Crash of an Antonov AN-12BP in Kisangani

Date & Time: Aug 15, 2000
Type of aircraft:
Operator:
Registration:
LZ-ITC
Flight Type:
Survivors:
Yes
MSN:
00 346 909
YOM:
1970
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The four engine airplane was completing a humanitarian flight to Kisangani on behalf of 'Médecins Sans Frontières'. After touchdown, the aircraft was unable to stop within the remaining distance, overran and came to rest, bursting into flames. All seven crew members escaped uninjured and the aircraft was destroyed.

Crash of a Rockwell Sabreliner 75A in Iron Wood: 2 killed

Date & Time: Aug 14, 2000 at 1822 LT
Type of aircraft:
Operator:
Registration:
N85DW
Survivors:
Yes
Schedule:
Brainerd – Flint
MSN:
380-27
YOM:
1975
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
13037
Captain / Total hours on type:
2560.00
Aircraft flight hours:
7185
Circumstances:
The airplane impacted heavily wooded terrain after experiencing a dual engine failure due to a reported lightning strike. The pilot received a weather brief that included information concerning a Convective Sigmet and a Severe Weather Watch. The weather briefer informed the pilot that a route to the southeast would keep the flight out of the heavy weather, and that, "... you'll get clobbered if you go due east." After departure, the pilot requested a turn to the northeast to stay clear of weather. While in the climb, the flight was advised of a Weather Watch that covered the area of their flight. The CVR revealed that Continuous Ignition was not selected prior to encountering turbulence. About 23 minutes after takeoff, the airplane was climbing at about 30,800 feet msl when the pilot reported a dual engine failure due to a lightning strike. The CVR indicated one engine quit and the second quit about two seconds later. The copilot established a 170 kts descent airspeed for "best glide." The airplane was vectored near a level 5 thunderstorm during the emergency descent. Two air starts were attempted when the airplane's altitude was outside of the air start envelope. Two more air starts were attempted within the air start envelope but were unsuccessful. The minimum airspeed for an air restart is 160 kts and the maximum speed for air start is 358 kts. The CVR indicated that the pilots did not call for the airplane's checklist, and no challenge and response checklists were used during the emergency descent. The CVR indicated the pilots did not discuss load shedding any of the electrical components on the airplane. The CVR indicated the hydraulic system cycled twice during the emergency descent and the landing gear was lowered using the hydraulic system during descent. During the descent the pilots reported they had lost use of their navigation equipment. The airplane impacted the terrain located about 166 nautical miles from the departure airport on a bearing of 083 degrees. No preexisting engines or airframe anomalies were found.
Probable cause:
The pilot's improper in-flight decision, the pilot's continued flight into known adverse weather, the pilot's failure to turn on the continuous ignition in turbulence, and the pilot's failure to follow the procedures for an airstart. Factors included the thunderstorms, the lightning strike, and the woods.
Final Report:

Crash of an Antonov AN-26 at Batajnica AFB

Date & Time: Aug 14, 2000
Type of aircraft:
Registration:
71385
Flight Type:
Survivors:
Yes
MSN:
38 07
YOM:
1976
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
For unknown reasons, the aircraft belly landed at Batajnica AFB and came to rest. There were no casualties but the aircraft was damaged beyond repair.

Crash of a Beechcraft B200 Super King Air in Spanish Cay

Date & Time: Aug 12, 2000 at 1115 LT
Registration:
N3199A
Flight Type:
Survivors:
Yes
Schedule:
Fort Lauderdale – Spanish Cay
MSN:
BB-1499
YOM:
1995
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On August 12, 2000, about 1115 eastern daylight time, a Beechcraft B200, N3199A, registered to and operated by Great Texas Food Inc. as a Title 14 CFR Part 91 personal flight, ran off the side of the runway during landing in Spanish Cay, Bahamas. Visual meteorological conditions prevailed at the time and a visual flight rules flight plan was filed. The private-rated pilot and the two passengers received no injuries. The flight originated from Fort Lauderdale, Florida, the same day, about 1030. The pilot stated that he made an uneventful landing and as he applied the brakes, the left brake did not respond. He stated that he lost control of the aircraft and exited the runway from the right side and impacted a berm. The right landing gear collapsed, the left wing and the front fuselage incurred substantial damage.

