Crash of a Beechcraft Beechjet 400A in Beckley

Date & Time: Apr 17, 1999 at 1451 LT
Type of aircraft:
Operator:
Registration:
N400VG
Survivors:
Yes
Schedule:
West Palm Beach – Beckley
MSN:
RK-113
YOM:
1996
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4719
Captain / Total hours on type:
107.00
Copilot / Total flying hours:
6250
Copilot / Total hours on type:
148
Aircraft flight hours:
1215
Circumstances:
The airplane touched down about 1/3 beyond the approach end of Runway 28, a 5,000 footlong, asphalt runway. The PIC stated, 'as usual,' he applied 'light' braking and attempted to actuated the airplane's thrust reverser (TR) system; however, the TR handles could not be moved beyond the 'Deploy-Reverse-Idle' position. After the PIC cycled the levers two or three times, he began to apply maximum braking. A passenger in the airplane stated he looked out of the cockpit window, saw the end of the runway, and the airplane seemed like it was still moving 'pretty fast.' As the airplane approached the end of the runway, he could see smoke, which he believed was coming from the airplane's tires. He then sensed the airplane was falling. The co-pilot stated he had no memory at all of the accident flight. Review of the CVR revealed the co-pilot said that the airplane was 'Vref plus about twenty,' when the airplane was 100 feet over the runway threshold. The PIC could not recall the airplane's touchdown speed, however, he stated that it seemed like the airplane was still traveling 50 to 60 knots when it departed the end of the runway. A pair of parallel tire marks were observed 3,200 feet beyond the approach end of the runway. The tire marks extended past the end of the runway and onto a 106 foot-long grass area. The airplane came to rest on a plateau about 90 feet below the runway elevation. Examination of the airplane, including the optional TR system did not reveal any pre-impact malfunctions. The airplane's estimated landing distance was calculated to be about 3,100 feet. The PIC reported about 4,700 hours of total flight experience, of which, 107 hours were in make and model. The PIC stated he had never performed a landing in the accident airplane without using the TR system. Winds reported at the time of the accident were from 290 degrees at 15 knots, with 21 knot gusts.
Probable cause:
The pilot-in-command misjudged his altitude and airspeed which resulted in an overrun. Contributing to the accident were the pilot's lack of total flight experience in make and model, the pilot's reliance on the airplane's optional thrust reverser system and his inability to engage the airplane's thrust reverser system for undetermined reasons.
Final Report:

Crash of a Learjet 24D in Ribeirao Preto: 5 killed

Date & Time: Apr 7, 1999 at 1147 LT
Type of aircraft:
Registration:
PT-LEM
Flight Type:
Survivors:
No
Schedule:
São Paulo - Ribeirão Preto
MSN:
24-270
YOM:
1973
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
4000
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
6000
Copilot / Total hours on type:
100
Circumstances:
The aircraft departed São Paulo-Congonhas on a training flight to Ribeirão Preto-Leite Lopes Airport, carrying five crew members, instructor and pilots. On final approach to runway 18, during the last segment, just prior to touchdown, the aircraft rolled to the right, causing the right wing tip to struck the runway surface. The pilot-in-command overcorrected, the aircraft went out of control and crashed 420 metres past the first impact, bursting into flames. All five occupants were killed.
Probable cause:
Contributing Factors:
- There was the participation of individual psychological variables in the pilot-in-command's performance due to the excess of self-confidence and self-demand in his customary behavior, besides the dissimulation regarding his real qualification for the type of flight. The personality with traces of permissiveness and insecurity of the co-pilot also contributed to the occurrence, as it allowed the aircraft to be operated by an unqualified pilot, with no employment link with the company.
- There was a lack of adequate supervision by Manacá Táxi Aéreo, as it allowed a crew member who had not operated the type of aircraft for one year and had not made any type of flight for four months, besides not having any employment relationship with that company. It is also necessary to consider the failure of supervision at the organizational level due to the issue of an incorrect license by the DAC, giving rise to the possibility of its use for the revalidation of license in aircraft for which the pilot was not qualified to exercise the function of commander.
- The entire sequence of events began with pilot errors resulting from the pilot's lack of flight experience in the left-hand seat on the aircraft in question.
- The inadequate use of cockpit resources destined to the aircraft operation, due to an ineffective accomplishment of the tasks assigned to each crew member, besides the interpersonal conflict resulting from the co-pilot's intervention in the pilot in command operation, in the final approach phase, already close to the aircraft's touchdown, configure the collaboration of this factor to the accident.
- The inadequate use of the aircraft commands, by the pilot in command, making excessive aileron corrections in the final approach phase, near the landing.
- The pilot was qualified as a co-pilot on the equipment, but due to a typing error, he was issued a pilot license. Thus, the situation and operation of the pilot in question were totally irregular.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 200 in Palm Beach

Date & Time: Apr 5, 1999 at 0945 LT
Operator:
Registration:
N838MA
Survivors:
Yes
Schedule:
Palm Beach - Kissimmee
MSN:
188
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8000
Captain / Total hours on type:
200.00
Aircraft flight hours:
16659
Circumstances:
The pilot reported that prior to takeoff, he completed a preflight inspection of the airplane that included checking the engine oil quantity. The line personnel topped off the oil reservoirs, and reportedly secured the engine oil reservoir filler caps. Approximately two minutes into the flight, the right engine oil pressure warning light illuminated. The pilot informed Palm Beach Approach Control of the engine oil pressure problem, shut down the right engine, and returned to Lantana. As the flight approached runway 03, the pilot heard a radio transmission from another airplane taxiing for takeoff. As the pilot continued the approach, with full flaps extended, he elected to go-around 1500 feet from the approach end of the 3000-foot runway. The airplane collided with the ground during the go-around maneuver to runway 15. The wreckage examination also disclosed that the right cowling showed oil streaming back from behind the engine and onto the wing strut. Inspection of the oil filler cap revealed that it had not been properly installed.
Probable cause:
The pilot's failure to secure the engine oil filler cap during the preflight inspection that resulted the subsequent loss of engine power, and his in-flight decision to attempt a single engine go-around with full wing flaps extended.
Final Report:

Crash of a Grumman G-21A Goose in Fort Lauderdale: 1 killed

Date & Time: Mar 25, 1999 at 1139 LT
Type of aircraft:
Registration:
N5548A
Flight Type:
Survivors:
Yes
Schedule:
Watson Island - Fort Lauderdale
MSN:
1150
YOM:
1942
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10000
Captain / Total hours on type:
520.00
Aircraft flight hours:
13136
Circumstances:
The pilot was receiving a competency flight in the seaplane from an FAA inspector. The pilot was returning to their initial departure airport, descended to 1,000 feet, contacted the control tower for landing instructions, and was instructed to enter on a right base. Before he could acknowledge the landing instructions the engines started to make loud, rough, and unusual noises. The pilot informed the control tower that he was 2 miles south , declared an emergency, and stated he had a bad engine on the left side. The FAA inspector stated the pilot started the emergency procedure, the manifold pressure and rpm was fluctuating. The inspector could not determine the dead engine by the dead foot, dead engine method, because her rudder pedals were stowed. She pointed out a pasture and the pilot stated they were going to the water. She did not recall the pilot shutting down the engine or feathering the propeller. She could not recall the final seconds of the flight. The airplane collided with a tree, canal bank, and came to rest inverted in the canal. Examination of the airframe and flight control systems revealed no evidence of a precrash mechanical failure or malfunction. Examination of the left propeller revealed it was not feathered. The No. 6 front forward spark plug ignition lead was disconnected from the spark plug. The ignition lead shroud threaded coupling on the No. 4 front forward spark plug was unscrewed and the carbon wire was exposed. The left and right engines were removed from the airplane and transported to an authorized FAA approved repair station. The left engine was placed in an engine test cell. The engine was started, developed rated power, and achieved takeoff power. The spark plug lead was removed from the No.6 forward cylinder. The left magneto had a 125 rpm drop during the magneto check. The right magneto had a 75 rpm drop. The magneto drop exceeded the allowable drop indicated by the engine overhaul manual. The right engine was placed in a engine test cell. The engine was started, developed rated power, and achieved takeoff power. Review of the FAA inspectors FAA Form 4040.6 revealed she was not Event Based Current (EBC) for the 4th quarter of the Flight Standards EBC program, and she did not meet the EBC quarterly events required by the end of the 14-day grace period. FAA Order 4040.9 states for an FAA inspector to be eligible / assigned to perform flight certification job function they must be EBC current., and inspectors should not accept assignments without being in compliance with the FAA Order. Managers and supervisors should not assign inspectors who are not current. The FAA inspector's supervisor was aware that the inspector was not current. He contacted the FAA Safety Regulation Branch, FAA Southern Region Headquarters, and stated that FAA Southern Region indicated that the inspector could administer the checkride. FAA Southern Region stated at no time did they approve or agree to an operation outside the parameters of the FAR's, Inspector Handbook or FAA Order.
Probable cause:
The pilots failure to correctly identify an in-flight emergency (fluctuating manifold pressure and rpm due to a disconnected spark plug lead / unscrewed ignition lead shroud) and failure to complete the engine shutdown procedure once it was initiated (propeller not feathered). This resulted in a forced landing and subsequent in-flight collision with a tree, dirt bank and canal. Contributing to the accident was the FAA inspectors improper supervision of the pilot, and the improper supervision of the inspector by her supervisor, in his failure to follow written procedures / directives in assigning a non-current inspector to conduct a competency flight.
Final Report:

Crash of an Airbus A300C4-620 in Rhodes

Date & Time: Mar 24, 1999 at 1210 LT
Type of aircraft:
Operator:
Registration:
A6-PFD
Survivors:
Yes
Schedule:
Dubai - Rhodes
MSN:
374
YOM:
1985
Country:
Region:
Crew on board:
19
Crew fatalities:
Pax on board:
252
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Dubai, the crew completed the approach to Rhodes-Diagoras Airport in rain falls and strong winds. The aircraft landed at a speed of 166 knots, about 22 knots above Vref. After touchdown, the ground spoilers did not deploy automatically because they had not been armed. Consequently the auto brake system, which operates by the deployment of spoilers, did not activate. The crew attempted manual braking but this operation was too late and the aircraft was unable to stop within the remaining distance. It overran, lost its undercarriage and came to rest few dozen metres further. All 271 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-6 Twin Otter in Davis Inlet: 1 killed

Date & Time: Mar 19, 1999 at 0945 LT
Operator:
Registration:
C-FWLQ
Flight Type:
Survivors:
Yes
Schedule:
Goose Bay - Davis Inlet
MSN:
724
YOM:
1980
Flight number:
PB960
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1600
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
70
Aircraft flight hours:
30490
Circumstances:
The flight was a pilot self-dispatched, non-scheduled cargo flight from Goose Bay to Davis Inlet, Newfoundland, and was operating as Speed Air 960 under a defence visual flight rules flight plan. Before the flight, the captain received weather information from the St. John's, Newfoundland, flight service station (FSS) via telephone and fax. The aircraft departed for Davis Inlet at 0815 Atlantic standard time (AST). The captain was the pilot flying (PF). During the first approach, the first officer (FO) had occasional visual glimpses of the snow on the surface. The captain descended the aircraft to the minimum descent altitude (MDA) of 1340 feet above sea level (asl). When the crew did not acquire the required visual references at the missed approach point, they executed a missed approach. On the second approach, the captain flew outbound from the beacon at 3000 feet asl until turning on the inbound track. It was decided that if visual contact of the surface was made at any time during the approach procedure, they would continue below the MDA in anticipation of the required visual references. The captain initiated a constant descent at approximately 1500 feet per minute with 10 degrees flap selected. The FO occasionally caught glimpses of the surface. At MDA, in whiteout conditions, the captain continued the descent. In the final stages of the descent, the FO acquired visual ground contact; 16 seconds before impact, the captain also acquired visual ground contact. At 8 seconds before impact, the crew selected maximum propeller revolutions per minute. The aircraft struck the ice in controlled flight two nautical miles (nm) from the airport (see Appendix B). During both approaches, the aircraft encountered airframe icing. The crew selected wing de-ice, which functioned normally by removing the ice.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The captain decided to descend below the minimum descent altitude (MDA) without the required visual references.
2. After descending below MDA, both pilots were preoccupied with acquiring and maintaining visual contact with the ground and did not adequately monitor the flight instruments; thus, the aircraft flew into the ice.
Findings as to Risk:
1. The flight crew did not follow company standard operating procedures.
2. Portions of the flight were conducted in areas where the minimum visual meteorological conditions required for visual flight rules flight were not present.
3. Although both pilots recently attended crew resource management (CRM) training, important CRM concepts were not applied during the flight.
4. The cargo was not adequately secured before departure, which increased the risk of injury to the crew.
5. The company manager and the pilot-in-command did not ensure that safe aircraft loading procedures were followed for the occurrence flight.
6. There were lapses in the company's management of the Goose Bay operation; these lapses were not detected by Transport Canada's safety oversight activities.
7. The aircraft was not equipped with a ground proximity warning system, nor was one required by regulation.
8. Records establish that the aircraft departed approximately 500 pounds overweight.
Other Findings:
1. The flight crew were certified, trained, and qualified to operate the flight in accordance with existing regulations and had recently attended CRM training.
2. During both instrument approaches, the aircraft was operating in instrument meteorological conditions and icing conditions.
3. There was no airframe failure or system malfunction prior to or during the flight. In particular, the airframe de-icing system was serviceable and in operation during both approaches.
4. It was determined that an ice-contaminated tailplane stall did not occur.
5. The fuel weight was not properly recorded in the journey logbook.
6. The wreckage pattern was consistent with a controlled, shallow descent.
7. The emergency locator transmitter was damaged due to impact forces during the accident, rendering it inoperable.
Final Report:

Ground fire of an ATR42-320 in Mucuri

Date & Time: Mar 16, 1999 at 1818 LT
Type of aircraft:
Operator:
Registration:
PT-MFI
Survivors:
Yes
Schedule:
São Paulo – Mucuri
MSN:
302
YOM:
1992
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10500
Captain / Total hours on type:
3550.00
Copilot / Total flying hours:
6500
Copilot / Total hours on type:
799
Circumstances:
On approach to Mucuri-Itabatã Airport runway 05, the right engine caught fire. The crew followed the checklist, continued the approach and completed a safe landing. After touchdown, the aircraft slightly deviated to the right and came to rest, bursting into flames. All 14 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
It is believed that the engine fire was the consequence of the failure of a fuel burner.
Final Report:

Crash of a Cessna 340A in Chesapeake: 2 killed

Date & Time: Mar 16, 1999 at 0950 LT
Type of aircraft:
Registration:
N13DT
Flight Type:
Survivors:
No
Schedule:
Chesapeake – Bunnell
MSN:
340A-0063
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4500
Captain / Total hours on type:
10.00
Aircraft flight hours:
3575
Circumstances:
After takeoff, the airplane returned to the departure airport for an emergency landing. The aircraft was observed in the vicinity of the runway threshold, about 500 feet above the ground, with it's left propeller feathered, when it entered a left bank which increased to about 90 degrees. The airplane then entered a spin, descended, and impacted the ground. Examination of wreckage revealed the camshaft of the left engine had failed as a result of a fatigue crack. No other abnormalities were observed of airframe or engine. The left engine had accumulated about 1,200 hours since overhaul. The pilot purchased the airplane about 1 month prior to the accident. At that time, he reported 700 hours of flight experience in multi-engine airplanes, of which, 10 hours were in the make and model of the accident airplane.
Probable cause:
The pilot's failure to maintain control of the airplane during a single engine emergency landing, after experiencing a failure of the left engine. A factor in this accident was the failure of the left engine's camshaft due to a fatigue crack.
Final Report:

Crash of a McDonnell Douglas MD-83 in Pohang

Date & Time: Mar 15, 1999 at 1155 LT
Type of aircraft:
Operator:
Registration:
HL7570
Survivors:
Yes
Schedule:
Seoul - Pohang
MSN:
53485
YOM:
1996
Flight number:
KE1533
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
150
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Pohang Airport, the crew encountered poor weather conditions with rain falls and strong winds. The captain decided to initiate a go-around procedure and started a second approach few minutes later. On approach to runway 10, the wind component changed and the crew continued the descent with a 20 knots tailwind. At an excessive speed of 158 knots, the aircraft landed 1,500 feet past the runway threshold. On a wet runway surface, the aircraft was unable to stop within the remaining distance (runway 10 is 7,000 feet long), overran, struck a 3 metres high embankment and came to rest in a ravine, broken in two. All 156 occupants were rescued, among them 60 passengers were injured, two seriously.
Probable cause:
The following findings were identified:
- Poor crew action during an approach in poor weather conditions,
- Excessive tailwind component,
- Misuse of brake and thrust reverser systems during the landing roll, about 27 seconds after touchdown only,
- The crew failed to initiate a go-around procedure as the landing was obviously missed,
- Poor ground assistance.

Crash of an Antonov AN-32 in New Delhi: 21 killed

Date & Time: Mar 7, 1999 at 0822 LT
Type of aircraft:
Operator:
Registration:
K2673
Flight Type:
Survivors:
No
Site:
Schedule:
Gwalior – New Delhi – Pokhran
MSN:
108
YOM:
1984
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
21
Circumstances:
While descending to New Delhi-Indira Gandhi Airport runway 10, the crew encountered poor visibility due to thick fog and requested ATC assistance. On short final, the crew failed to realize his altitude was insufficient when the aircraft struck successively a concrete water tank and power cables then crashed in the Pappankalan district, about 2,4 km short of runway. The aircraft and a building were destroyed. All 18 occupants were killed as well as three people on the ground.
Probable cause:
The crew was completing the final approach below the minimum safe altitude in reduced visibility due to thick fog.