Crash of a Rockwell Grand Commander 680FL in Helena: 1 killed

Date & Time: Jun 16, 1998 at 1800 LT
Operator:
Registration:
N446JR
Flight Type:
Survivors:
No
Schedule:
Kalispell - Helena
MSN:
680-1325-10
YOM:
1963
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1506
Captain / Total hours on type:
344.00
Aircraft flight hours:
17972
Circumstances:
The pilot of the Part 135 cargo flight was executing the 'full' ILS runway 27 approach at Helena Regional Airport in a non-radar environment. Although the approach calls for the pilot to maintain 7,000 feet until intercepting the glideslope, the aircraft impacted the terrain at 5,300 about 1.5 miles prior to reaching the point where the pilot should have crossed the Hauser NDB at an altitude of 6,741 feet. According to the approach plate, the aircraft should not have descended to an altitude below 5,400 feet until reaching the outer marker, which is located about five and one-half miles west of the impact site.
Probable cause:
The pilot's failure to maintain the correct altitude while turning inbound during a procedure turn to the ILS final approach course. Factors include hilly/mountainous terrain and clouds in the area where the course reversal was performed.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off Jersey: 1 killed

Date & Time: Jun 12, 1998 at 1842 LT
Operator:
Registration:
CN-TFP
Flight Type:
Survivors:
No
Schedule:
Tangier - Saint Peter
MSN:
31-7552086
YOM:
1975
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
9100
Aircraft flight hours:
5253
Circumstances:
The pilot, sole on board, departed Tangier on a delivery flight to Saint Peter-La Villiaze, Guernsey Island, where the aircraft should be taken over by another crew to be ferried to Iceland. While approaching the Channel Islands, the pilot informed ATC about technical problems and elected to divert to Jersey Airport. Shortly later, after both engines stopped due to a fuel exhaustion, the plane lost height and crashed in the sea about 3 nm northwest of Jersey Island. The aircraft was destroyed and the pilot was killed.
Probable cause:
The following causal factors were identified:
- The commander had not made an appropriate allowance for adverse headwind components before or during the flight.
- The aircraft was not carrying sufficient fuel for the intended flight.
- The commander apparently ignored pre-flight and in-flight indications that he should land and refuel in France.
- The commander's chances of survival were adversely affected by not adopting the optimum configuration and heading for ditching.
Final Report:

Crash of a Beechcraft 65-80 Queen Air in North Myrtle Beach

Date & Time: Jun 5, 1998 at 1531 LT
Type of aircraft:
Registration:
N215AB
Flight Type:
Survivors:
Yes
Schedule:
Malone - North Myrtle Beach
MSN:
LD-58
YOM:
1963
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
535
Captain / Total hours on type:
48.00
Aircraft flight hours:
6758
Circumstances:
After a 4.7 hour flight, while turning onto final, the airplane landed short. The pilot did not mention engine problems during a police interview. He subsequently told an FAA Inspector that the left engine failed, then later, that the right engine failed. He told the Safety Board that both engines failed. Adequate fuel was confirmed. The previous day, the right engine failed approaching another airport. The pilot performed a single-engine go-around, with landing gear and flaps down. He refused assistance and performed his own maintenance. He cleaned the fuel filters of both engines. During a ground runup, the right engine was hard to start, and required a high fuel flow to remain running. After the pilot re-cleaned the right fuel filter the engine ran fine. The flight was uneventful until the accident. Post-flight examination revealed all propeller blades bent back 90 degrees, with significant chordwise scoring on one blade per engine. The left engine fuel filter was relatively clean, with some brown residue which contained ferrous material. The right engine fuel filter was heavily coated with a white residue which contained aluminum, and brown material which contained ferrous material. The pilot received his multi-engine rating on April 22, 1998.
Probable cause:
The pilot's failure to follow emergency procedures, and his failure to maintain control of the airplane after a loss of power from one engine. Factors include fuel filter blockage, inadequate maintenance, and the pilot's lack of experience in multi-engine airplanes.
Final Report:

Crash of a Swearingen SA227AC Metro III in Santa Fe

Date & Time: Jun 3, 1998 at 0722 LT
Type of aircraft:
Operator:
Registration:
LV-WIL
Flight Type:
Survivors:
Yes
Schedule:
Buenos Aires – Santa Fe – Posadas
MSN:
AC-537
YOM:
1983
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While descending to Santa Fe-Sauce Viejo Airport by night, the crew was informed about poor weather conditions at destination. The visibility was estimated to be 30 metres in foggy conditions, well below minimums. As the crew elected to attempt an approach, he as cleared for and ILS approach to runway 03. On short final, the aircraft descended below the MDA and struck the ground 430 metres short of runway threshold. On impact, it lost its undercarriage and slid for another 180 metres before coming to rest. Both pilots escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
It was determined that the crew descended below the established minima during an instrument approach until the aircraft impacted terrain. The following contributing factors were identified:
- Inadequate flight planning, since there was reduced visibility at Sauce Viejo Airport from 01:00 hrs,
- Inappropriate request from the captain who attempted to make an approach in below minima weather conditions,
- Erroneous decision of the captain, knowing the meteorological conditions, to continue the approach below the decision height.

Crash of a Convair CV-240-17 in Aguadilla

Date & Time: Jun 1, 1998
Type of aircraft:
Registration:
N87949
Flight Type:
Survivors:
Yes
Schedule:
Aguadilla - Aguadilla
MSN:
202
YOM:
1950
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a local training flight at Aguadilla-Rafael Hernández Airport. Following several touch-and-go manoeuvres, the crew was approaching the airport when he inadvertently raised the landing gear prior to landing. The aircraft belly landed and came to rest. All three crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Belly landing after the crew mistakenly raised the landing gear.

Crash of a Pilatus PC-12/45 in Brno: 2 killed

Date & Time: May 26, 1998 at 0615 LT
Type of aircraft:
Operator:
Registration:
HB-FOJ
Flight Type:
Survivors:
No
Schedule:
Brno - Altenburg
MSN:
158
YOM:
1996
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
651
Captain / Total hours on type:
397.00
Circumstances:
After takeoff from runway 28 at Brno-Tuřany Airport, the pilot reported on the tower frequency that she needs to land. She received instruction to continue a southern (left-hand) circuit and to report final for runway 28. At this time the first contact was made with the aeroplane by secondary radar at a height of about 520 feet AAL and 560 metres north from runway 28. The pilot did not confirm the instruction, did not turn for the southern (left-hand) circuit, but continued to turn for the northern (right-hand) one. Since she did not confirm repeated approval for the left-hand circuit and continued the right-hand one, she received information from tower that it is possible to continue the northern circuit, clearance to land to runway 28 ans was offered assistance after landing. Without any confirmation. At this time the height was approximately 930 feet AAL and position 2,8 km north from the aerodrome. The aeroplane started gradually to descend and to turn as the pilot probably intended to accomplish approach for runway 28. However it did not happen and the aeroplane hit the ground at 0615,28 approximately 600 metres north from the runway 28 threshold. The aeroplane was flying very low in the last phase of flight according to statements of witnesses. The last height recorded by the secondary radar was approximately 120 feet AAL 13 seconds prior to the impact onto ground. Witnesses described the attitude of the aeroplane prior to strike to ground as very unusual. Both occupants were killed.
Probable cause:
The following factors were identified:
- The critical situation was caused by flap asymmetry. It occurred as a result of shear in torsion of the left-hand inner flexible shaft.
- Loss of controllability caused by reduction of airspeed with use of Beta range in the final phase of the flight was the direct cause of the accident.
- Incorrect application of emergency procedures for flap retraction listed in the Pilot's Operating Handbook was the main cause of the accident.
Final Report:

Crash of a Douglas C-47A-90-DL in Point McKenzie

Date & Time: May 24, 1998 at 0024 LT
Registration:
N67588
Flight Type:
Survivors:
Yes
Schedule:
Unalakleet - Anchorage
MSN:
20536
YOM:
1944
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14000
Captain / Total hours on type:
7000.00
Aircraft flight hours:
34232
Circumstances:
The captain/operator, the first officer and one passenger, departed on a cross-country positioning flight. The airplane contained about 300 gallons of fuel. After 3.9 hours en route, the flight was cleared for a visual approach to the destination airport. During the approach, both engines lost power about 2,000 feet mean sea level. The pilot stated the right fuel tank was empty. He estimated that 50 to 60 gallons of fuel remained in the left fuel tank. While the airplane was descending toward an area of open water, he attempted to restart the engines without success. He then lowered the landing gear, and made a right turn toward a small airstrip, located about 5 miles northwest of the destination airport. The airplane touched down in an area of soft, marsh covered, terrain. During the landing roll, the airplane nosed down and received damage to the forward, lower portion of the fuselage. An inspection of the airplane by an FAA inspector revealed the left fuel tank contained about 1 inch of fuel. The right fuel selector was positioned on the right auxiliary fuel tank. The left fuel selector was positioned between the left main, and the left auxiliary fuel tanks.
Probable cause:
The pilot's inadequate in-flight planning/decision which resulted in fuel exhaustion and subsequent loss of engine power. A related factor was the soft, marshy terrain at the forced landing area.
Final Report:

Crash of a Learjet 24B in Orlando

Date & Time: May 23, 1998 at 0330 LT
Type of aircraft:
Registration:
N100DL
Flight Type:
Survivors:
Yes
Schedule:
Miami - Orlando
MSN:
24-201
YOM:
1969
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18395
Captain / Total hours on type:
318.00
Aircraft flight hours:
8138
Circumstances:
During landing roll, the airplanes normal braking system failed as a result of hydraulic fluid leak(s). At the pilot's request, deployment of the drag chute and application of the emergency braking system was performed by the first officer. According to the first officer, application of the emergency brakes caused the airplane to yaw. The first officer then pulled up on the emergency brakes handle followed by re-application of braking pressure. This action took place several times during the landing roll. Gates' Learjet Flight Training Manual (Page 105) states, 'In using the emergency brake lever, slow steady downward pressure is required. Each time the lever is allowed to return upward to the normal position, nitrogen is evacuated overboard. Brace your hand so you will not allow the lever to move up and down inadvertently on a bumpy runway.' The airplane overran the end of the runway and collided with the Instrument Landing System back course antennae.
Probable cause:
The first officer's failure to perform proper emergency braking procedures.
Final Report:

Crash of an Embraer EMB-820C Navajo in Guanambi: 3 killed

Date & Time: May 20, 1998 at 1442 LT
Operator:
Registration:
PT-ENP
Flight Type:
Survivors:
No
Schedule:
Salvador - Guanambi
MSN:
820-075
YOM:
1978
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
9850
Captain / Total hours on type:
4940.00
Copilot / Total flying hours:
867
Copilot / Total hours on type:
218
Circumstances:
The twin engine aircraft was completing a cargo flight from Salvador to Guanambi, carrying one passenger, two pilots and a load consisting of briefcases containing valuables. On final approach to Guanambi Airport, following a 1 hour and 42 minutes of flight, both engines lost power. The crew lost control of the airplane that crashed few hundred metres short of runway. All three occupants were killed.
Probable cause:
The following findings were identified:
- Failure of the left engine on final approach,
- Possible over-correction on part of the pilot-in-command, causing a loss of control after a full rudder compensation,
- The aircraft was in a flaps and landing gear down configuration and it is believed that the copilot failed to assist the pilot during an emergency situation,
- The distance between the aircraft and the ground was insufficient to expect recovery,
- The crew used the auxiliary fuel tanks during all flight without paying attention to the potential danger of such procedure,
- Lack of crew support and crew training on part of the operator,
- Lack of crew resources management.
Final Report:

Crash of a Piper PA-31T Cheyenne I in Great Falls: 2 killed

Date & Time: May 19, 1998 at 1536 LT
Type of aircraft:
Registration:
N121BE
Flight Type:
Survivors:
No
Schedule:
Great Falls - Great Falls
MSN:
31-8004036
YOM:
1980
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2347
Aircraft flight hours:
2226
Circumstances:
The flight was on a practice nondirectional beacon (NDB) approach to Great Falls runway 34 in visual conditions. Abeam the final approach fix, the aircraft was 4 miles right of course. Upon being advised of this by ATC, the pilot corrected back to final with a 60-degree intercept angle, rolling out on course 3 miles from the runway. When the pilot called missed approach, the local controller (a trainee) instructed the pilot to make a 360-degree right turn to enter right downwind for runway 3, and the pilot acknowledged. The controller trainee then amended this instruction to a 180-degree right turn to enter right downwind for runway 21, then to a 180- degree right turn to enter right downwind for runway 3. The crew did not acknowledge the amended instruction. Controllers then observed the airplane had crashed. Witnesses reported the airplane entered a steep descent from a right turn and impacted the ground at a steep angle. The flight was described as recurrent training required by the owner's insurance; however, the second aircraft occupant's airline transport pilot and flight instructor certificates had been revoked, and he held only a private pilot certificate. Investigators found no evidence of aircraft malfunctions.
Probable cause:
The flight crew's failure to maintain aircraft control.
Final Report: