilot was the pilot-in-command while the operator policy stipulated that approached to Port Harcourt must be completed by captain only. The following findings were identified:
- It was defined in the operational procedures that the autopilot could not be used below the altitude of 2,000 feet on approach but the copilot failed to comply with,
- Poor crew coordination,
- There were no calls on final approach between both flying and non flying pilots,
- The crew suffered a lack of situational awareness following a misinterpretation of the visual references on approach.