Crash of a Cessna 340 in Griesheim: 3 killed

Date & Time: Aug 9, 2000 at 1435 LT
Type of aircraft:
Registration:
N4424X
Flight Type:
Survivors:
No
Schedule:
Zweibrücken – Egelsbach
MSN:
340-0217
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1829
Captain / Total hours on type:
28.00
Aircraft flight hours:
4800
Circumstances:
The twin engine aircraft departed Zweibrücken Airport on a VFR flight to Egelsbach, carrying two passengers and one pilot. Following an uneventful flight at an altitude of 5,000 feet and while approaching the destination, the pilot informed ATC about technical problems and elected to divert to Griesheim-August-Euler Airport. On short final, while completing a left turn, the aircraft stalled and crashed 160 metres short of runway 25 threshold, bursting into flames. The aircraft was destroyed and all three occupants were killed.
Probable cause:
Failure of the left engine because the fuel selector valve was in OFF position. For unknown reasons, the pilot failed to feather the left propeller and on short final, the aircraft's speed was below minimum, causing the aircraft to stall and to crash. No technical anomalies were found on the aircraft.
Final Report:

Crash of a Douglas DC-9 in Greensboro

Date & Time: Aug 8, 2000 at 1544 LT
Type of aircraft:
Operator:
Registration:
N838AT
Survivors:
Yes
Schedule:
Greensboro - Atlanta
MSN:
47442/524
YOM:
1970
Flight number:
FL913
Crew on board:
5
Crew fatalities:
Pax on board:
58
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
22000
Captain / Total hours on type:
15000.00
Copilot / Total flying hours:
8000
Copilot / Total hours on type:
2000
Circumstances:
Examination of the area of the fire origin revealed that relay R2-53, the left heat exchanger cooling fan relay, was severely heat damaged, as were R2-54 and the other relays in this area. However, the R2-53 relay also exhibited loose terminal studs and several holes that had burned through the relay housing that the other relays did not exhibit. The wire bundles that run immediately below the left and right heat exchanger cooling fans and the ground service tie relays exhibited heat damage to the wire insulation, with the greatest damage located just below the R2-53 relay. The unique damage observed on the R2-53 relay and the wire damage directly below it indicates that fire initiation was caused by an internal failure of the R2-53 relay. Disassembly of the relay revealed that the R2-53 relay had been repaired but not to the manufacturer's standards. According to the manufacturer, the damage to the relay housing was consistent with a phase-to-phase arc between terminals A2 and B2 of the relay. During the on-scene portion of the investigation, three of the four circuit breakers in the left heat exchanger cooling fan were found in the tripped position. To determine why only three of the four circuit breakers tripped, all four were submitted to the Materials Integrity Branch at Wright-Patterson Air Force Base, Dayton, Ohio, for further examination. The circuit breakers were visually examined and were subjected to an insulation resistance measurement, a contact resistance test, a voltage drop test, and a calibration test (which measured minimum and maximum ultimate trip times). Testing and examination determined that the circuit breaker that did not trip exhibited no anomalies that would prevent normal operation, met all specifications required for the selected tests, and operated properly during the calibration test. Although this circuit breaker appeared to have functioned properly during testing, the lab report noted that, as a thermal device, the circuit breaker is designed to trip when a sustained current overload exists and that it is possible during the event that intermittent arcing or a resistive short occurred or that the circuit opened before the breaker reached a temperature sufficient to trip the device.
Probable cause:
A phase-to-phase arc in the left heat exchanger cooling fan relay, which ignited the surrounding wire insulation and other combustible materials within the electrical power center panel. Contributing to the left heat exchanger fan relay malfunction was the unauthorized repair that was not to the manufacturer's standards and the circuit breakers' failure to recognize an arc-fault.
Final Report:

Crash of a Beechcraft A60 Duke in Halle-Oppin

Date & Time: Aug 2, 2000 at 1424 LT
Type of aircraft:
Operator:
Registration:
D-IMEI
Flight Type:
Survivors:
Yes
Schedule:
Halle-Oppin - Halle-Oppin
MSN:
P-145
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft was completing a local test flight at Halle-Oppin Airport. For unknown reasons, it belly landed and came to rest. All three occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-6 Twin Otter 200 in Raleigh: 1 killed

Date & Time: Jul 31, 2000 at 0034 LT
Operator:
Registration:
N201RH
Flight Type:
Survivors:
Yes
Schedule:
Hinckley - Louisburg
MSN:
163
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1725
Captain / Total hours on type:
147.00
Aircraft flight hours:
28711
Circumstances:
The flight had proceeded without incident until a visual approach was made to the destination airport, but a landing was not completed because of poor visibility due to ground fog. The pilot then requested vectors to another airport, and was advised by ATC that he was below radar coverage, and he could not be radar identified. The pilot stated he would proceed to a third airport; he was given a heading, instructed to proceed direct to the airport, and report the field in sight. He was told to over-fly the airport, and might be able to descend through a clearing in the clouds. An inbound air carrier flight reported instrument meteorological conditions on the final approach to a parallel runway. At a location of 1.13 miles east of the airport, the flight, for no apparent reason, turned south, away from the airport. The last radio contact with pilot was after ATC told him his heading was taking him away from the airport and he said he was turning back. The last known position of N201RH was 1.95 miles southeast of the airport, at 500 feet MSL. According to the statement of the passenger that was sitting in the co-pilot's seat, "...all we could see were city lights and darkness underneath us. We were in a right turn, when I saw the trees and subsequently hit it." According to the pilot's log book and FAA records revealed a limitation on his commercial pilot certificate prohibited him from carrying passengers for hire at night and on cross-country flights of more than 50 nautical miles. The records did not show any instrument rating. As per the entries in his personal flight logbook, he had accumulated a total of 1,725.2 total flight hours, 1,550.9 total single engine flight hours, and 184.3 total flight hours in multi-engine aircraft of which 145.6 hours were in this make and model airplane. In addition, the logbooks showed that he had a total of 487.3 cross country flight hours, 61.9 total night flight hours, and 21.6 simulated instrument flight hours.
Probable cause:
The pilot's continued VFR flight into IMC conditions, by failing to maintain altitude, and descending from VFR conditions into IMC, which resulted in him subsequently impacting with trees. Factors in this accident were: reduced visibility due to dark night and fog. An additional factor was the pilot was not certified for instrument flight.
Final Report:

Crash of a Beechcraft B200C Super King near Kulu-Bhuntar: 5 killed

Date & Time: Jul 29, 2000 at 1332 LT
Registration:
VT-EIE
Flight Type:
Survivors:
No
Site:
Schedule:
New Delhi – Kulu-Bhuntar
MSN:
BL-63
YOM:
1983
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
8340
Captain / Total hours on type:
776.00
Copilot / Total flying hours:
526
Aircraft flight hours:
6243
Aircraft flight cycles:
5646
Circumstances:
The twin engine aircraft departed New Delhi-Indira Gandhi Airport on an ambulance flight to Kulu-Bhuntar, carrying three doctors and two pilots. While descending to Kulu-Bhuntar Airport in IMC conditions, the crew failed to realize his altitude was insufficient when the aircraft struck the slope of a mountain located 20 km from the destination airport. The aircraft was destroyed and all five occupants were killed.
Probable cause:
The pilot descended below minimum sector altitude in Instrument Meteorological Condition in hilly area.
Contributing factors were:
1. ATC Chandigarh contributed to the accident by permitting IFR flight to descend below minimum sector altitude.
2. Inadequate Supervision, Lack of Safety culture and poor pre-flight planning. Factor: Pilot: Non-adherence to standard operating procedure.
Final Report:

Crash of a Grumman G-159 Gulfstream I in Montreal

Date & Time: Jul 27, 2000 at 2350 LT
Type of aircraft:
Registration:
C-GPTG
Flight Type:
Survivors:
Yes
Schedule:
Toronto - Montreal
MSN:
189
YOM:
1968
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Airwave flight 9806, a G-159 Gulfstream I, was flying IFR from Toronto (YYZ) to Montreal-Dorval (YUL). When it was on final for runway 06R, the pilot reported a problem with the landing gear. The crew recycled the gear and performed the emergency extension procedure unsuccessfully before trying various flight manoeuvres to free the gear. They then circled Montreal until minimum fuel was reached, declared an emergency and landed. On landing, the aircraft veered to the left and came to a halt 60 feet from the runway. Both pilots escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
Preliminary investigation revealed that an apprentice AME moved a line in the landing gear well prior to the flight. The work was neither scheduled nor required. The apprentice left the work unfinished when he went to do something else, then forgot that a fastener was not in place. There was no flag or note to inform the other technicians or the crew that the aircraft was not in an airworthy state. The apprentice has two years experience with this company. The management was satisfied with the quality of his work. Two other licensed AMEs were working in the hangar with the apprentice. He was the only apprentice they had to supervise. The apprentice attended a type training course for this aircraft.