Crash of a Cessna 208B Super Cargomaster in Victoria: 2 killed

Date & Time: Nov 23, 1998 at 0030 LT
Type of aircraft:
Operator:
Registration:
N9352B
Flight Type:
Survivors:
No
Schedule:
Vancouver - Victoria
MSN:
208-0061
YOM:
1987
Flight number:
RXX434
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1653
Captain / Total hours on type:
400.00
Copilot / Total flying hours:
120
Aircraft flight hours:
6717
Circumstances:
Regency Express Air Operations Flight 434, a Cessna 208 Caravan (serial number 208B0061), was en route from Vancouver International Airport to Victoria International Airport, British Columbia, on a night visual flight rules (VFR) flight when it collided with trees on Saltspring Island, about five nautical miles (nm) north of the Victoria International Airport. The aircraft broke apart on impact and a post-crash fire occurred. The two pilots, who were the sole occupants of the aircraft, sustained fatal injuries, and the aircraft was destroyed. The accident occurred at 0030 Pacific standard time (PST).
Probable cause:
Findings as to Causes and Contributing Factors:
A. Although weather information was available by radio from the Vancouver FSS specialists or from the Victoria Terminal controllers, there is no indication that the pilots requested weather updates from either of these units.
B. The crew of RXX434 would have encountered the lower ceiling in the vicinity of Beaver Point. This lower layer of cloud would have restricted the crew's view of the ground lighting and reduced the ambient lighting available to navigate by visual means.
C. With the loss of ground references, it is unlikely that the crew would have been able to perceive the divergence of the aircraft's flight path away from its intended track by visual means.
D. The crew was unable to maintain separation between the aircraft and the terrain by visual means.
E. The published VFR arrival and departure routes for Victoria were not consistent with obstacle clearance requirements for commercial operators.
F. Regency Express Air Operations' crew manual suggested an en route altitude of 1,500 feet for this particular flight. That route and altitude combination is not consistent with published obstacle clearance requirements.
Other Findings:
1. At the time the crew completed their flight planning, the weather at the departure airport of Vancouver and the arrival airport of Victoria was suitable for a night VFR flight.
2. An amended terminal forecast for Victoria indicating the presence of a temporary ceiling at 2,000 feet asl was issued after the crew had completed their preflight planning activities.
3. The regulation requiring GPWS equipment does not apply to air taxi operations because the aircraft used in those operations do not meet weight or propulsion criteria.
Final Report:

Crash of a Pilatus PC-6/B2-H4 Turbo Porter in Namche Bazar: 1 killed

Date & Time: Nov 19, 1998 at 1538 LT
Operator:
Registration:
9N-ABK
Flight Type:
Survivors:
No
Site:
Schedule:
Kathmandu - Namche Bazar
MSN:
755
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
5762
Circumstances:
The pilot, sole on board, departed Kathmandu-Tribhuvan Airport on a positioning flight to Namche Bazar to pick up passengers. During the pre-flight briefing, he was informed about the good weather conditions along the route and at destination. But en route, these conditions deteriorated and upon arrival, clouds were present up to 3,600 metres. He made several circuits expecting weather improvement. Few minutes later, he saw a hole in the clouds and initiated a descent when the aircraft struck the slope of Mt Kongri Himal located 3 km north of the airfield. The aircraft was destroyed and the pilot was killed.
Probable cause:
Controlled flight into terrain.

Crash of a Cessna 207A Skywagon in Koror: 9 killed

Date & Time: Nov 17, 1998
Registration:
RP-C606
Survivors:
No
MSN:
207-0105
YOM:
1969
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
The single engine airplane was completing a charter flight with seven passengers and two pilots on board. While approaching Koror Airport, the crew encountered poor weather conditions with limited visibility due to heavy rain falls. The crew decided to abandon the approach and made a go-around procedure. Few minutes later, a second attempt to land was also abandoned, as well as a third and a fourth attempt. During the fifth approach, the aircraft crashed few km from the airport, killing all nine occupants. It was reported that the crew was trying to land under VFR mode in IMC conditions.

Crash of a Boeing 707-355C in Ostend

Date & Time: Nov 14, 1998 at 0544 LT
Type of aircraft:
Operator:
Registration:
5N-VRG
Flight Type:
Survivors:
Yes
Schedule:
Ostend - Lagos
MSN:
19664
YOM:
1968
Flight number:
VGO302
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
67790
Aircraft flight cycles:
15984
Circumstances:
The aircraft departed Ostend Airport at 0328LT on a cargo flight to Lagos, carrying five crew members and a load of 35 tons of electronics. About 20 minutes into the flight, while cruising at an altitude of 24,000 feet over the border between Brussels and Paris ARTCC, the crew informed ATC about severe turbulences. Few seconds later, he reported the loss of the engine n°3 that separated and elected to return to Ostend. After being cleared, the crew started a circuit and while descending to Ostend Airport, the hydraulic systems failed. The crew completed a holding pattern to burn fuel and was later cleared to land on runway 26. After touchdown, the aircraft was unable to stop within the remaining distance, overran, lost its undercarriage, slid for few dozen metres and eventually came to rest near the localizer antenna. All five crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Laboratory analyses revealed the presence of a fatigue crack on the inner mid spar fitting of the engine n°3. The crack has been present for a reasonable time. The Airworthiness Directive 93-11-02 asks the replacement of the fittings by improved model at least for July 97. The fittings of engine n°3 were from the old design. Due to the non application of AD 93-11-02, the aircraft was in a non-airworthy condition.

Crash of a Beechcraft RC-12K Huron near Giebelstadt AFB: 2 killed

Date & Time: Nov 6, 1998
Type of aircraft:
Operator:
Registration:
85-0151
Flight Type:
Survivors:
No
MSN:
FE-5
YOM:
1987
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The twin engine aircraft was approaching Giebelstadt AFB when it crashed in the Sommerhausen zoo located about 8 km northeast of the airfield. Both pilots were killed.

Crash of a Boeing 737-2P6 in Atlanta

Date & Time: Nov 1, 1998 at 1848 LT
Type of aircraft:
Operator:
Registration:
EI-CJW
Survivors:
Yes
Schedule:
Atlanta - Dallas
MSN:
21355
YOM:
1977
Flight number:
FL867
Crew on board:
5
Crew fatalities:
Pax on board:
100
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15000
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
4976
Copilot / Total hours on type:
167
Aircraft flight hours:
45856
Aircraft flight cycles:
49360
Circumstances:
The first officer of AirTran Airways flight 890, which preceded AirTran flight 867 in the accident airplane, identified and reported a leak from the right engine of the Boeing 737-200 during a postflight inspection at William B. Hartsfield Atlanta International Airport (ATL), Georgia. AirTran mechanics at ATL identified the source of the leak as a chafed hydraulic pressure line to the right thrust reverser. They found the part in the illustrated parts catalog (IPC), which was not designed as a troubleshooting document and does not contain sufficient detail for such use. One of the mechanics telephoned an AirTran maintenance controller in Orlando, Florida, for further instructions. The mechanics who initially identified the source of the leak had little experience working on the Boeing 737 because they had worked for ValuJet Airlines, which flew DC-9s only, until ValuJet and AirTran merged in September 1997. On the basis of the information provided by the mechanic, and without questioning his description of the line or verifying the part number that he had provided against the IPC or some other appropriate maintenance document, the maintenance controller instructed the mechanic to cap the leaking line and deactivate the right thrust reverser in accordance with AirTran's Minimum Equipment List procedures. However, instead of capping the hydraulic pressure line, the mechanics capped the right engine hydraulic pump case drain return line. The mechanics performed a leak check by starting the auxiliary power unit and turning on the electric hydraulic pumps to pressurize the airplane's hydraulic systems; no leaks were detected. Although the mechanics were not required by company procedures to test their repair by running the engines, this test would have alerted the mechanics that they had incorrectly capped the hydraulic pump case drain line, which would have overpressurized the hydraulic pump and caused the hydraulic pump case seal to rupture. However, because the mechanics did not perform this test, the overpressure and rupture occurred during the airplane's climb out, allowing depletion of system A hydraulic fluid. Depletion of system A hydraulic fluid activated the hydraulic low-pressure lights in the cockpit, which alerted the flight crew that the airplane had a hydraulic problem. The crew notified air traffic control that the airplane would be returning to ATL and subsequently declared an emergency. The flight crew's initial approach to the airport was high and fast because of the workload associated with performing AirTran's procedures for the loss of hydraulic system A and the limited amount of time available to perform the procedures. Nevertheless, the crew was able to configure and stabilize the airplane for landing. However, depletion of system A hydraulic fluid disabled the nosewheel steering, inboard flight spoilers, ground spoilers, and left and right inboard brakes. The flight crew was able to land the airplane using the left thrust reverser (the right thrust reverser was fully functional but intentionally deactivated by the mechanics), outboard brakes (powered by hydraulic system B), and rudder. The flight crew used the left thrust reverser and rudder in an attempt to control the direction of the airplane down the runway, but use of the rudder pedals in this manner had depleted the system A accumulator pressure, which would have allowed three emergency brake applications. The use of the right outboard brake without the right inboard brake at a higher-than-normal speed (Vref for 15-degree flaps is faster than Vref for normal landing flaps) and with heavy gross weight (the airplane had consumed only 4,650 pounds of the 28,500 pounds of fuel on board at takeoff) used up the remaining friction material on the right outboard brake, causing it to fail. (The left outboard brake was still functional at this point.) The lack of brake friction material on the right outboard brake caused one of the right outboard brake pistons to overtravel and unport its o-ring, allowing system B hydraulic fluid to leak out; as a result, the left outboard brake also failed. Loss of the left and right inboard and outboard brakes, loss of nosewheel steering, and use of asymmetric thrust reverse caused the flight crew to lose control of the airplane, which departed the left side of the runway and came to rest in a ditch.
Probable cause:
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
(1) the capping of the incorrect hydraulic line by mechanics, which led to the failure of hydraulic system A;
(2) the mechanics' lack of experience working with the Boeing 737 hydraulic system; and
(3) the maintenance controller's failure to ascertain more information regarding the leaking hydraulic line before instructing the mechanics to cap the line and deactivate the right thrust reverser.
Contributing to the cause of the accident were:
(1) the asymmetric directional control resulting from the deactivation of the right thrust reverser;
(2) the depletion of the left and right inboard brake accumulator pressure because of the flight crew's use of the rudder pedals with only the left thrust reverser to control the direction of the airplane down the runway;
(3) the failure of the right outboard brake because the airplane was slowed without the use of the left and right inboard brakes and was traveling at a higher-than-normal speed and with heavy gross weight;
(4) the failure of the right outboard brake after one of the right outboard pistons overtraveled and unported its o-ring, allowing system B hydraulic fluid to deplete and the left outboard brake to fail; and
(5) the mechanics' improper use of the illustrated parts catalog for maintenance and troubleshooting and the maintenance controller's failure to use the appropriate documents for maintenance and troubleshooting.
Final Report:

Crash of a Douglas C-47A-90-DL in Quetzaltenango: 11 killed

Date & Time: Nov 1, 1998 at 1430 LT
Operator:
Registration:
N3FY
Flight Type:
Survivors:
Yes
Schedule:
Playa Grande - Quetzaltenango
MSN:
20562
YOM:
1944
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The aircraft was completing a humanitarian flight from Playa Grande to Quetzaltenango on behalf of the Living Water Teaching Ministries owned by Jim and Marion Zirkle. On board were 16 passengers and two pilots, among them doctors and a load of medicines and first aid kits for the victims of hurricane Mitch. The approach was completed in poor weather conditions with heavy rain falls and thick fog when the aircraft struck the ground few km from the airport. Seven people were rescued while 11 others were killed, among them Jim Zirkle and his son.
Probable cause:
The crew was approaching the airport under VFR mode in IMC conditions.

Crash of a Piper PA-31T Cheyenne II in São Francisco do Sul: 3 killed

Date & Time: Oct 30, 1998 at 2036 LT
Type of aircraft:
Operator:
Registration:
PT-WHI
Survivors:
No
Schedule:
Rio de Janeiro – Joinville
MSN:
31-7920077
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2420
Captain / Total hours on type:
603.00
Circumstances:
Following an uneventful flight from Rio de Janeiro-Santos Dumont Airport, the pilot started the descent to Joinville Airport by night and marginal weather conditions. He was informed about the visibility at destination being 2 km with ceiling at 650 feet. At 2032LT, he initiated the approach and reported to ATC that if it was raining, he would divert to Curitiba. Four minutes later, on final approach, the twin engine aircraft struck trees and crashed about 15 km southeast of runway 33 threshold. The aircraft was destroyed by impact forces and a post crash fire and all three occupants were killed.
Probable cause:
The following findings were identified:
- There was the participation of psychological variables at individual level, related to the profile of the pilot, such as excessive self-confidence in assuming that he always reached his destination, the knowledge of the region and probably the self-induced pressures by the situation in the cabin, combined with the prevailing meteorological condition, as well as the fact that he made a mistake with the procedure he was performing, demonstrating the adoption of an inadequate decision, excessive motivation for landing and lack of attention to the correct procedure.
- It was not possible to perform an effective analysis on the parts and instruments of the aircraft, in view of their degree of destruction, thus the contribution of this factor to the accident could not be determined.
- Weather conditions at destination were fickle and deteriorated during the execution of the descent procedure of the aircraft, contributing to the accident.
- The pilot failed to comply with the planned descent profile in use.
- Despite being aware of the meteorological conditions at destination, the pilot did not adequately plan the accomplishment of the procedure of descent by instruments, coming to throw out of the established profile, suggesting that he did not undertake the briefing of descent.
- The performance of the procedure outside the foreseen profile and in instrument flight conditions, determine the participation of this aspect in the occurrence.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Hayden: 1 killed

Date & Time: Oct 28, 1998 at 0858 LT
Operator:
Registration:
N35533
Flight Type:
Survivors:
No
Schedule:
Colorado Springs - Hayden
MSN:
31-8052047
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1800
Captain / Total hours on type:
375.00
Aircraft flight hours:
12411
Circumstances:
The Part 135 cargo flight was approaching its destination on an IFR flight plan. The pilot had requested the ILS-DME approach to runway 10, but 2 minutes later, he changed his request to the VOR-B approach to runway 28. ARTCC cleared him for the approach to the non-towered airport. The pilot contacted the airport's Unicom, and requested that the ramp personnel be standing by with fuel and oxygen. The airplane was found 5.8 nm from the approach end of runway 28, at 7,900 feet. The approach minimums for the VOR-B was 7,900 feet, which the pilot could descend to at 8.7 nm. The VOR was located 285 degrees at 13.6 nm from the accident site, and the ILS-DME transmitter was located 285 degrees at 5.6 nm from the accident site. The airplane was equipped with a single DME display head, and it had a Nav 1/Nav 2 selector switch.
Probable cause:
The pilot not following instrument procedures and subsequently descended to minimums prematurely. Factors were the mountainous terrain and the falling snow.
Final Report:

Crash of a Learjet 45 in Wallops Flight Facility

Date & Time: Oct 27, 1998 at 1456 LT
Type of aircraft:
Operator:
Registration:
N454LJ
Flight Type:
Survivors:
Yes
Schedule:
Wallops Flight Facility - Wallops Flight Facility
MSN:
45-004
YOM:
1998
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13073
Captain / Total hours on type:
767.00
Aircraft flight hours:
339
Circumstances:
The Learjet was participating in water ingestion tests, which required multiple landing rolls through a diked pool on the runway. On one of the landing rolls, the airplane's left main landing gear and nose landing gear tracked through the pool, while the right main landing gear tracked outside the pool. The airplane veered to the left, departed the left side of the runway, and struck a pickup truck parked adjacent to the runway. The airplane came to rest inverted and on fire. Formal hazard identification and risk management procedures were not employed and no alignment cues were in place on the runway to facilitate pool entry alignment. Further, the accident truck, other vehicles, heavy equipment, and personnel were placed hundreds of feet inside the FAA recommended runway-safe and object-free areas during the test.
Probable cause:
The failure of the pilot to obtain/maintain alignment with the water pool, which resulted in the loss of control. Factors in the accident were the inadequate preflight planning of the flight test facility and the airplane manufacturer which resulted in hazards in the test area and the subsequent collision of the airplane with a vehicle.
Final Report: