Crash of a BAe 125-600B in Lagos

Date & Time: May 15, 2001
Type of aircraft:
Operator:
Registration:
5N-RNO
Survivors:
Yes
Schedule:
Yola – Lagos
MSN:
256054
YOM:
1975
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Lagos-Murtala Muhammed Airport, both engines failed simultaneously due to fuel exhaustion. The aircraft lost height, collided with approach lights and crashed short of runway threshold. All four occupants escaped with minor injuries while the aircraft was damaged beyond repair. The exact date of the mishap remains unknown, somewhere in May 2001.
Probable cause:
Double engine failure on final approach due to fuel exhaustion. Poor flight preparation.

Crash of a Boeing 727-44F in Nzagi

Date & Time: May 10, 2001
Type of aircraft:
Operator:
Registration:
D2-FCK
Flight Type:
Survivors:
Yes
Schedule:
Luanda – Nzagi
MSN:
18892
YOM:
1965
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to runway 08 at Nzagi Airport, the aircraft was too low, causing the right main gear to struck an earth mound located about 100 metres short of runway threshold. Upon touchdown, the right main gear collapsed and the aircraft came to rest partially on its belly. All 11 occupants escaped uninjured while the aircraft was damaged beyond repair. It was reported that the copilot was the pilot-in-command at the time of the accident. Wind was from 130 at 12-15 knots.

Crash of a Piper PA-31-350 Navajo Chieftain off Nahant

Date & Time: May 5, 2001 at 2015 LT
Registration:
N3558G
Flight Type:
Survivors:
Yes
Schedule:
Nantucket – Beverly
MSN:
31-8052068
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1030
Captain / Total hours on type:
65.00
Aircraft flight hours:
3000
Circumstances:
The pilot departed his home airport for a 90 mile personal flight with eight passengers. The pilot stated he departed with 24 gallons of fuel in the outboard tanks, and 80 gallons of fuel in the main tanks. After landing, the airplane was refueled with 100 low-lead aviation gasoline; 12 gallons in each main fuel tank. Before departing for the return flight, the pilot performed a preflight inspection of the airplane, which did not include a visual check of the airplane's fuel tanks. After takeoff, the pilot experienced a "small surge in both engines," while climbing through 1,150 and 3,300 feet, respectively. He further described the surges as "minor but still noticeable." About 30 minutes later, after the airplane had descended, and was leveling at 1,500 feet, the pilot experienced an intermittent illumination of the "right aux fuel pump light," which was followed by a total loss of power on the right engine. Shortly thereafter, the left engine began "surging," and after about "three or four minutes, at most," he feathered the left engine propeller. The pilot ditched the airplane in Massachusetts Bay. The airplane was recovered about 1 month later. The fuel selectors were positioned to the outboard tanks, and the airplane's fuel tanks revealed fluid consistent with seawater with "some odor of fuel;" however, no visible evidence of fuel was observed. According to the airplane's information manual, the airplane's total fuel capacity was 192 gallons, of which, 182 gallons were usable. Examination of the airframe and engine did not reveal evidence of any pre-impact mechanical malfunctions. The pilot reported he had purchased the airplane and attended 5-day type specific training course in March 2001. He reported about 1,050 hours of total fight experience, which included 800 hours in multi-engine airplanes, of which 65 hours was in the make and model. Additionally, the pilot reported he had not experienced any prior mechanical problems. He believed he had flown the airplane the day prior to the accident as well. The last documented refueling of the airplane prior to the date of the accident occurred on May 3, 2001, when the airplane was refueled with 128 gallons of aviation gasoline. The last flight documented in the pilot's logbook was on May 4, 2001, when the pilot logged 1.9 hours in the accident airplane. The pilot said he normally flew a 65 percent power, an "a little rich," and experienced a fuel burn of about 20 to 21 gallons per hour, for each engine.
Probable cause:
A loss of engine power due to fuel exhaustion for undetermined reasons. A factor in this accident was the pilot's failure to visual check the airplane's fuel quantity prior to takeoff.
Final Report:

Crash of a Cessna 208B Super Cargomaster in Steamboat Springs: 1 killed

Date & Time: May 5, 2001 at 0858 LT
Type of aircraft:
Operator:
Registration:
N948FE
Flight Type:
Survivors:
No
Schedule:
Casper – Steamboat Springs
MSN:
208B-0052
YOM:
1987
Flight number:
FDX8810
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2916
Captain / Total hours on type:
43.00
Aircraft flight hours:
8690
Circumstances:
The pilot obtained a weather briefing, filed an IFR flight plan, and departed on a nonscheduled domestic cargo flight, carrying 270 pounds of freight. The flight proceeded uneventfully until it was established on the VOR/DME-C approach. Radar data indicates that after turning inbound towards the VORTAC from the DME arc, the airplane began its descent from 10,600 feet to the VOR crossing altitude of 9,200 feet. Enlargement of the radar track showed the airplane correcting slightly to the left as it proceeded inbound to the VORTAC at 9,400 feet. Shortly thereafter, aircraft track and altitude deviated 0.75 miles northwest and 9,700 feet, 0.5 miles southeast and 9,600 feet, and 0.5 miles northwest and 9,400 feet before disappearing from radar. Witnesses said the weather at the time of the accident was 600 foot overcast, 1.5 miles visibility in "misting" rain that became "almost slushy on the ground," and a temperature of 36 degrees Fahrenheit. One weather study indicated "an icing potential greater than 50% and visible moisture" in the accident area. Another report said "icing conditions were likely present in the area of the accident." The airplane was equipped and certified for flight into known icing conditions. The wreckage was found in a closely area. There was no evidence of pre-impact airframe, engine, or propeller malfunction/failure. The pilot was properly certificated, but his flight time in aircraft make/model was only 38 hours. He had previously recorded 16 icing encounters, totaling 11.2 hours in actual meteorological conditions. He recorded no ice encounters and only 1.0 hour of simulated (hooded) instrument time in the Cessna 208. Microscopic examination of annunciator light bulbs revealed the GENERATOR OFF light was illuminated. This condition indicates a generator disconnection due to a line surge, tripped circuit breaker, or inadvertent switch operation. The operator's chief pilot agreed, noting that one of the items on the Before Landing Checklist requires the IGNITION SWITCH be placed in the ON position. The START SWITCH is located next to the IGNITION SWITCH. Inadvertently moving the START SWITCH to the ON position would cause the generator to disconnect and the GENERATOR OFF annunciator light to illuminate. He said this would be distracting to the pilot.
Probable cause:
An inadvertent stall during an instrument approach, which resulted in a loss of control. Contributing factors were the pilot's attention being diverted by an abnormal indication, conditions conducive to airframe icing, and the pilot's lack of total experience in the type of operation (icing conditions) in aircraft make/model.
Final Report:

Crash of a Cessna 402B in Del Rio: 1 killed

Date & Time: Apr 26, 2001 at 0830 LT
Type of aircraft:
Registration:
N80Q
Flight Type:
Survivors:
No
Schedule:
San Antonio – Del Rio
MSN:
402B-1384
YOM:
1978
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1140
Captain / Total hours on type:
70.00
Aircraft flight hours:
19279
Circumstances:
Upon arrival at the destination airport, the commercial pilot of the Part 135 cargo flight reported to the tower that he was 7 miles to the east, intending to land on runway 13. Subsequently, the pilot reported that he would circle the airport a few times "because he was having trouble with his autopilot." After circling, the pilot positioned the airplane on final approach to runway 13. The pilot of another airplane in the traffic pattern observed the accident airplane on a "one to two mile final, in a normal flight attitude but possibly a little low." After looking at her instruments for several seconds, she made visual contact again and observed the airplane impact the ground with the "tail of the aircraft falling forward on top of a fence." She further stated that all of the radio transmissions from the accident airplane were "calm and completely un-alarmed prior to the accident." Another witness, who was located at a fixed base operator at the airport, observed the airplane turn onto final. He stated that the airplane "suddenly stalled and slammed into the ground from about two hundred feet." The 1,140 hour pilot had accumulated a total of 70 hours in the Cessna 402. The airplane was found to be within its prescribed weight and balance limitations at the time of the accident. Ground impressions and airframe deformations indicated that the impact angle was approximately 25 degrees nose down on a magnetic heading of 155 degrees with the landing gear extended and the flaps partially extended. A post-impact fire destroyed the airplane. Flight control continuity was established from the aft section of the cockpit to the rudder and elevator flight control surfaces. The elevator trim tab (located on the right elevator) was measured with a protractor and found to be in the 28 degrees tab-up position (aircraft nose down). According to the airplane manufacturer's specifications, the maximum tab-up travel limit (when connected) is 5 degrees. The trim tab would not move freely by hand forces and appeared to be jammed. The elevator skin was cut open (top side) to observe the trim tab connecting hardware. It was observed that the clevis end of the trim tab actuator rod was wedged against the front spar of the elevator's internal structure. Additionally, the bolt which connected the clevis end of the tab actuator rod to the actuator screw, was missing. After further inspection, neither the bolt nor the nut were found in the cavity of the elevator structure or the surrounding area. The clevis end of the actuator rod and the actuator screw were not damaged, and no impact damage was apparent on the trim tab. The operator's maintenance records showed that the right elevator had been replaced 10 flight hours prior to the accident.
Probable cause:
The loss of control due to a jammed trim tab, which resulted from the failure of maintenance personnel to properly secure the trim tab actuator rod when installing a replacement elevator.
Final Report:

Crash of a Mitsubishi MU-2B-36 Marquise in Caucasia: 1 killed

Date & Time: Apr 15, 2001
Type of aircraft:
Operator:
Registration:
HK-2245P
Flight Type:
Survivors:
No
Schedule:
Bogotá – Caucasia
MSN:
684
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
While on final approach to Caucasia Airport, the twin engine aircraft crashed in unknown circumstances 3 km short of runway. The aircraft was destroyed and the pilot, sole on board, was killed.

Crash of a Beechcraft A100 King Air in Grande Prairie

Date & Time: Apr 7, 2001 at 0512 LT
Type of aircraft:
Operator:
Registration:
C-FWPN
Survivors:
Yes
Schedule:
Fort Saint John – Grande Prairie
MSN:
B-51
YOM:
1970
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Fort Saint John, the crew started a night approach to Grande Prairie Airport. The aircraft landed slightly to the left of the runway centerline. After touchdown on a snow covered runway (about two inches of snow), the left wing struck a windrow of snow. Out of control, the aircraft veered off runway and came to rest in snow. All five occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Boeing 737-2E1F in Saint John's

Date & Time: Apr 4, 2001 at 0615 LT
Type of aircraft:
Operator:
Registration:
C-GDCC
Flight Type:
Survivors:
Yes
Schedule:
Hamilton – Montréal – Halifax – Saint John’s
MSN:
20681
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
At 2320, Newfoundland daylight time, on 03 April 2001, the Royal Cargo flight, a Boeing 737-200, left Mirabel, Quebec, for a scheduled instrument flight rules cargo flight with two pilots on board. The flight was headed for Hamilton, Ontario; Mirabel; Halifax, Nova Scotia; St. John's, Newfoundland; and Mirabel. The flights from Mirabel to Halifax were uneventful. Before departure from Halifax, the pilot flying (PF) received the latest weather information for the flight to St. John's from the company dispatch; he did not ask for, or receive, the latest notices to airmen (NOTAMs). At 0545, the aircraft departed Halifax for St. John's. The PF was completing his line indoctrination training after having recently upgraded to captain. The training captain, who was the pilot not flying (PNF), occupied the right seat. After departure from Halifax, he contacted Halifax Flight Service Station (FSS) and received the latest weather report for St. John's, the 0530 aviation routine weather report (METAR). The weather was as follows: wind 050° magnetic (M) at 35, gusting to 40, knots; visibility 1 statute mile in light snow and blowing snow; ceiling 400 feet overcast; temperature -1°C; dew point -2°C; and altimeter 29.41 inches of mercury. The FSS passed runway surface condition (RSC) reports for both runways (11/29 and 16/34), including Canadian runway friction index (CRFI) readings of 0.25 for Runway 11/29 and 0.24 for Runway 16/34. The FSS specialist also provided the NOTAMs for St. John's, which included a NOTAM released more than five hours earlier advising of the unserviceability of the instrument landing system (ILS) for Runway 11. The flight crew had initially planned an ILS approach, landing on Runway 11 at St. John's. Because of the marginal weather, the loss of Runway 11/29, and his greater experience, the training captain decided to switch seats and assume the duties and full responsibilities as captain and PF. Returning to Halifax was not considered because the aircraft would be overweight for landing there. The option of diverting the flight to the alternate airport was also discussed by the crew; however, in the end, they felt that a safe landing was achievable in St. John's. At 0638:27, the PF contacted St. John's tower to ask if the approach to Runway 34 was still an option. The response indicated that Runway 34 was probably the only option because of the wind: 050°M (estimated) at 35, gusting to 40, knots. The ILS on Runway 11 was unserviceable, and the glidepath for Runway 29 was unserviceable. The only instrument approaches available were the localizer back course Runway 34 and the ILS Runway 16. Also, at about 0638, the Gander Area Control Centre (ACC) controller suggested to the crew that they obtain the 0630 automatic terminal information service (ATIS) for St. John's. The ATIS was reporting surface winds of 055°M at 20, gusting to 35, knots. The PNF attempted to obtain the ATIS information; however, because of a simultaneous radio transmission on the second VHF radio between the PF and St. John's tower, the ATIS information was not obtained. At 0641, the PNF contacted Gander ACC, which reported the winds at St. John's as 040°M at 13, gusting to 18, knots. The PNF pointed out the discrepancy in the two wind reports to the PF; however, there was no acknowledgement of the significance of the discrepancy. It was later determined that the discrepancy was an unserviceable anemometer at the St. John's airport due to ice accretion on the anemometer. The anemometer was providing a direct reading of the incorrect wind information to Gander ACC. Gander ACC was unaware of the unserviceability and unknowingly passed the incorrect wind information on to the flight crew. At 0644, Gander ACC transmitted a significant meteorological report (SIGMET), issued at 0412 and valid from 0415 to 0815, that included St. John's. The SIGMET forecast severe mechanical turbulence below 3000 feet due to surface wind gusts in excess of 50 knots. However, the crew may not have been listening to the SIGMET broadcast: while the ACC transmitted the SIGMET, the crew were discussing the application of an 18-knot quartering tailwind for the approach to Runway 16. This tailwind was well under the 50 knots described by the SIGMET. The crew did not acknowledge receipt of the SIGMET until prompted by the controller. Before the descent into St. John's, the crew discussed approach options. The approach to Runway 11 was discounted because of the unserviceability of the ILS, and Runway 34 was eliminated as an option because the weather was below its published approach minimums. The crew discussed the ILS approach to Runway 16. Although the PNF expressed concern about the tailwind, it was decided to attempt the approach because the wind reported by Gander ACC was within the aircraft's landing limits. In calculating the approach speed in preparation for the approach, there was confusion during the application of the tailwind and gust corrections to the landing reference speed (Vref ). The crew had correctly established a flap-30 Vref of 132 knots indicated airspeed (KIAS) and ultimately an approach speed of 142 KIAS. The approach speed calculations were derived using the incorrect wind information from Gander ACC; further, the crew added five knots for the gust increment to the nominal approach speed (Vref + 5 knots), that is, Vref + 10 knots. This incorrect calculation (adding the gust factor) was consistent with company practice at the time of the accident. During the descent, the crew also had difficulty completing the descent and approach checklists; there were several missteps and repeated attempts at completion of checks. Clearance for an ILS approach to Runway 16 was obtained from Gander ACC , and the crew was advised to contact St. John's tower. Just over two minutes before landing, the tower advised that the wind was 050°M (estimated) at 20, gusting to 35, knots and provided the following RSC report for Runway 16: Full length 170 feet wide, surface 30% very light dusting of snow and 70% compact snow and ice; remainder is 20% light snow, 80% compact snow and ice, windrow along the east side of the runway; friction index 0.20; and temperature -1°C at 0925. The aircraft crossed the final approach fix on the ILS glideslope at 150 KIAS. During the final approach, the airspeed steadily increased to 180 KIAS (ground speed 190 knots); the glidepath was maintained with a descent rate of 1000 feet per minute. From 1000 feet above sea level, no airspeed calls were made; altitude calls were made and responses were made. The Royal Boeing 737 operations manual states that the PNF shall call out significant deviations from programmed airspeed. In the descent, through 900 feet above sea level, the aircraft encountered turbulence resulting in uncommanded roll and pitch deviations and airspeed fluctuations of +/- 11 knots. At about 300 feet above decision height, the crew acquired visual references for landing. Approximately one minute before landing, St. John's tower transmitted the runway visual range, repeated the estimated surface wind (050°M [estimated] at 20, gusting to 35, knots), and issued a landing clearance to the aircraft; the PNF acknowledged this information. The aircraft touched down at 164 KIAS (27 KIAS above the desired touchdown speed of Vref), 2300 to 2500 feet beyond the threshold. Radar ground speed at touchdown was 180 knots. The wind at this point was determined to be about 050°M at 30 knots. Shortly after touchdown, the speed brakes and thrust reversers were deployed, and an engine pressure ratio (EPR) of 1.7 was reached 10 seconds after touchdown. Longitudinal deceleration was -0.37g within 1.3 seconds of touchdown, suggesting that a significant degree of effective wheel braking was achieved. With approximately 1100 feet of runway remaining, through a speed of 64 KIAS, reverse thrust increased to about 1.97 EPR on engine 1 and 2.15 EPR on engine 2. As the aircraft approached the end of the runway, the captain attempted to steer the aircraft to the right, toward the Delta taxiway intersection. Twenty-two seconds after touchdown, the aircraft exited the departure end of the runway into deep snow. The aircraft came to rest approximately 75 feet beyond and 53 feet to the right of the runway centreline on a heading of 235°M.
Probable cause:
Findings as to Causes and Contributing Factors:
1. A combination of excessive landing speed, extended touchdown point, and low runway friction coefficient resulted in the aircraft overrunning the runway.
Findings as to Risk:
1. Before departure from Halifax, the flight crew did not request nor did dispatch personnel inform the crew of the notice to airmen (NOTAM) advising of the instrument landing system's failure for Runway 11 at St. John's International Airport.
2. The St. John's dynamic wind information provided to the Gander Area Control Centre controller was inaccurate. The controller was not aware of this inaccuracy.
3. The crew applied tailwind corrections in accordance with company practices; however, these practices were not in accordance with those stated in the operations manual.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Marco Island: 1 killed

Date & Time: Mar 31, 2001 at 1015 LT
Operator:
Registration:
N900CE
Flight Type:
Survivors:
No
Schedule:
Venice - Marco Island
MSN:
61-0555-239
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12980
Aircraft flight hours:
3633
Circumstances:
Witnesses watching N900CE's approach for landing to runway 17 at Marco Island Executive Airport stated the pilot appeared to have difficulty aligning the Machen modified Aerostar with the runway centerline. They stated the aircraft appeared unstable about the yaw and roll axes, and appeared too fast. Winds were from the southwest at about 15 knots, gusting to about 20 knots. One pilot/witness close to the touchdown area saw the right wheel touch down instantly, and climb back up to about 50 feet, agl without the full addition of engine power. Most witnesses thought he was either performing a go-around or an extended touch down further down the runway. The airplane continued, "..more and more wobbly" until it entered a climbing attitude and sharp left bank and turn. About half way down the runway the left wing dropped until it contacted the terrain left of the runway, and the aircraft slid into mangrove trees and burned. During postcrash examination, flight control continuity from surface to cockpit floorboards was confirmed. No condition was found with either engine or propeller that would have precluded proper operation, precrash. A witness listening to the pilot's initial radio call up for approach and landing stated that no abnormality was reported by the pilot. Postmortem toxicology testing on specimens obtained from the pilot by the FAA Toxicology and Accident Research Laboratory and the Dade County Medical Examiner revealed quinine found in the blood and urine. The side effects of quinine can include disturbances of vision, hearing, and balance.
Probable cause:
The failure of the pilot to maintain control of the aircraft during a rejected landing and the collision with the terrain and mangrove trees. A finding in the investigation was the presence of quinine in the blood and urine during postmortem toxicological testing of specimens from the pilot.
Final Report:

Crash of a Gulfstream GIII in Aspen: 18 killed

Date & Time: Mar 29, 2001 at 1901 LT
Type of aircraft:
Operator:
Registration:
N303GA
Survivors:
No
Schedule:
Burbank – Los Angeles – Aspen
MSN:
303
YOM:
1980
Crew on board:
3
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
18
Captain / Total flying hours:
9900
Captain / Total hours on type:
1475.00
Copilot / Total flying hours:
5500
Copilot / Total hours on type:
913
Aircraft flight hours:
7266
Aircraft flight cycles:
3507
Circumstances:
On March 29, 2001, about 1901:57 mountain standard time, a Gulfstream III, N303GA, owned by Airbourne Charter, Inc., and operated by Avjet Corporation of Burbank, California, crashed while on final approach to runway 15 at Aspen-Pitkin County Airport (ASE), Aspen, Colorado. The charter flight had departed Los Angeles International Airport (LAX) about 1711 with 2 pilots, 1 flight attendant, and 15 passengers. The airplane crashed into sloping terrain about 2,400 feet short of the runway threshold. All of the passengers and crew members were killed, and the airplane was destroyed. The flight was being operated on an instrument flight rules (IFR) flight plan under 14 Code of Federal Regulations (CFR) Part 135.
Probable cause:
The flight crew's operation of the airplane below the minimum descent altitude without an appropriate visual reference for the runway. Contributing to the cause of the accident were the Federal Aviation Administration's (FAA) unclear wording of the March 27, 2001, Notice to Airmen regarding the nighttime restriction for the VOR/DME-C approach to the airport and the FAA's failure to communicate this restriction to the Aspen tower; the inability of the flight crew to adequately see the mountainous terrain because of the darkness and the weather conditions; and the pressure on the captain to land from the charter customer and because of the airplane's delayed departure and the airport's nighttime landing restriction.
Final Report: