Crash of a Saab 340B in Killeen

Date & Time: Mar 21, 2000 at 1914 LT
Type of aircraft:
Operator:
Registration:
N353SB
Survivors:
Yes
Schedule:
Dallas - Killeen
MSN:
353
YOM:
1993
Flight number:
AA3789
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
33
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12518
Captain / Total hours on type:
9251.00
Copilot / Total flying hours:
2105
Copilot / Total hours on type:
1040
Aircraft flight hours:
11976
Circumstances:
The captain was the flying pilot for the night landing on runway 01 in instrument meteorological conditions (IMC), with a right cross wind from 110 degrees at 14 gusting 18 knots, drizzle, and a wet runway. Prior to starting the approach, the flightcrew determined that the landing approach speed (Vref) and the approach speed (Vapp) were 122 and 128 knots, respectively. DFDR data showed the airplane flying on autopilot as it passed the middle marker at 200 feet AGL at 130 knots on the ILS approach. Approximately 3 seconds after the first officer called "runway in sight twelve o'clock," the captain disconnected the autopilot, while at a radio altitude of 132 feet and on a heading of approximately 18 degrees. Within approximately 11 seconds after the autopilot disconnect, the glideslope and localizer deviation increased. The first officer called "runway over there." Approximately 5 seconds before touchdown, the airplane rolled right, then left, then right. DFDR data-based performance calculations showed the airplane crossed the threshold at an altitude of 35 feet and 130 knots. The airplane touched down 2,802 feet from the approach end of the 5,495-foot runway (844- foot displaced threshold) at 125 knots on a heading of 10 degrees. The airplane overran the runway and struck a ditch 175 feet beyond the departure end of the runway. Landing roll calculations showed a ground roll of 2,693 feet after touchdown, consisting of 1,016 feet ground roll before braking was initiated and 1,677 feet ground roll after braking was initiated until the airplane exited the pavement. According to Saab, for a wet runway, the aircraft would have needed 1,989 feet from the time of braking initiation to come to a complete stop. The American Eagle Airlines, Inc., FAA approved aircraft operating manual (AOM), states in part: Stabilized approaches are essential when landing on contaminated runways. Landing under adverse weather conditions, the desired touch-down point is still 1,000 feet from the approach end of the runway. Touchdown at the planned point. Cross the threshold at Vapp, then bleed off speed to land approximately Vref -5. Use reverse, if needed. To achieve maximum braking effect on wet runway, apply maximum and steady brake pressure. In 1992, the City of Killeen submitted a proposal that included extending the north end of runway 01 by 194 feet. The FAA originally disapproved the proposal, in part, because the runway extension decreased the length of the runway safety area (RSA) which was already shorter than the recommended 1,000 feet for a 14 CFR Part 139 certificated airport. The proposal was subsequently approved and a drainage ditch was installed in the north RSA, perpendicular to the runway and approximately 175 feet north of the departure end of runway 01. In 1993, the airport received FAA Part 139 certification. The 1998 and 1999, FAA airport certification inspection reports noted the inadequate RSA; however, neither letter of correction, sent from the FAA to the City of Killeen following the inspections, mentioned the RSA. Following this accident, the ILS runway 01 was flight checked by the FAA and all components were found to be operating within prescribed tolerances. Examination of the airplane found no anomalies that would have prevented it from operating per design prior to departing the runway and encountering the ditch.
Probable cause:
The captain's failure to follow standard operating procedure for landing on a contaminated runway in that he touched down long, which combined with his delayed braking resulted in a runway overrun. Contributing factors were the captain's failure to maintain runway alignment following his disconnect of the autopilot, the gusty crosswind and the wet runway. In addition, the following were contributing factors:
(1) the airport operator's failure to fill in a ditch in the runway safety area,
(2) the FAA's granting of 14 CFR Part 139 approval to the airport when the runway safety area (RSA) did not meet the recommended length for a Part 139 airport, and
(3) the FAA's continued lack of acknowledgement to the airport of the inadequate RSA following their annual airport inspection checks.
Final Report:

Crash of a Beechcraft C90 King Air in Bursa: 1 killed

Date & Time: Mar 21, 2000
Type of aircraft:
Operator:
Registration:
TC-LMK
Survivors:
Yes
Schedule:
Ankara - Bursa
MSN:
LJ-1080
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
On final approach to Bursa-Yenisehir Airport, the pilot encountered poor weather conditions. Due to low visibility, he was unable to establish a visual contact with the approach and runway lights and initiated a go-around procedure. While completing a circuit, the twin engine aircraft struck the top of a hill located near the airport and crashed. A passenger was killed while four other occupants were injured.

Crash of an Antonov AN-26B in Goma

Date & Time: Mar 19, 2000
Type of aircraft:
Operator:
Registration:
UR-26586
Flight Type:
Survivors:
Yes
MSN:
13805
YOM:
1984
Location:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was completing a humanitarian flight to Goma on behalf of the United Nations Organization. On final approach, at a distance of 1,000 metres from the runway threshold, the aircraft encountered windshear. The captain initiated a go-around procedure but the aircraft continued to descent until it struck the ground and crashed to the right of the runway. All 10 occupants were injured and the aircraft was destroyed.

Crash of a Douglas C-47A-5-DK in Ennadai Lake: 2 killed

Date & Time: Mar 17, 2000 at 1230 LT
Operator:
Registration:
C-FNTF
Flight Type:
Survivors:
No
Schedule:
Points North Landing - Ennadai Lake
MSN:
12344
YOM:
1944
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8200
Captain / Total hours on type:
840.00
Copilot / Total flying hours:
4300
Copilot / Total hours on type:
85
Circumstances:
The Douglas DC-3 departed Points North Landing, Saskatchewan, about 1125 central standard time on a visual flight rules flight to Ennadai Lake, Nunavut, with two pilots and 6600 pounds of cargo on board. The flight was one of a series of flights to position building materials for the construction of a lodge. The pilots had completed a similar flight earlier in the day. The runway at Ennadai, oriented northeast/southwest, was an ice strip about 2700 feet long by 150 feet wide marked with small evergreens. The ice strip was constructed on the lake, and the approaches were flat, without obstacles. The snow was cleared so there were no snow ridges on the runway ends. The arrival at Ennadai Lake, toward the southwest, appeared to be similar to previous arrivals. The aircraft was observed to touch down nearly halfway along the ice strip, the tail of the aircraft remained in the air, and the aircraft took off almost immediately. The main landing gear was seen to retract. The aircraft reached the end of the runway then abruptly entered a steep, nose-up attitude, banked sharply to the left, turned left, and descended into the ice. The left wing made first contact with the ice. The aircraft rotated around the left wing and struck the ice in a steep, nose-down attitude about 400 feet from the end of the ice strip. There was no fire. The crew were killed instantly. Canadian Forces rescue specialists were air-dropped to the site on the day of the accident.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot lost control of the aircraft while conducting a go-around from a balked landing on an ice strip.
2. The aircraft's centre of gravity (C of G) on the accident flight was beyond the aft C of G limit.
3. The actual C of G of the aircraft at basic operating weight was 16.7 inches aft of the C of G provided in the weight and balance report.
4. The load sheet index number used by the crew was inaccurate.
5. The stack of 2x4 lumber was inadequately secured and may have shifted rearward during the go-around.
6. The crew did not recalculate the aircraft's weight and balance for the second flight.
7. Leaks in the heater shroud allowed carbon monoxide gas to contaminate cockpit and cabin air.
8. The captain's carboxyhaemoglobin level was 17.9%, which may have adversely affected his performance, especially his decision making and his visual acuity.
Other Findings:
1. The carbon monoxide detector had no active warning system. The user directions for the detector, which are printed on the back of the detector, are obscured when the detector is installed.
2. The company maintenance facility overhauled the heater as required by the Transport Canada-approved inspection program.
3. Although the manufacturer's maintenance instruction manual for the S200 heater, part number 27C56, lists inspection and overhaul procedures, it does not specify their intervals.
4. No maintenance instructions are available for the heater, part number 27C56. The company maintenance facility did not conduct inspections, overhauls, or pressure decay tests as specified for later manufactured heaters.
Final Report:

Crash of an Embraer EMB-110P1A Bandeirante in Kaduna

Date & Time: Mar 17, 2000 at 1047 LT
Operator:
Registration:
5N-AXM
Survivors:
Yes
Schedule:
Abuja - Jos
MSN:
110-446
YOM:
1984
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8733
Captain / Total hours on type:
1008.00
Copilot / Total flying hours:
3100
Copilot / Total hours on type:
200
Aircraft flight hours:
10926
Circumstances:
On the day of the accident, the aircraft was engaged in a charter operation for the Central Bank of Nigeria. The first segment of the flight (Lagos - Abuja) was flown by the Commander. The aircraft departed Lagos about 0630 hours UTC and initially at cruise, the crew had a momentary problem setting power on the starboard engine after which the flight continued normally to Abuja. The aircraft which departed Abuja for Jos at 0900 hours UTC had 6 souls on board, 5 hours endurance with the first officer at the controls. At FL 90 and about 30NM from Abuja, the crew again had problems with the cruise power setting on the starboard engine. The torque remained at 1400. The crew retarded the right power lever to the minimum with the aim of achieving a cruise setting of 1300 but the gear warning came on. The Commander at this stage took over the controls from the first officer. At 0923 hours UTC, the aircraft contacted Kaduna Tower that it would be diverting to Kaduna as against its scheduled destination giving its flight level as 90 at a distance of 61 miles and estimating TMA at 24 miles, 'KC' at 41 miles, 6 souls on board and 5 hours endurance at departure. The tower then gave the aircraft an inbound clearance to 'KC' locator maintaining FL 90 and to expect no delay for a locator approach runway 05. Weather report at 0900 hours UTC was also passed to the aircraft as wind 090/05 knots, QNH 1014 and temperature 30°c. At 0928 hours UTC the airplane at about 42 miles, speed between 150-160 kts, requested descent and was cleared to 4,500H, QNH 1014. At about 0935 hours UTC, the pilots contacted tower that they would make a single engine approach because they were having problems controlling power on the starboard engine and it would be shut down. The tower in response, asked whether they would need fire coverage on landing to which the pilots affirmed. The commander then reviewed the single engine approach with the first officer estimating 4,500 ft at 8NM. Approaching 4,500 ft at 11 NM, the crew initiated right engine shut down after which the speed was decayed from 150 to 140 kts. At 0946 hours UTC, the pilot reported 6nm final and field in sight while the tower requested hire to report 4 miles final. Shortly, the controller reported having the aircraft in sight and subsequently cleared it to land on runway 05 giving wind as north easterly 06 knots. Descending at 500ft/min, the commander requested for 25% of flap when the first officer selected full flap. Shortly, the speed started decaying and bleeding faster. When the aircraft was at 2,700 ft high, the speed had already decayed to between 100 - 110 kts. The crew applied full power on the port engine to arrest the speed decay but to no avail . The pilot was trying to correct the descent rate, speed decay and the asymmetry when the stall warning came on. At this juncture, all effort by the controller to establish further contact with the airplane proved abortive. Suddenly, the controller observed a gust of dust in the atmosphere which gave him an indication that the aircraft had crashed. The aircraft crashed into the new VOR/DME site being constructed about 1175m from the threshold of runway 05. Time of accident was 0947 hours UTC.
Probable cause:
The probable cause of this accident was the poor handling by the crew of the one-engine inoperative approach.
The following findings were identified:
- The aircraft was properly registered and certified in accordance with the Civil Aviation Regulations of Nigeria.
- The commander of the aircraft was certified and qualified to take the flight while the first officer did not have a licence on board on the clay of the accident. The licence had expired and yet to he renewed.
- The proficiency check attended by the GWW was Without some critical manoeuvres such as simulated single engine approach and stalls.
- The aircraft on departure from Abuja was to land at Jos but diverted to Kaduna.
- The crew informed Kaduna Control Tower that they were doing to make a single engine (port) approach since they were having problems controlling power of the starboard engine.
- The pilots did not adhere to the laid down procedures for a one-engine inoperative approach.
- Crew coordination was practically lacking in this flight.
- The Control Tower lost contact with the aircraft at about 4NM to the airfield.
- The Landing Configuration of the aircraft was full flaps, gear up with power only on the poet engine.
- The starboard engine propeller was not feathered.
- The aircraft crashed into the new VOR/DME site being constructed about Urn from the threshold of runway 05.
- The final resting position of the aircraft was about 68m from the first point of impact and almost turning 180° from its initial direction (flight path).
- There was power on the port engine as there was severe flexural damage to the propeller blades (tips chip off).
Final Report:

Crash of a Boeing 737-3T5 in Burbank

Date & Time: Mar 5, 2000 at 1811 LT
Type of aircraft:
Operator:
Registration:
N668SW
Survivors:
Yes
Schedule:
Las Vegas - Burbank
MSN:
23060
YOM:
1984
Flight number:
WN1455
Crew on board:
5
Crew fatalities:
Pax on board:
137
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11000
Captain / Total hours on type:
9870.00
Copilot / Total flying hours:
5022
Copilot / Total hours on type:
2522
Circumstances:
On March 5, 2000, about 1811 Pacific standard time (PST), Southwest Airlines, Inc., flight 1455, a Boeing 737-300 (737), N668SW, overran the departure end of runway 8 after landing at Burbank-Glendale-Pasadena Airport (BUR), Burbank, California. The airplane touched down at approximately 182 knots, and about 20 seconds later, at approximately 32 knots, collided with a metal blast fence and an airport perimeter wall. The airplane came to rest on a city street near a gas station off of the airport property. Of the 142 persons on board, 2 passengers sustained serious injuries; 41 passengers and the captain sustained minor injuries; and 94
passengers, 3 flight attendants, and the first officer sustained no injuries. The airplane sustained extensive exterior damage and some internal damage to the passenger cabin. During the accident sequence, the forward service door (1R) escape slide inflated inside the airplane; the nose gear collapsed; and the forward dual flight attendant jump seat, which was occupied by two flight attendants, partially collapsed. The flight, which was operating on an instrument flight rules flight plan, was conducted under 14 Code of Federal Regulations (CFR) Part 121. Visual meteorological conditions (VMC) prevailed at the time of the accident, which occurred
in twilight lighting conditions.
Probable cause:
The flight crew's excessive airspeed and flightpath angle during the approach and landing and its failure to abort the approach when stabilized approach criteria were not met. Contributing to the accident was the controller's positioning of the airplane in such a manner as to leave no safe options for the flight crew other than a go-around maneuver.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Stony Rapids

Date & Time: Feb 27, 2000 at 2200 LT
Operator:
Registration:
C-FATS
Survivors:
Yes
Schedule:
Edmonton - Stony Rapids
MSN:
31-7952072
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7850
Captain / Total hours on type:
1450.00
Circumstances:
The Piper Navajo Chieftain PA-31-350, serial number 31-7952072, departed Edmonton, Alberta, on an instrument flight rules charter flight to Stony Rapids, Saskatchewan, with one pilot and six passengers on board. The pilot conducted a non-directional beacon approach at night in Stony Rapids, followed by a missed approach. He then attempted and missed a second approach. At about 2200 central standard time, while manoeuvring to land on runway 06, the aircraft struck trees 3.5 nautical miles west of the runway 06 button and roughly one quarter nautical mile left of the runway centreline, at an altitude of 1200 feet above sea level. The aircraft sustained substantial damage, but no fire ensued. The pilot and one passenger were seriously injured, and the remaining five passengers sustained minor injuries. Canadian Forces search and rescue specialists were air-dropped to the site at 0300 and provided assistance to the pilot and passengers. Local ground search parties later assisted with the rescue.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot executed a missed approach on his first NDB approach, and, during the second missed approach, after momentarily seeing the runway, he decided to conduct a visual approach, descending below MDA in an attempt to fly under the cloud base.
2. In flying under the cloud base during the visual portion of his approach, the pilot likely perceived the horizon to be lower on the windscreen than it actually was.
3. There was no indication that there was any form of pressure from management to influence the pilot to land at the destination airport. However, the pilot may have chosen to land in Stony Rapids because he had an early flight the following day, and he did not have the keys for the accommodations in Fond-du-Lac.
Findings as to Risk:
1. No scale was available to the pilot in Edmonton for weighing aircraft loads.
2. The maximum allowable take-off weight of the aircraft was exceeded by about 115 pounds, and it is estimated that at the time of the crash, the aircraft was 225 pounds below maximum landing weight. The aircraft's centre of gravity was not within limits at the time of the crash.
3. The rear baggage area contained 300 pounds of baggage, 100 pounds more than the manufacturer's limitation.
4. Two screws were missing from each section of the broken seat track to which the anchor points were attached.
5. Cargo net anchorage system failure contributed to passenger injuries.
6. The stitching failed on the seat belt's outboard strap that was mounted on the right, middle, forward-facing cabin seat.
Other Findings:
1. Hand tools were required to access the ELT panel, since the cockpit remote switch could not be accessed.
Final Report:

