Crash of a Piper PA-31-350 Navajo Chieftain in Val d'Or

Date & Time: Feb 20, 2001 at 1900 LT
Operator:
Registration:
C-GNIE
Flight Type:
Survivors:
Yes
Schedule:
Rouyn – Val d’Or – Saint-Hubert
MSN:
31-7552047
YOM:
1975
Flight number:
APO1023
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
900
Captain / Total hours on type:
30.00
Circumstances:
A Piper PA-31-350, registration C-GNIE, serial number 31-7552047, was on a scheduled (APO1023) instrument flight rules mail service flight between Rouyn Airport, Quebec, and Val-d'Or Airport, Quebec, at approximately 1845 . After checking for prevailing weather conditions at the destination airport, the pilot decided to make a visual approach on runway 36. The pilot reported by radio at two miles on final approach for runway 36 and then stated that he was going to begin his approach again after momentarily losing visual contact with the runway. This was the last radio contact with the aircraft. No emergency locator transmitter signal was received by the flight service station specialist. Emergency procedures were initiated, and searches were conducted. The aircraft was found by a search and rescue team about three hours after the crash. The aircraft was lying about two miles southeast of the end of runway 36; it was substantially damaged. The pilot suffered serious injuries.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The environmental conditions and loss of visual ground references near Val-d'Or Airport were conducive to spatial disorientation. Because of a lack of instrument flight experience, the pilot probably became disoriented during the overshoot and was unable to regain control of the situation.
2. During the approach, the pilot did not plan to and did not pull up towards the centre of the airport, thereby contributing to spatial disorientation.
3. Although the pilot-in-command received training required by Transport Canada, Aéropro did not ensure that the pilot-in-command completed the required Pilot Proficiency Check (PPC) and was adequately supervised and experienced to conduct a night IFR flight safely as pilot-in-command.
Final Report:

Crash of a Rockwell Gulfstream 695A Jetprop 1000 in Puerto López: 8 killed

Date & Time: Feb 19, 2001
Operator:
Registration:
EJC-114
Flight Type:
Survivors:
No
MSN:
695-96083
YOM:
1985
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
On approach to Puerto López Airport, the twin engine aircraft was too low and crashed in hilly terrain located few km from the airfield. The aircraft was destroyed and all 8 occupants were killed.

Crash of a Piper PA-31-T1040 Cheyenne III in Kousséri: 3 killed

Date & Time: Feb 14, 2001 at 2300 LT
Type of aircraft:
Operator:
Registration:
TJ-AIQ
Survivors:
Yes
Schedule:
Douala – N’Djamena
MSN:
31-8275025
YOM:
1982
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine aircraft departed Douala on a charter flight to N'Djamena, carrying one pilot, one steward and two members of the Chadian Government. While approaching N'Djamena Airport, weather conditions deteriorated and the visibility was limited due to a sand storm. Probably to establish a visual contact with the ground, the pilot reduced his altitude when the aircraft struck a tree and crashed about 3 km from the runway 05 threshold, near Kousséri, Cameroon. The steward was seriously injured while all three other occupants were killed, among them the pilot, a Spanish citizen and both passengers who were Amderamane Dadi, General Secretary of the Presidency, and Ali Ahmed Lanine, Chadian Minister for Economic Promotion and Development.

Crash of a Cessna 421A Golden Eagle in Talladega: 5 killed

Date & Time: Feb 13, 2001 at 1840 LT
Type of aircraft:
Registration:
N5AY
Survivors:
No
Schedule:
Hamilton – Talladega
MSN:
421A-0133
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
2000
Captain / Total hours on type:
29.00
Aircraft flight hours:
4887
Circumstances:
The pilot and passengers were on a instrument flight returning home. When they were within range of the destination airport, the controller cleared the flight for an instrument approach. Moment later the pilot canceled his instrument flight plan and told the controller that he was below the weather. Low clouds, reduced visibility and fog existed at the destination airport at the time of the accident. The airplane collided with a river bank as the pilot maneuvered for the visual approach. The post-crash examination of the airplane failed to disclose a mechanical problem.
Probable cause:
The pilot continued visual flight into instrument weather conditions that resulted in the inflight collision with a river bank. Factors were reduced visibility and dark night.
Final Report:

Crash of a Mitsubishi MU-2B-25 Marquise in Macapá

Date & Time: Feb 10, 2001 at 1230 LT
Type of aircraft:
Operator:
Registration:
PT-LEW
Survivors:
Yes
Schedule:
Belém – Macapá
MSN:
244
YOM:
1972
Location:
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3680
Captain / Total hours on type:
55.00
Copilot / Total flying hours:
4512
Copilot / Total hours on type:
644
Circumstances:
On final approach to Macapá Airport, the left engine exploded and caught fire. The aircraft lost height, descended below the glide and eventually crash landed in a grassy area to the right of the runway and came to rest, bursting into flames. All five occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Failure of the second stage of the high pressure compressor disk in the left engine. Investigations were unable to determine the exact cause of the this failure, maybe following fatigue cracks or a construction defect. It was reported that the left engine accumulated 3,000 flying hours since the last compressor overhaul.
Final Report:

Crash of a GAF Nomad N.24A in Jacobkondre: 10 killed

Date & Time: Feb 10, 2001
Type of aircraft:
Operator:
Registration:
PZ-TBP
Survivors:
No
Schedule:
Paramaribo – Jacobkondre
MSN:
73
YOM:
1978
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Circumstances:
On approach to Jacobkondre Airfield, the twin engine aircraft was too low. It collided with trees and crashed near the Salamacca River. The wreckage was found on a hill located about 3 km from the airfield. All 10 occupants were killed.

Crash of a Swearingen SA227AT Merlin IVC in Beaver Island: 2 killed

Date & Time: Feb 8, 2001 at 1920 LT
Registration:
N318DH
Survivors:
Yes
Schedule:
Chicago – Beaver Island
MSN:
AT-469
YOM:
1982
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6500
Captain / Total hours on type:
250.00
Copilot / Total flying hours:
800
Aircraft flight hours:
7207
Circumstances:
The airplane was on an on-demand air-taxi flight operating under 14 CFR Part 135 and was destroyed when it impacted trees and terrain while circling to land during a non-precision instrument approach at night. The airplane came to rest 1.74 nautical miles and 226 degrees magnetic from the intended airport. A weather briefing was obtained and instrument meteorological conditions were present along the route of flight at the time of the briefing. Weather conditions for the two reporting stations closest to the destination were obtained by the airplane prior to executing the approach. The weather reports listed ceilings and visibilities as 400 to 500 feet overcast and 5 to 7 statute miles. The airport elevation is 669 feet and the minimum descent altitude for the approach was listed as 1,240 feet. There was no weather reporting station at the destination airport at the time of the accident. According to the operators General Operations Manual, the pilot was responsible for the dispatch of the airplane including flight planning, and confirming departure, en-route, arrival and terminal operations compliance. The manual also states, "For airports without weather reporting, the area forecast and reports from airports in the vicinity must indicate that the weather conditions will be VFR [visual flight rules] at the ETA so as to allow the aircraft to terminate the IFR operations and land under VFR. (Note: a visual approach is not approved without weather reporting)." For 14 CFR Part 135 instrument flight operations conducted at an airport, federal regulations require weather observations at that airport. Furthermore, the regulations state that, for 14 CFR Part 135 operations, an instrument approach cannot be initiated unless approved weather information is available at the airport where the instrument approach is located, and the weather information indicates that the weather conditions are at or above the authorized minimums for the approach procedure. The commercial pilot held a type rating for the accident airplane. The right seat occupant was a commercial pilot employed by the operator and did not hold an appropriate type rating for the accident airplane. The pitch trim selector switch was found set to the co-pilot side. The regulations state that 14 CFR Part 135 operators cannot use the services of any person as an airman unless that person is appropriately qualified for the operation for which the person is to be used. The circling approach was made over primarily unlit land and water. An FAA publication states that during night operations, "Distance may be deceptive at night due to limited lighting conditions. A lack of intervening Page 2 of 17 CHI01FA083 references on the ground and the inability of the pilot to compare the size and location of different ground objects cause this. This also applies to the estimation of altitude and speed. Consequently, more dependence must be placed on flight instruments, particularly the altimeter and the airspeed indicator." No anomalies were found with respect to the airframe, engines, or systems that could be associated with a pre-impact condition.
Probable cause:
The flightcrew not maintaining altitude/clearance during the circling instrument approach. Factors were the pilot in command initiating the flight without proper weather reporting facilities at the destination, the flightcrew not flying to an alternate destination, the flightcrew not following company and FAA procedures/directives, the lack of certification of the second pilot, the operator not following company and FAA procedures/directives, and the dark night and the low ceiling.
Final Report:

Crash of a Learjet 35A in Nuremberg: 3 killed

Date & Time: Feb 8, 2001 at 1540 LT
Type of aircraft:
Registration:
I-MOCO
Flight Type:
Survivors:
No
Schedule:
Nuremberg - Rome
MSN:
35-445
YOM:
1981
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2641
Captain / Total hours on type:
54.00
Copilot / Total flying hours:
575
Copilot / Total hours on type:
192
Circumstances:
During an inspection of the right engine a technician found chips in the oil filter. The damage should have been repaired within the next 20 flight hours. Since the maintenance organization in Switzerland, who usually carry out necessary repairs, did not have the spare parts available on time, the task was assigned to an organization in Nuernberg. On 07.02.2001, the airplane was ferried to Nuernberg and repaired in the presence of the chief technician of the operator. The repairs and the replacement of the parts exclusively on the right engine were certified properly. The return flight to Rome was planned for the 8th of February 2001 at about 1530 o’clock. A charter flight from Rome was to be carried out on the following day. Two pilots and the chief technician of the operator were aboard the aircraft. The flight preparation was carried out by phone from the repair facility. A weather briefing and the NOTAM´s for the flight were obtained properly. The check lists for the take-off were read. During the preparation the unbalanced fuel distribution between the right and left-hand tanks, and the fact that the total amount yet was equal on both sides was discussed. Immediately afterwards the second pilot noticed the failure of his gyro instruments. The airplane was taxied via the taxiways "Juliet" and "Foxtrot" to runway 10. Pilot at the controls was the pilot in command while the second pilot carried out the radio communications with the air traffic control. The pilots received the clearance for a departure via the departure route Noerdlingen (NDG 1 M) to Rome. The take-off was at 1531 o'clock. After 5 nautical miles the airplane turned to the south, following the departure route. At 15:33:49 o'clock the left-hand engine failed without a previous warning. The noise of a down running engine was also heard by several witnesses on the ground. Smoke or a fire was not seen by them. The second pilot reported an emergency with the left-hand engine shortly after the occurrence to the control tower and informed them that they wanted to return for a landing on the runway 10. At that time there were visual meteorological conditions, and the runway was continuously to be seen. Since the departure control Nuernber APP wished to coordinate the flight, the frequency was changed for a short time upon request. After the second pilot had declared the emergency once again they switched back to the tower again and continued the approach to runway 10. Up to the final approach the flight was without particular occurrences. The flaps were first set to 8° and later on to 20°, afterwards the landing gear was extended. At this time the airplane was somewhat north of the extended centerline slightly above the glide path for an instrument approach. Approximately one kilometer in front of the runway, when flying over the main road no. 4 near the small town of Buch, the airplane was observed by different witnesses as it made unusual flight maneuvers. The airplane deviated then from the landing direction to the north, and made some reeling movements. Afterwards it seemed for a short
period that the pilot intended to turn right to reach the runway. Immediately afterwards and near the ground the airplane abruptly stalled to the left approximately maintaining its height, then assuming a bank angle of more than 90°, and crashed nearly upside down at 1540 o’clock into a forest north of the runway. The airport fire service, who were in a standby position due to the announced safety landing of the Learjet reached the accident site approximately 4 minutes later and started to extinguish the fire. All three occupants had lost their lives during the impact. The airplane was destroyed.
Probable cause:
The accident was caused by an in-flight failure of the left power plant approximately 3 minutes after take-off and an inadequate conduct of the subsequent single-engine landing procedure so that in short final the airplane stalled and crashed from low height. The failure of the left engine was caused by intergranular fractures of retention posts on the high pressure turbine disk. As a result of incorrect service life recordings the maximum number of cycles had considerably been exceeded.
Final Report:

Crash of an Airbus A320-214 in Bilbao

Date & Time: Feb 7, 2001 at 2309 LT
Type of aircraft:
Operator:
Registration:
EC-HKJ
Survivors:
Yes
Schedule:
Barcelona – Bilbao
MSN:
1278
YOM:
2000
Flight number:
IB1456
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
136
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10805
Copilot / Total flying hours:
423
Aircraft flight hours:
1149
Aircraft flight cycles:
869
Circumstances:
The aircraft was on its final approach to runway 30 of Bilbao Airport. The aircraft, operated by Iberia, was employed on flight IB1456, a scheduled domestic flight from Barcelona to Bilbao, with 136 passengers and 7 crew members on board. The expected flight time was 53 minutes. The current conditions in Bilbao were night VMC, with a 10 knots and southwest (SW) wind and gusts of up to 25 knots. Visibility was more than 10 km and there were scattered clouds above 5,600 feet. The sun had set four hours earlier and all electronic and visual aids in the airport were fully operational. There was no rain and the flight was conducted unter IFR rules. Since the takeoff from Barcelona at 2201LT, the flight had been uneventful. The pilot flying was seated on the right hand side, and he was in line flying under supervision. The captain seated on the left hand side was supervising the flight. A third flight crew member, seated in the jumpseat, was the first officer who had given his seat to the pilot under supervision on the right hand seat. On course to Bilbao, the aircraft flew over Pamplona at FL150, where they were informed of possible light turbulence. A about 25 NM from their destination and at 7,500 feet altitude, they crossed a small cumulus with strong turbulence. Descending through 6,000 feet and established on the Bilbao localizer they found winds of 55 knots. The ATC tower (TWR) of Bilbao cleared them to land on runway 30, and informed the decision height, 247 feet, under VMC conditions and continued the approach to land. One minute prior to touchdown, the tower informed of wind conditions of 240° 8 knots. The aircraft conditions during the approach were: weight, 62,380 kilos; centre of gravity, 28,66% MAC, full flaps. The reference speed (Vref) was 132 knots and the approach speed (Vapp), 142 knots. Autopilot was disconnected by the crew at 400 feet to continue the approach manually. In the last few seconds prior to touchdown, the vertical descent speed was very high, around 1,200 feet per minute (6 metres per second) and the 'sink rate' warning of the GPWS sounded twice. The aircraft did not react to the pitch-up order input applied by both pilots on the side-sticks, due to the design software logic that operates at these specific moments, and did not flare. Announcements of 'dual-input' warning were heard at the time. Then the captain, in view of the 'sink rate' warnings, selected TOGA power setting to go around and abort the landing. The pilot's actions on the flight controls could not avoid a hard touchdown of the aircraft in a slight nose down attitude, and the captain decided to continue the landing and to stop the aircraft. The aircraft slowed-down along 1,100 metres of the runway within the paved surface. It finally came to a stop with its horizontal axis at an angle of 60° to the right of the runway centerline. During the landing roll the nose landing gear collapsed, the four tires of the main gear burst and the engine nacelles, on which the aircraft was leaning after the collapse, dragged along the pavement. Once the aircraft came to a halt, the captain ordered its evacuation, which was carried out using all the exit doors and their slides. During the evacuation a cabin crew member and 24 passengers were injured. All injuries were considered minor except for one, a female passenger whose injuries were considered serious. Seven injured people were taken to hospital.
Probable cause:
The cause of the accident was the activation of the angle of attack protection system which, under a particular combination of vertical gusts and windshear and the simultaneous actions of both crew members on the sidesticks, not considered in the design, prevented the aeroplane from pitching up and flaring during the landing.
Final Report:

Crash of a Short 360-100 in Sheffield

Date & Time: Feb 4, 2001 at 1921 LT
Type of aircraft:
Operator:
Registration:
EI-BPD
Survivors:
Yes
Schedule:
Dublin – Sheffield
MSN:
3656
YOM:
1984
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
25
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4484
Captain / Total hours on type:
1392.00
Circumstances:
The crew were planned to fly a scheduled passenger flight from Dublin to Sheffield airport and the commander was the handling pilot for the flight. Both pilots had operated into Sheffield between five and ten times in the previous three months. The aircraft, which was serviceable, took off from Dublin at 1814 hrs and was routed to Sheffield via the VOR/DME navigation beacon at Wallasey at FL90. Prior to descent, the crew obtained the most recent information from the Automatic Terminal Information Service (ATIS); this report, timed at 1820 hrs, was identified as 'Information Hotel'. The reported conditions at Sheffield were: surface wind variable at 03 kt, visibility 4,000 metres in rain and snow, a few clouds at 600 feet, scattered cloud at 1,200 feet and broken cloud at 3,000 feet, the temperature and dew point were coincident at +1°C and the QNH was 989 hPa. Air traffic control was passed to the Sheffield approach controller when the aircraft was 12 nm from the overhead at which time it was descending to 5,000 feet on the QNH. The crew were informed that the current ATIS was now 'Information India' and the aircraft was cleared to descend to 3,000 feet when within 10 nm of the airport. 'Information India', timed at 1850 hrs, contained no significant changes from 'Information Hotel'. The aircraft weight for the landing was calculated to be 11,100 kg with an associated threshold speed of 103 kt. The aircraft was cleared for the ILS/DME procedure for Runway 28 and the crew requested the QFE which was 980 hPa. The decision height for the approach was 400 feet. During the initial stages of the manually flown ILS approach the commander's flight director warning flag appeared briefly but then disappeared and did not reappear during the remaining period of flight. The de-ice boots had been selected to 'ON' early in the descent when the aircraft had briefly encountered light icing. These de-ice boots were selected to 'OFF' when at 5 nm from the runway at which stage there were no indications of icing and the indicated outside air temperature was +5°C. (This is indicative of an actual air temperature of +2°C.) At 1918:11 hrs the crew reported that they were established on the localiser. When the aircraft intercepted the glidepath, the flaps were set to 15° correctly configuring the aircraft for the approach. The handling pilot recalled that initially the rate of descent was slightly higher than the expected 650 ft/min leading him to suspect the presence of a tailwind, however, the rate of descent returned to a more normal value when approximately 4 nm from the runway. The propellers were set to the maximum rpm at 1,200 feet agl. When the crew reported that they were inside 4 nm they were cleared to land and passed the surface wind, which was variable at 2 kt; they were also warned that the runway surface was wet. Both pilots saw the runway lights when approaching 400 feet agl; the flaps were selected to 30° and confirmed at that position. Both pilots believed that the airspeed was satisfactory but, as the commander checked back on the control column for the landing, the rate of descent increased noticeably and the aircraft landed firmly. Both pilots believed that the power levers were in the flight idle position and neither was aware of any unusual control inputs during the landing flare. Two separate witnesses saw the aircraft during the later stages of the approach and the subsequent landing, one of these witnesses was in the control tower and the other was standing in front of the passenger terminal. They both saw the aircraft come into view at a height of approximately 400 feet and apparently travelling faster than normal. They described the aircraft striking the ground very hard with the left wing low; both heard a loud noise coincident with the initial contact. They then reported that the aircraft bounced before hitting the ground again, this time with the nose wheel first, before bouncing once more. Crew statements and flight data evidence indicate that the aircraft lifted no more than 8 feet before settling on the runway and then remained on the ground. The aircraft was then seen to travel about half way along the runway before slewing to the left and running onto the grass. When the aircraft stopped the left wing tip appeared to be touching the grass. When the aircraft came to rest the tower controller asked the crew if they required assistance, this call was timed at 1921:15 hrs. The crew asked for the fire services to be placed on standby but the controller judged that the situation required an immediate and full emergency response and activated the fire and rescue services. The airfield fire services arrived at the aircraft at 1924 hrs and all the passengers had been evacuated by 1925 hrs. The South Yorkshire fire and rescue services arrived at 1933 hrs and assisted in ferrying passengers to the terminal building.
Probable cause:
Evidence from the CVR indicated that the flight was conducted in a thoroughly professional manner in accordance the operator's normal procedures until the final stages of the approach. The recorded data indicate that three seconds prior to touchdown the propeller blade angle changed from the flight range to the ground range. Coincident with this change the CVR recorded sounds consistent with the propellers 'disking' and the FDR indicated that the aircraft then decelerated longitudinally and accelerated downwards. The engineering investigation revealed that the propeller control rigging and the operation of the flight idle baulk were correct. Selection of ground fine requires the pilot to firstly release the flight idle baulk and then lift and pull the propeller levers further back, this combined action rapidly becomes a programmed motor skill in the routine of daily operations. It is therefore possible that the handling pilot unintentionally selected the propellers into the ground fine position whilst still in the air.
Final Report: