Crash of a De Havilland DHC-6 Twin Otter 300 in Goroka: 2 killed

Date & Time: Jul 18, 1997 at 1032 LT
Registration:
P2-MMU
Survivors:
Yes
Site:
Schedule:
Port Moresby - Mount Hagen - Chimbu - Goroka
MSN:
250
YOM:
1969
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
En route from Chimbu to Goroka, the crew encountered poor weather conditions with rain falls and fog. Other crew diverted to Madang Airport but the crew decided to continue. While flying at an altitude of 7,400 feet in limited visibility, the aircraft struck the slope of Mt Yasirua located 7,2 km northeast of Goroka Airport. A pilot and a passenger survived while both other occupants were killed.
Probable cause:
Controlled flight into terrain.

Crash of a Fokker F27 Friendship in Bandung: 28 killed

Date & Time: Jul 17, 1997 at 1155 LT
Type of aircraft:
Operator:
Registration:
PK-YPM
Survivors:
Yes
Site:
Schedule:
Bandung - Jakarta
MSN:
10415
YOM:
1969
Flight number:
TGN304
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
45
Pax fatalities:
Other fatalities:
Total fatalities:
28
Circumstances:
The aircraft departed Bandung-Husein Sastranegara Airport on a regular schedule flight to Jakarta, carrying 45 passengers and 5 crew members. Shortly after takeoff, the captain informed ATC that the left engine lost power and elected to diver to the Bandung-Sulaiman AFB for an emergency landing. On final approach to runway 13, the crew was unable to maintain a safe altitude when the aircraft struck roofs and crashed. Twenty occupants were rescued while 28 others were killed, including all five crew members. All occupants were Indonesian citizens except for one passenger from Singapore.
Probable cause:
Failure of the left engine for unknown reasons.

Crash of a Learjet 35A in Avon Park

Date & Time: Jul 15, 1997 at 1953 LT
Type of aircraft:
Registration:
N19LH
Flight Type:
Survivors:
Yes
Schedule:
Fort Lauderdale - Avon Park
MSN:
35-279
YOM:
1980
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
20076
Captain / Total hours on type:
1500.00
Aircraft flight hours:
13726
Circumstances:
Witnesses near the airport saw the flight approach on a left base to runway 4, touchdown on the runway, and takeoff again. One witness, a pilot, said the airplane turned onto final to the 'south' (right) of the runway centerline.' The airplane made a 'sharp' turn to the left to realign with the runway center, slightly overshot the runway to the left, turned to the right 'sharply,' and touched down on the runway. The witness further stated, '...by the time the pilot was on the runway he had wasted approximately 1,200 to 1,500 feet of runway 4, they hit reverse thrusters [sic] and were on full bore till they crossed runway 27 and 9.' The witness saw heat come out of both engine thrust reversers, the nose gear touched down and then came up again. He then saw the airplane come off the ground about 30 to 40 feet, wobble left and right at a 'slow airspeed,' crossover a highway at a low altitude, right wing low, strike some wires, go into a field, and catch fire. The pilot said, when he touched down on the runway, the airplane seemed to 'lurch' to the side. He said at this point his airspeed was 126 knots. He elected to abort the landing, and applied full power. He said the engines would not develop thrust and he elected to land in a field less than 1/4 mile in front of him. Examination of the left thrust reverser revealed that the translator was in the deployed position, with the blocker doors fully open. Both the left and right pneumatic latches were found in the unlocked position. Examination of the right thrust reverser revealed that the translator was in the deployed position, with the blocker doors fully closed. The left pneumatic latch was found in the locked position. The right pneumatic latch was found in the unlocked position. The inboard sequence latches were found about 2 inches forward of full aft travel. The thrust reverser switch was found in the 'NORMAL' position. According to Gates Lear Jet Airworthiness Directive (AD) 79-08-01, '...to preclude inadvertent thrust reverser deployment and possible loss of aircraft control....,' the following limitations apply to all gates Lear Jet Model 35, 36, 35A, 36A, aircraft equipped with Aeronca Thrust reversers. According to the AD, Section I-LIMITATION; '....Thrust Reversers must not be operated prior to takeoff...Thrust Reversers must not be used for touch and go landings...After Thrust Reversers have been deployed, a visual check of proper door stowing must be made prior to takeoff...Operational Procedures in this Thrust Reverser Supplement are mandatory.' According to Lear Jet and FlightSafety International, the procedures that are taught to Lear Jet pilots in the use of thrust reverse and spoilers during landings are; '...pilots [are] to use thrust reverse only on full stop Lear Jet landings. Pilot are trained not to deploy spoilers or thrust reverse during touch and go's or during balked landings.' The pilot-in-command of N19LH at the time of the accident, told the NTSB investigator-in-charge (IIC) that he was 'aware' of the limitations on the Aeronca Thrust Reverser and he knew that once the Thrust Reverser was deployed that he was 'committed' to land. The pilot told the IIC that he knew of the limitations and that he was committed to land.
Probable cause:
A loss of engine power as a result of the thrust reversers being deployed and subsequent inflight collision was wires. Factors in this accident were the pilot's disregard for procedures, and the improper use of the thrust reversers.
Final Report:

Crash of a Cessna 402C in Great Harbour Cay

Date & Time: Jul 10, 1997 at 1700 LT
Type of aircraft:
Registration:
N2717Y
Survivors:
Yes
Schedule:
Nassau - Great Harbour Cay
MSN:
402C-0226
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft ran off the runway and collided with a ditch at Great Harbour Airport, Great Harbour Cay, Bahamas, while on a foreign air taxi flight. Visual meteorological conditions prevailed at the time and no flight plan was filed. The aircraft was destroyed. The commercial-rated pilot and seven passengers received minor injuries. One passenger received serious injuries. The flight originated from Nassau, Bahamas, the same day, about 1630. The pilot reported the brakes failed during the landing roll. While approaching the end of the runway he elected to steer the aircraft off the left side of the runway to avoid a steep drop off at the end of the runway. The aircraft collided with a ditch and a post crash fire erupted and destroyed the aircraft.

Crash of a Casa 212 Aviocar 20 in Ambon: 3 killed

Date & Time: Jul 9, 1997 at 1157 LT
Type of aircraft:
Operator:
Registration:
PK-NCS
Flight Type:
Survivors:
No
Schedule:
Langgur - Ambon
MSN:
201/41N
YOM:
1981
Flight number:
MZ7979
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The departure from Langgur was delayed for few hours due to technical problems with the right engine, so it was decided to ferry the airplane to Ambon for repairs. On final approach to Ambon-Pattimura Airport in light rain and mist, the aircraft stalled and crashed 270 metres short of runway. The aircraft was destroyed and all three crew members were killed.
Probable cause:
Failure of the right engine on final approach for unknown reasons.

Crash of a Rockwell Shrike Commander 500U in Córdoba

Date & Time: Jul 8, 1997
Operator:
Registration:
LV-IYO
Flight Type:
Survivors:
Yes
Schedule:
La Rioja - Buenos Aires
MSN:
500-1673-19
YOM:
1967
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While on a cargo flight from La Rioja to Buenos Aires, the pilot encountered engine problems and decided to divert to Córdoba-Ambrosio Taravella Airport. On final approach, both engines failed and the pilot attempted an emergency landing when the aircraft crash landed in a field located 1,200 metres short of runway. It slid for few dozen metres before coming to rest in a grassy area. All four occupants escaped with minor injuries and the aircraft was damaged beyond repair.
Probable cause:
It was determined that both engines failed due to the malfunction of the fuel supply system due to poor maintenance.

Crash of a Dassault Falcon 10 in White Plains

Date & Time: Jun 30, 1997
Type of aircraft:
Registration:
N10YJ
Survivors:
Yes
MSN:
57
YOM:
1975
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
6784
Circumstances:
On approach to White Plains-Westchester County Airport, the crew noted a left main gear unsafe light. The gear was recycled and the crew agreed with ATC to perform a low pass to check the gear. Few minutes later, upon landing, the left main gear collapsed. All four occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
No investigations were conducted on this event.

Crash of a Cessna 207A Skywagon in Nome: 2 killed

Date & Time: Jun 27, 1997 at 1633 LT
Operator:
Registration:
N207SP
Survivors:
No
Schedule:
Brevig Mission - Nome
MSN:
207-0412
YOM:
1977
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1745
Captain / Total hours on type:
200.00
Aircraft flight hours:
12771
Circumstances:
The flight was landing under special VFR conditions. Special VFR operations are permitted with a visibility of 1 mile, and clear of clouds. The airport was the pilot's base of operations. The flight had held outside the airport surface area for 26 minutes, waiting for a special VFR clearance. While outside the airport surface area, the pilot was required to maintain 500 feet above the ground and 2 miles visibility. While holding, the weather at the airport was reported as 300 feet overcast. The visibility decreased from 4 miles to 1 mile in mist. The pilot was new to the area of operations, having worked at the company for 24 days, during which he accrued 69 hours of flight time. Four minutes after receiving clearance to enter the surface area for landing, the airplane collided with a 260 feet tall radio antenna tower at 222 feet above the ground. The tower was located 3.85 nautical miles east of the airport. The radio tower was not considered by the FAA to be an object affecting navigable airspace, but was depicted as an obstruction on the VFR sectional chart for the area. The tower was equipped with obstruction lighting for night illumination, and was painted alternating aviation orange and white for daytime marking. One minute after the collision, the overcast was reported at 200 feet, and the visibility was 5/8 mile.
Probable cause:
The pilot's continued VFR flight into instrument meteorological conditions, and his failure to maintain adequate clearance from an obstruction (antenna tower). Factors in the accident were low ceilings and visibility, and the pilot's lack of familiarity with the geographic area.
Final Report:

Crash of a Swearingen SA226TC Metro II in Ottawa

Date & Time: Jun 13, 1997 at 1248 LT
Type of aircraft:
Registration:
C-FEPW
Flight Type:
Survivors:
Yes
Schedule:
Hamilton - Ottawa
MSN:
TC-294
YOM:
1979
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2240
Captain / Total hours on type:
1930.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
55
Circumstances:
The flight crew were properly licensed and certified to conduct the flight. The pilot had a total flying time of approximately 2,240 hours, of which 1,930 were on the occurrence aircraft type. The co-pilot received his commercial pilots license in 1988 and had approximately 500 hours total flying time. He completed his instrument rating on 15 December 1996 and his initial training on the SA226-TC was completed in March 1997 in British Columbia with a different company. He had not flown for 44 days at the time his recurrent training was completed on 09 June 1997. This was the co-pilot=s third day of operational flying for the company; he had accumulated approximately 55 hours total time on the aircraft type. The co-pilot was flying the aircraft for a radar-vectored, localizer/back-course approach to runway 25 of the Ottawa/Macdonald-Cartier airport. Descending out of 10,000 feet above sea level, the crew completed a briefing for the approach. The weather conditions at the time did not necessitate a full instrument approach briefing because the crew expected to fly the approach in visual conditions. Air traffic control requested that the crew fly the aircraft at a speed of 180 knots or better to the Ottawa non-directional beacon (NDB), which is also the final approach fix (FAF) for the approach to runway 25. At approximately eight nautical miles from the airport the aircraft was clear of cloud and the crew could see the runway. In order to conduct some instrument approach practice, the pilot, who was also the company training pilot, placed a map against the co-pilot=s windscreen to temporarily restrict his forward view outside the aircraft. The approach briefing was not amended to reflect the simulated instrument conditions for the approach. The co-pilot accurately flew the aircraft on the localizer to the FAF, at which point, he began to slow the aircraft to approximately 140 knots and requested that the pilot set 2 flap, which he did. Once past the FAF, the copilot=s workload increased, and he had difficulty flying the simulated approach. On short final to runway 25, the pilot removed the map from the co-pilot=s windscreen. The co-pilot noted that the aircraft was faster and higher than normal and he tried to regain the proper approach profile. By the time the aircraft reached the threshold of the runway 25, it was approximately 500 feet above ground, and at a relatively high speed, so the pilot took control of the aircraft for the landing. The pilot attempted to descend and slow the aircraft as it proceeded down the length of the runway and stated that he had just initiated an overshoot when he heard the first sounds of impact. Runway 25 is 8,000 feet long. The first signs of impact on the runway were made by the propellers, with propeller marks beginning about 4,590 feet from the threshold of runway 25. The aircraft came to rest about 6,770 feet from the threshold, and a fire broke out in the area of the right engine. The co-pilot opened the main door of the aircraft while the pilot shut down the aircraft systems, and both exited the aircraft uninjured. The maximum speed for extending the landing gear on this aircraft is 176 knots, and the company standard operating procedures (SOPs) for a normal instrument approach stipulate that the aircraft should cross the final approach fix at a speed of 140 knots, with a 2-flap setting, and with the landing gear lowered. The company SOPs require that all checklist items, from the after start checks through to the after landing checks inclusive, be actioned through a challenge and response method with each item called individually. The first item of the before landing checks is a landing gear .....Down/3 greens@. The co-pilot did not recall being challenged for the landing gear check, and the pilot could not remember selecting the landing gear switch to the down position. Neither pilot checked for the three green lights prior to the occurrence. The pilot stated that it was his habit to check if the landing lights were on prior to landing because it was his habit to turn them on only after the landing gear had been extended. He remembered checking to see that the landing lights were on and so was satisfied that the gear was down. The co-pilot assumed that, because the aircraft had passed the NDB, the before landing checks had been completed; they are normally completed before or at that point during an approach. Neither pilot recalled hearing a gear warning horn prior to the impact. When the aircraft systems were inspected, the landing gear selector was found in the up position. Tests were conducted on the landing gear warning system which revealed that the gear warning horn did not function. A closer examination of the system revealed a faulty diode. The diode was replaced and when the warning system was checked again, it functioned properly. The pilot stated that the gear warning horn on the aircraft had functioned properly during the training for the co-pilot one week earlier.
Probable cause:
The aircraft was landed with the landing gear retracted because the flight crew did not follow the standard operating procedures and extend the landing gear. Contributing to the occurrence were the lack of planning, coordination, and communication on the part of the crew; and the failure of the landing gear warning system.
Final Report:

Crash of a Harbin Yunsunji Y-12 II in Mandalgov: 7 killed

Date & Time: Jun 10, 1997
Type of aircraft:
Operator:
Registration:
JU-1020
Survivors:
Yes
Schedule:
Ulan Bator - Mandalgov - Dalanzadgad
MSN:
0067
YOM:
1991
Flight number:
OM447
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
On final approach to Mandalgov Airport, at a height of 30 metres, the aircraft nosed down and crashed short of runway threshold. Seven passengers were killed while five other occupants were injured.
Probable cause:
Loss of control on final approach after the aircraft encountered windshear.