Crash of a Cessna 402B near Mojotoro: 4 killed

Date & Time: Feb 23, 2000 at 0925 LT
Type of aircraft:
Operator:
Registration:
LV-MEW
Survivors:
No
Site:
Schedule:
Orán – Salta
MSN:
402B-1310
YOM:
1977
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
890
Captain / Total hours on type:
83.00
Copilot / Total flying hours:
680
Copilot / Total hours on type:
70
Circumstances:
The twin engine aircraft departed Orán Airport at 0845LT on an executive flight to Salta, carrying two passengers and two pilots. At 0910LT, while flying under VFR mode, the crew reported his position over Moxat at an altitude of 8,000 feet. At 0923LT, he informed ATC about his position 15NM northeast of Salta Airport and was instructed to contact Salta Tower. Shortly later, the aircraft struck the slope of a mountain (Finca el Desmonde) located near Mojotoro. The aircraft disintegrated on impact and all four occupants were killed.
Probable cause:
Controlled flight into terrain after the crew decided to continue the descent under VFR mode in IMC conditions. It was reported that both pilots have the qualifications for IFR flight but were never trained to fly in such conditions.
Final Report:

Crash of an Antonov AN-32 in Bangalore

Date & Time: Feb 23, 2000
Type of aircraft:
Operator:
Registration:
K2690
Flight Type:
Survivors:
Yes
Site:
MSN:
03 05
YOM:
1984
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was approaching Bangalore-Hindustan Airport when it crashed in unknown circumstances in the district of Vijayanagar, about 13 km short of runway 09 threshold. There were no casualties.

Crash of a Piper PA-31T3-T1040 Cheyenne in Kotzebue

Date & Time: Feb 21, 2000 at 1123 LT
Type of aircraft:
Operator:
Registration:
N219CS
Survivors:
Yes
Schedule:
Point Lay - Kotzebue
MSN:
31-8275005
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13500
Captain / Total hours on type:
4900.00
Aircraft flight hours:
11098
Circumstances:
The airplane collided with frozen pack ice, three miles from the airport, during a GPS instrument approach. Instrument conditions of 3/4 mile visibility in snow and fog were reported at the time of the accident. The pilot stated that he began a steep descent with the autopilot engaged. He indicated that as the airplane crossed the final approach course, the autopilot turned the airplane inbound toward the airport. He continued the steep descent, noted the airplane had overshot the course, and the autopilot was not correcting very well. He disengaged the autopilot and manually increased the correction heading to intercept the final approach course. During the descent he completed the landing checklist, extended the landing gear and flaps, and was tuning both the communications and navigation radios. The pilot said he looked up from tuning the radios to see the sea ice coming up too quickly to react, and impacted terrain. The pilot relayed there were no pre accident anomalies with the airplane, and that he 'did not stay ahead of the airplane.'
Probable cause:
The pilot descended below the minimum descent altitude. Factors associated with this accident were the task overload of the pilot during the instrument approach, and not performing a level off.
Final Report: