Crash of an Antonov AN-12BP in Honiara

Date & Time: Oct 16, 2001
Type of aircraft:
Operator:
Registration:
ER-ADT
Flight Type:
Survivors:
Yes
Schedule:
Brisbane - Honiara
MSN:
2 3 406 05
YOM:
1962
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful cargo flight from Brisbane, the crew started the approach to Honiara-Henderson Airport. On final approach, the four engine airplane was too low when the right main gear struck the sea and was torn off. The crew increased engine power, continued the approach and completed the landing on runway 24. After touchdown, the aircraft went out of control, veered off runway at high speed and came to rest. All six occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Piper PA-31-350 Navajo Chieftain in Fort Liard: 3 killed

Date & Time: Oct 15, 2001 at 2233 LT
Operator:
Registration:
C-GIPB
Survivors:
Yes
Schedule:
Yellowknife – Fort Liard
MSN:
31-7852170
YOM:
1978
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1157
Captain / Total hours on type:
77.00
Aircraft flight hours:
11520
Circumstances:
A Piper PA-31 Navajo Chieftain, C-GIPB, serial number 31-7852170, departed Yellowknife, Northwest Territories, at 2043 mountain daylight time on a night instrument flight rules (IFR) charter flight to Fort Liard. One pilot and five passengers were on board. On arrival at Fort Liard, in conditions of moderate to heavy snow, the pilot initiated a non-directional beacon approach with a circling procedure for Runway 02. At about 2233, the aircraft struck a gravel bar on the west shoreline of the Liard River, 1.3 nautical miles short of the threshold of Runway 02, and 0.3 nautical mile to the left of the runway centreline. The aircraft sustained substantial damage, but no fire ensued. Three passengers were fatally injured, and the pilot and two passengers were seriously injured. The emergency locator transmitter activated and was received by the search and rescue satellite system, and two Canadian Forces aircraft were dispatched to conduct a search. The wreckage was electronically located the following morning, and a civilian helicopter arrived at the accident site approximately 10 hours after the occurrence.
Probable cause:
Findings as to Causes and Contributing Factors:
1. For undetermined reasons, the pilot did not maintain adequate altitude during a night circling approach in IMC and the aircraft struck the ground.
2. The pilot and front seat passenger were not wearing available shoulder harnesses, as required by regulation, which likely contributed to the severity of their injuries.
Findings as to Risk:
1. The aircraft was not fitted with, and was not required to be fitted with, a GPWS or a radio altimeter.
2. The pilot used an unauthorized remote altimeter setting that would have resulted in the cockpit altimeters reading approximately 200 feet higher than the actual altitude.
3. The pilot did not meet the night recency requirements necessary to carry passengers, as specified in CAR 401.05 (2).
4. Risk management responsibilities had been placed almost entirely on the pilot.
5. While the company had taken the voluntary initiative to appoint a safety officer, and appeared to have a safety program in place, the program may not have been directed at the needs.
Other Findings:
1. Approximately 28 hours of flight time that the pilot had logged as multi-engine dual would not have qualified as flight experience for the issue of a higher license.
2. CAR do not define 'flight familiarization', 'flight experience', or 'dual', and therefore do not address flight time 'quality'.
3. Opportunities for local community searchers to identify and access the accident site earlier were hampered by initial inaccurate SARSAT location information, by the time required to locate SAR aircraft to the Fort Liard area, and by darkness and poor weather conditions.
4. The decreased time required to alert the SAR system and the higher degree of accuracy permitted by the utilization of a 406 MHz ELT, particularly one interfaced with the onboard GPS, would have likely permitted rescuers to access the site in a more timely manner.
5. 703 Air Taxi operations continue to have a much higher accident rate than 704 Commuter and 705 Airline operations.
Final Report:

Crash of a Rockwell Grand Commander 690 in Temecula

Date & Time: Oct 13, 2001 at 2220 LT
Registration:
N690JM
Flight Type:
Survivors:
Yes
Schedule:
Flagstaff – Temecula
MSN:
690-11072
YOM:
1973
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12880
Captain / Total hours on type:
4205.00
Aircraft flight hours:
4844
Circumstances:
The airplane collided with an airport boundary fence during an aborted landing. The pilot made a normal approach following the visual approach slope indicator (VASI) with gear down and full flaps and touched down just past the numbers and began to decelerate. The pilot selected reverse thrust with both engines. As he added power to decelerate, the airplane suddenly veered to the left and off the runway when the right engine did not go into reverse thrust. He deselected reverse thrust and aligned the airplane with the runway. He was approaching the end of the runway at high speed and elected to attempt a takeoff. The airplane went off the end of the runway onto smooth grass. The pilot rotated the airplane, but the airplane collided with an airport boundary fence and came to rest in a field. In a post accident examination, when the power levers were placed in the full reverse position, the left fuel control measured 4°, while the right measured 0°. The left pitch control measured 10°, while the right measured 0°; the controls should have read 0°. A controls engineer determined that during landing, there would be a 10° propeller pitch control (PPC) angle mismatch, which would be about 2.5° of BETA angle. With matched levers, there would be asymmetric reverse thrust with the left engine lower in torque. This would result in the airplane turning towards the left if both propellers had gone into reverse pitch.
Probable cause:
A misrigging of the engine controls that resulted in an asymmetric reverse thrust condition.
Final Report:

Crash of a Swearingen SA226TC Metro II in Shamattawa: 2 killed

Date & Time: Oct 11, 2001 at 2333 LT
Type of aircraft:
Operator:
Registration:
C-GYPA
Flight Type:
Survivors:
Yes
Schedule:
Gods Lake Narrows – Shamattawa
MSN:
TC-250
YOM:
1978
Flight number:
PAG962
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3100
Captain / Total hours on type:
1100.00
Copilot / Total flying hours:
1200
Copilot / Total hours on type:
900
Circumstances:
Perimeter Airlines Flight PAG962, a Fairchild SA226TC (Metroliner), with two pilots and a flight nurse on board, departed Gods Lake Narrows, Manitoba, at approximately 2300 central daylight time, on a MEDEVAC flight to Shamattawa. Approaching Shamattawa, the crew began a descent to the 100 nautical mile minimum safe altitude of 2300 feet above sea level (asl) and, when clear of an overcast cloud layer at about 3000 feet asl, attempted a night, visual approach to Runway 01. The aircraft was too high and too fast on final approach and the crew elected to carry out a missed approach. Approximately 30 seconds after the power was increased, at 2333, the aircraft flew into trees slightly to the left of the runway centreline and about 2600 feet from the departure end of Runway 01. The aircraft was equipped with a cockpit voice recorder (CVR) that indicated the crew were in control of the aircraft; they did not express any concern prior to impact. The aircraft broke apart along a wreckage trail of about 850 feet. Only the cabin aft of the cockpit retained some structural integrity. The captain and first officer were fatally injured on impact. The flight nurse was seriously injured but was able to exit the wreckage of the cabin. A post-crash fire was confined to the wings which had separated from the cabin and cockpit wreckage.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The aircraft was flown into terrain during an overshoot because the required climb angle was not set and maintained to ensure a positive rate of climb.
2. During the go-around, conditions were present for somatogravic illusion, which most likely led to the captain losing situational awareness.
3. The first officer did not monitor the aircraft instruments during a critical stage of flight; it is possible that he was affected by somatogravic illusion and/or distracted by the non-directional
beacon to the extent that he lost situational awareness.
Other Findings:
1. The absence of approach aids likely decreased the crew=s ability to fly an approach from which a landing could be executed safely.
2. The company standard operating procedures (SOPs) did not define how positive rate is to be determined.
Final Report:

Crash of a Beechcraft C90 King Air in Dallas

Date & Time: Oct 9, 2001 at 1322 LT
Type of aircraft:
Registration:
N690JP
Survivors:
Yes
Schedule:
Taos - Dallas
MSN:
LJ-690
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7000
Captain / Total hours on type:
100.00
Aircraft flight hours:
2356
Circumstances:
The commercial pilot flew the airplane on a cross-country flight of at least 2 hours and 47 minutes before dropping of his passengers, and flew back for 2 hours and 7 minutes without refueling. The pilot reported that as the airplane turned onto final approach, the right engine began to surge. He reduced the power on the right engine and increased power on the left, but the airplane started to roll right so he elected to reduce the power on the left engine and land in an alley. Prior to impacting wires, the pilot retracted the landing gear and brought the condition levers to "cut-off." A witness observed the airplane prior to impact and noted that the "motor wasn't on." The airplane impacted power lines, a tree, a natural gas meter, two residences, and a fence. The fuel tanks were compromised during the impact sequence, and the fire department sprayed the area with fire retardant foam. A test of the water runoff revealed "negative results for petroleum risk." Examination of both engines' fuel lines between their respective firewalls and fuel heaters, and fuel pumps and fuel control units revealed that they were void of fuel.
Probable cause:
The pilot's failure to refuel the airplane, which resulted in fuel exhaustion and subsequent loss of dual engine power while on approach.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Mollet Lake: 3 killed

Date & Time: Oct 8, 2001 at 1730 LT
Type of aircraft:
Operator:
Registration:
C-GPUO
Survivors:
Yes
Schedule:
Iyachisakus Lake - Mollet Lake
MSN:
810
YOM:
1955
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
900
Aircraft flight hours:
13140
Circumstances:
The float-equipped Beaver de Havilland DHC-2 Mk 1, registration C-GPUO, serial number 810, took off at 1710 eastern daylight time from Iyachisakus Lake, Quebec, with the pilot and six passengers on board, for a visual flight rules flight to an outfitter on Mollet Lake, 26 nautical miles (nm) to the east. At about 1730, a witness at the outfitter heard the seaplane flying on an easterly heading to the south of the lake. About 20 minutes later, noting that the aircraft had not arrived at the dock, the manager of the outfitter sent a boat to look for C-GPUO. The Beaver was found 1 nm east of the outfitter. It was lying partly submerged in Mollet Lake near the north shore, with the nose in the water and leaning backward. Four injured occupants who were clinging to the fuselage were rescued. The pilot and two of the passengers were fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The seaplane stalled at an altitude that did not allow the pilot time to recover from the stall.
2. The stall occurred in circumstances conducive to illusions created by drift.
Findings as to Risks:
1. The aircraft was not equipped with a stall warning device, which could have alerted the pilot to the onset of a stall.
2. The chances of surviving the impact would have been improved if the front seat occupants had been wearing their shoulder harnesses as prescribed by aviation regulations.
3. Life jackets were available, but the occupants who evacuated the aircraft do not seem to have had time to find, retrieve, and don them.
4. The emergency locator transmitter was not capable of emitting a distress signal because a short circuit occurred when the antenna came into contact with the water.
Final Report:

Crash of a Cessna 414 Chancellor in Marshfield: 3 killed

Date & Time: Sep 29, 2001 at 1700 LT
Type of aircraft:
Operator:
Registration:
N414NG
Flight Type:
Survivors:
No
Schedule:
Wisconsin Rapids - Poplar Bluff
MSN:
414-0496
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The airplane was destroyed after an attempted landing following a reported partial power loss of the left engine while en route. The flight did not divert to the closest airport located about 27 nautical miles to the southwest while at an altitude of about 15,900 feet. This airport was a controlled field equipped with airport rescue and fire fighting (ARFF), and its longest runway was 9,005 feet. The flight diverted to the departure airport located about 93 nautical miles to the north. This airport was an uncontrolled field not equipped with ARFF, and its longest runway was 5,000 feet. No emergency was declared. The airplane was reported by a witness to be too high and too fast to land on runway 34 at the airport. The winds were from 140 degrees at 6 knots. The wreckage distribution was consistent with an impact resulting from a Vmc (minimum control speed with the critical engine inoperative) roll to the left. The pilot received a checkout from the right seat in the accident airplane by the airplane owner. The checkout was about 20 minutes in duration and did not include any single-engine flight maneuvers or emergency procedures. The owner did not hold a certified flight instructor certificate. The pilot had stopped flying for 12 years and just began giving flight instruction and flying in single-engine airplanes about a year prior to the accident. The pilot's recent multiengine flight experience was limited to a couple of non-revenue flights within the past year while seated in the right seat of a King Air. The King Air was used for commercial charter work which would involve one or two landings per flight. One landing was made on the day prior to the accident. The accident pilot asked the King Air pilot to accompany him along on the accident flight; the King Air pilot declined. A multiengine commercial rated pilot-rated passenger, who the accident pilot knew, was seated in the right front seat. Examination of the airplane's supplemental type certificate (STC) revealed that the airplane had undergone numerous inspections by different maintenance personnel. The left engine's variable absolute pressure controller had safety wire around its control arm, which precluded its normal operation and a pressure relief valve that was not called for in the STC drawings. At the time of issuance, Federal Regulation's did not require STC instructions for continued airworthiness. Reliance on the airplane and engine maintenance manuals would not have provided enough information for continued airworthiness in accordance with the STC and could have yielded a setting exceeding those for which the STC parts were originally certificated to and thus increasing Vmc speed. Examination of the left engine revealed a cylinder head separation on the number six cylinder assembly, which had accumulated an estimated time since installation of 240 hours. Visual inspection of the assembly revealed the presence of some undecipherable characters in its parts numbering. A cylinder head separation from another airplane was also examined. This cylinder assembly accumulated about 270 hours since installation. Both cylinder assembly examinations revealed the presence of additional material on the cylinder barrel threads and fatigue fracture on the cylinder head.
Probable cause:
The pilot's failure to maintain adequate airspeed (Vmc) which resulted in a loss of control. Contributing factors were the improper in-flight planning/decision not to land at a closer airport and the lack of recent experience in multiengine airplanes by the pilot-in-command, the cylinder head separation, the inadequate manufacturing process, and the lack of continued airworthiness instructions relating to the Riley Super-8 STC.
Final Report:

Crash of a Lockheed C-130E Hercules near Campo dos Afonsos AFB: 9 killed

Date & Time: Sep 27, 2001 at 1215 LT
Type of aircraft:
Operator:
Registration:
2455
Flight Type:
Survivors:
No
Site:
MSN:
4202
YOM:
1967
Country:
Crew on board:
9
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
While descending to Campo dos Afonsos AFB, the crew encountered poor weather conditions with limited visibility due to fog and rain falls. Too low, the four engine aircraft struck the slope of a mountain located about 15 km southeast of the airbase. All nine occupants were killed.

Crash of a Douglas DC-6BF in Nuiqsut

Date & Time: Sep 25, 2001 at 1609 LT
Type of aircraft:
Operator:
Registration:
N867TA
Flight Type:
Survivors:
Yes
Schedule:
Deadhorse - Nuiqsut
MSN:
45202
YOM:
1957
Flight number:
NAC690
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
22000
Captain / Total hours on type:
14000.00
Copilot / Total flying hours:
6100
Copilot / Total hours on type:
3000
Aircraft flight hours:
7754
Circumstances:
The crew was conducting a GPS instrument approach in a Douglas DC-6B airplane under IFR conditions. Both pilots were certificated and type-rated in the Douglas DC-6B airplane. The first pilot, seated in the right seat, was one of the company's senior check airman, and possessed a right seat dependency endorsement. The second pilot, seated in the left seat, had less experience in the DC-6B airplane. It had been previously agreed that the second pilot would fly the leg of the flight on which the accident occurred. The first pilot reported that light snow showers were present, with visibility reported at 4 miles. During final approach as the airplane passed over the airstrip threshold, a higher than normal sink rate was encountered. He said that the initial touchdown was "firm," but was thought to be within acceptable tolerances. Just after touchdown, the left wing broke free from the airplane at the wing to fuselage attach point. The airplane veered to the left, continued off the left side of the 5,000 feet long by 75 feet runway, down an embankment, and came to rest in an area of wet, tundra covered terrain. A postcrash fire heavily damaging the center section of the fuselage. The cockpit voice recorder (CVR) revealed that as the airplane progressed along the approach, the first pilot says: "You're only one mile from it....Take it on down ah three." As the airplane passes over the runway threshold, the first pilot says: "Keep that, keep that (expletive) power off.... Just push forward on the nose." The sound of impact is heard 4 seconds later. The minimum descent altitude (MDA) for the approach is 400 feet msl (383 feet agl). A contract weather observer reported lower ceilings, with about 1 mile visibility, over the approach end of the runway at the same time as the accident.
Probable cause:
The flightcrew's continued use of an unstabilized GPS approach. Factors associated with the accident were low ceilings, and the inadequate coordination between the crew.
Final Report:

Crash of a Piper PA-31-310 Navajo near Antananarivo: 7 killed

Date & Time: Sep 24, 2001
Type of aircraft:
Registration:
F-GRDT
Survivors:
No
Site:
Schedule:
Mahajanga – Antananarivo – Saint-Denis
MSN:
31-7300931
YOM:
1973
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The twin engine aircraft departed Mahajanga, Madagascar, on a charter flight to Saint-Denis de La Réunion, with an intermediate stop in Antananarivo, carrying five passengers and two pilots. While approaching Antananarivo-Ivato Airport, the aircraft went out of control and crashed in a mountainous area located about 30 km from the airport. The aircraft was destroyed and all seven occupants were killed.
Probable cause:
Loss of control following a double engine failure on approach due to fuel exhaustion.