Crash of a Britten-Norman BN-2A-21 Islander in Coolangatta

Date & Time: Apr 7, 1996 at 2138 LT
Type of aircraft:
Registration:
VH-HIA
Survivors:
Yes
Schedule:
Tangalooma – Coolangatta
MSN:
415
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
881
Captain / Total hours on type:
177.00
Circumstances:
The aircraft was the third in a stream of five company aircraft departing the Tangalooma Resort airstrip at two-minute intervals on a clear moonlit evening. Following a routine departure at 2105 EST, the aircraft was climbed to 3,000 ft for the flight back to Coolangatta. Early in the cruise phase of the flight, the pilot found that the fourth aircraft was catching up to his and he elected to descend to 2,000 ft to ensure continued separation. At 2127 EST, the pilot reported to Coolangatta Approach Control that the aircraft had severe problems, but did not inform the controller of the nature of his emergency. However, the controller activated the airport emergency procedures when he observed on his radar display that the aircraft was losing altitude. The pilot had his second VHF radio transceiver tuned to his company frequency, and was answering transmissions received from other company pilots on this frequency while transmitting on the Coolangatta Approach frequency. The pilot later said that after the aircraft passed the seaway at Southport, the right engine surged, which resulted in the aircraft yawing. After he switch the electric fuel pump to "on", the symptoms disappeared. About a minute later he switched the pump off, then on again. He said that when the engine began surging again, he shut the engine down, feathering the propeller. Left engine power was increased and the aircraft maintained 1,500 ft in level flight. He switched the left engine's fuel supply to the right main tank, believing that this action would ensure supply from both main fuel tanks. The pilot said that after the aircraft passed Burleigh Heads, many things appeared to go wrong at once. The left engine began to splutter and did not respond to the throttle. He recalled attempting to restart the right engine. This proved to be unsuccessful. As the descent continued he planned to land on a beach. The pilot selected a stretch of beach for a forced landing. During late final approach, aided by bright moonlight, he noticed that any overrun would take the aircraft into a crowded car park. He changed his aim point to the stretch of beach south of the Currumbin Lifesavers Clubhouse. Following the flare for landing, the right wing struck a low rocky outcrop and the aircraft crashed into the surf. The entire wing assembly separated from the fuselage, which came to rest on its left side. Some of the nine passengers, and the pilot, escaped from the semi-submerged fuselage while bystanders rescued others.
Probable cause:
The following findings were reported:
1. The pilot shut down an engine following surging but did not feather the propeller.
2. The aircraft was not flown at (or near) its best single-engine performance speed after the right engine was shut down.
Final Report:

Crash of a Mitsubishi MU-2B-20 Marquise in Batesville

Date & Time: Apr 7, 1996 at 1155 LT
Type of aircraft:
Registration:
N310MA
Flight Type:
Survivors:
Yes
Schedule:
Montgomery - Batesville
MSN:
167
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1400
Captain / Total hours on type:
89.00
Aircraft flight hours:
5400
Circumstances:
The pilot reported that loss of power occurred in both engines after he entered the traffic pattern for a full stop landing. The airplane collided with trees during an emergency landing in a cotton field near the airport. Subsequent review of the aircraft maintenance logs disclosed that Mitsubishi MU-2 Service Bulletin (SB) 130A had not been accomplished on this airplane. According to the manufacturer, an inadvertent failure or the improper installation of a filler cap after refueling may cause an air pressure differential between the center and outboard portions of the main integral fuel tank. Air leakage from the filler cap may result in failure of the fuel transfer system to move fuel from the outboard tank section to the center tank section. To eliminate this possible malfunction, the operator was to remove vent check valves from the bulkhead between the tanks in accordance with SB 130A. The operator's maintenance policies required that, company jet and turbo propeller aircraft be maintained under a maintenance program in accordance with FAR Parts 135.415, 135.417, 135.423, 135.443, and a corporate flight management approved aircraft inspection program (AAIP). The maintenance inspection program also included compliance with manufacturers' service bulletins and service letters.
Probable cause:
An anomaly in the fuel system that allowed a pressure differential to occur between the center and outer portions of the main integral fuel tank, which in turn resulted in fuel starvation of both engines. A factor relating to the accident was: failure of company maintenance personnel to remove fuel system vent check valves as recommended by Mitsubishi MU-2 Service Bulletin 130A.
Final Report:

Crash of a Dornier DO228-212 off Matsu Nangan

Date & Time: Apr 5, 1996 at 1625 LT
Type of aircraft:
Operator:
Registration:
B-12257
Survivors:
Yes
Schedule:
Taipei - Matsu Nangan
MSN:
8223
YOM:
1993
Flight number:
VY7613
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
On approach to Matsu Nangan Airport, the crew encountered poor weather conditions with reduced visibility due to fog. The descent was completed under VFR mode in IMC conditions. On final, the copilot who was the pilot-in-command continued the approach despite he did not establish any visual contact with the runway, and failed to monitor the instruments. Eventually, the crew attempted to make a go-around but this decision was taken too late. The aircraft struck the water surface and crashed in the sea about 1,600 metres offshore. Six passengers were killed while 11 other occupants were injured.
Probable cause:
Wrong approach configuration on part of the crew who continued the descent under VFR mode in IMC conditions, below the MDA until the aircraft struck the water surface. Poor supervision on part of the captain. Poor crew coordination and poor approach and landing planning.

Crash of an Ilyushin II-76TD near Petropavlovsk-Kamchatsky: 20 killed

Date & Time: Apr 5, 1996 at 1444 LT
Type of aircraft:
Operator:
Registration:
RA-76752
Flight Type:
Survivors:
No
Site:
Schedule:
Novosibirsk - Petropavlovsk-Kamchatsky
MSN:
00934 98967
YOM:
1989
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
20
Aircraft flight hours:
7172
Aircraft flight cycles:
2085
Circumstances:
The aircraft was completing a cargo flight from Novosibirsk to Petropavlovsk-Kamchatsky, carrying 11 passengers, nine crew members and a load of 57 tons of meat and detergent powder. Upon takeoff from Novosibirsk-Yeltsovka Airport, the total weight of the aircraft was 17 tons above MTOW. While descending to Petropavlovsk-Kamchatsky Airport in limited visibility due to low clouds, at an altitude of 900 metres, the aircraft disappeared from radar screens after it struck the slope of a mountain located about 40 km from runway 34R threshold. The aircraft disintegrated on impact and all 20 occupants were killed. The wreckage was found 300 metres below the summit.
Probable cause:
The accident was the consequence of a controlled flight into terrain. The following contributing factors were reported:
- Following a wrong setting of the navigation system, the crew failed to follow the approach procedures and was not on the correct track for the airport,
- ATC gave a premature clearance to the crew to descent while he was not aware of the exact position of the aircraft that was not yet on his radar,
- Lack of visibility due to low clouds,
- At the time of the accident, the aircraft was off course by 23 km.

Crash of a Swearingen SA226T Merlin III in Ushuaia

Date & Time: Apr 4, 1996 at 1350 LT
Operator:
Registration:
LV-WLW
Flight Type:
Survivors:
Yes
Schedule:
Río Grande – Ushuaia
MSN:
T-230
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Ushuaia Airport, following an uneventful cargo flight from Río Grande, the twin engine aircraft collided with a flock of birds. The windshield was broken and the left engine lost power. The crew was able to continue the approach and landing. After touchdown, the aircraft went out of control and collided with a snow wall. Both pilots escaped with minor injuries and the aircraft was damaged beyond repair.
Probable cause:
Bird strike on final approach.

Crash of a Boeing CT-34A in Dubrovnik: 35 killed

Date & Time: Apr 3, 1996 at 1457 LT
Type of aircraft:
Operator:
Registration:
73-1149
Flight Type:
Survivors:
No
Schedule:
Tuzla - Dubrovnik
MSN:
20696
YOM:
1973
Flight number:
IFO21
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
29
Pax fatalities:
Other fatalities:
Total fatalities:
35
Circumstances:
A United States Air Force Boeing T-43A (USAF designation for the Boeing 737-200) was destroyed after impacting a hillside during an NDB approach to Dubrovnik Airport, Croatia. All 35 on board were killed. The aircraft was engaged in a mission to fly United States Secretary of Commerce Ron Brown and a delegation of industry executives around the region for visits. The party was to be flown from Zagreb to Tuzla and Dubrovnik before returning to Zagreb. Operating with a call sign of IFO21, the accident aircraft departed Zagreb at 06:24 hours. The crew landed at Tuzla at 07:15 after an uneventful flight. The passengers deplaned, and the aircraft was then repositioned to Split because of insufficient ramp space at Tuzla to park the aircraft for the duration of the visit. At 12:47, the aircraft landed at Tuzla, where the passengers reboarded. The accident flight departed Tuzla for Dubrovnik at 13:55. After crossing Split at 14:34 the flight was cleared to descend from FL210 to FL140. Further descent clearance was given to FL100. After the aircraft reached FL100 at 14:45, south of Split VOR, Zagreb Center transferred control to Dubrovnik Approach/Tower. The controller cleared IFO21 direct to the Kolocep (KLP) NDB. After opposite-direction traffic had been cleared, IFO21 was cleared to descend to 5000 feet. At 14:52, the crew told Dubrovnik Approach/Tower that they were 16 NM from the airport. They were cleared to descend to 4,000 feet and told to report crossing the KLP beacon. At 14:53, the aircraft crossed KLP, which was the Final Approach Fix (FAF), at 4100 feet and began the approach without approach clearance from Dubrovnik Tower. At that point the aircraft was slightly high and fast and not completely configured for the approach, as it should have been. At 14:54, the copilot of IFO21 called Dubrovnik Approach/Tower and said, "We’re inside the locator, inbound." IFO21 was then cleared for the NDB approach to runway 12. The aircraft tracked a course of 110 degrees after crossing KLP, instead of tracking the published course of 119 degrees. The aircraft maintained this track from KLP to the point of impact. The accident aircraft descended to 2200 feet which was consistent with the published minimum descent altitude of 2,150 feet. At 14:57, the aircraft impacted a rocky mountainside approximately 1.7 NM to the left (northeast) of the extended runway centerline and 1.8 NM north of the approach end of runway 12 at Dubrovnik Airport.
Probable cause:
Controlled flight into terrain. The following findings were reported:
- The command failure to comply with directives that required a review of all instrument approach procedures, not approved by the Defense Dept,
- Preflight planning errors, combined with errors made during the flight made by the aircrew,
- Improper design of the Dubrovnik NDB.

Crash of a Douglas C-47B-20-DK in Villavicencio

Date & Time: Mar 30, 1996 at 0835 LT
Registration:
HK-2497
Survivors:
Yes
Schedule:
Villavicencio - La Macarena
MSN:
15634/27079
YOM:
1945
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
0
Copilot / Total flying hours:
2107
Copilot / Total hours on type:
353
Aircraft flight hours:
20486
Circumstances:
After takeoff from Villavicencio-La Vanguardia Airport, while climbing to an altitude of 1,900 feet, the captain reported severe vibrations with the left engine and was cleared to return. The crew shut down the left engine and started the approach to runway 22. But on final, he realized he could reach the airport so he completed a belly landing one km short of runway threshold. The aircraft came to rest in a field and was damaged beyond repair. All 20 occupants escaped uninjured.
Probable cause:
It was determined that the vibrations and the subsequent failure of the left engine was the consequence of a bad adjustment of the intake valves on cylinders n°8 and 9, which remained stuck in open position, causing high temperature and a loss of power.
Final Report:

Crash of a Vickers Viscount 808 in Belfast

Date & Time: Mar 24, 1996 at 2135 LT
Type of aircraft:
Operator:
Registration:
G-OPFE
Flight Type:
Survivors:
Yes
Schedule:
Belfast - Belfast
MSN:
291
YOM:
1958
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15601
Captain / Total hours on type:
3918.00
Circumstances:
The two crew members had reported at Stansted at 1130 hrs to catch a passenger flight to Belfast where they were rostered for a training detail; immediately prior to this duty day, they both had two days off. The first officer had completed a command course on the simulator the previous week and this training detail was part of his conversion to the left hand seat; the training captain had also been involved in the simulator the previous week. The detail was planned to involve two flights; the first would cover the mandatory items for the type rating test (1179) and the second would complete the first officer's base check and initial line check. On arrival at Belfast, the crew checked in to the airport hotel,changed into uniform and went to the meteorological office at approximately 1600 hrs for a weather briefing. This briefing indicated that the weather was close to the limits required for the completion of the type rating test items but, with a forecast of a suitable area to the north of the airfield, the crew decided to carry on with the detail. For the first flight, G-OPFE left the stand at 1815 hrs and took off at 1827 hrs. All the necessary items were completed successfully, albeit with some difficulty because of the variable cloud base, and the crew landed at 2010 hrs. By 2015 hrs, G-OPFE was back on stand and the crew kept the engines running while they had a short brief for the second flight. At 2025 hrs,they taxied off stand and positioned for a departure off Runway 07. On this second flight, following a take off at 2031 hrs, the training captain initiated an outboard engine failure just after VR by retarding the associated throttle. The appropriate remedial actions were simulated andthe first officer carried out a 3 engine ILS approach and go-around to Runway 17; there had been no abnormal switch positions required because of the simulated engine failure. The go-around was followed by a 3 engine VOR approach to landon Runway 07. The different runways were used because there is no ILS on Runway 07, the runway in use. After landing,the first officer repositioned G-OPFE and made a full power take-off from Runway 07, commencing his roll at the intersection with Runway 17. The aircraft was climbed to 4,000 feet amsl and established in the cruise at 200 kt IAS. During this cruise, there were no unserviceabilities noted with G-OPFE. The crew continued in a north-westerly direction until approximately 5 nm from Eglinton Airport when they requested, and were given, permission to turn back towards Belfast International Airport. For the subsequent approach, the surface wind was 090°/15 kt,visibility was 2,500 metres and the cloud was scattered at 1,000 feet and overcast at 4,200 feet agl. After establishing contact with Aldergrove radar, the crew were cleared to commence a VOR/DME approach to Runway 07 for afinal landing. It was confirmed from the CVR that the 'Initial Approach' checks were completed 'down to the line'. However,although the first officer at one stage commented that it was a bit early to complete the rest of the 'Initial Approach' checks,there was no evidence that these or the 'Finals' checks were subsequently requested or actioned. The landing gear would normally be selected down during the 'Initial Approach, below the line' checks and confirmed during the 'Finals' checks. The final approach profile was closely monitored by the commander and, from comments on the CVR, the approach appeared very stable. In the later stages of approach, the first officer was heard asking for 85% flap andthe training captain was heard confirming this selection. These were the only comments heard referring to flap selection or position,although it is acceptable company practice for crews to request flap changes by visual means. The final flap position (100%)is used to decrease ground roll and is selected during the flare or after touchdown. Other relevant comments which were heardon the CVR included a reference to landing lights; this is the last item on the "Finals" checks. As the throttles were retarded in the flare, the gear warning horn was heard on the CVR, followed within 23 seconds by sounds of the propellers contacting the runway surface. After coming to a stop on the runway, the crew secured and evacuated the aircraft. The airport Rescue and Fire Fighting Service were on the scene inless than one minute.
Probable cause:
Subsequent runway and aircraft examination showed that G-OPFE had made a gentle touchdown on Runway 07 close to the PAPI position, somewhat left of the centreline. Initial contact wason both inboard propeller tips. After a few metres, both outboard propellers contacted the runway, progressively followed by radio aerials mounted beneath the fuselage, the fuselage undersurface, the inboard part of both inboard flaps and the No 3 engine nacelle. The aircraft continued down the left side of the runway,across the intersecting Runway 17/35, and came to rest on Runway 07 after a ground slide of approximately 480 metres. Damage consisted of severe bending and scraping of all propeller blades, abrasion of much of the undersurface of the fuselage and the No 3 engine nacelle lower cowl, and abrasion and moderate distortion of the inboard flaps A very small quantity of fuel was reportedly released from the No 3 engine nacelle. There was no fire. Examination showed that the flaps had been in the fully deployed position (100%, 47°) at touchdown and the flap lever was found selected at 47°. All three landing gear legs had been fully retracted at touchdown and throughout the ground slide. After the aircraft had been lifted, the three legs deployed into downlock without difficulty using the emergency lowering procedure. The landing gear selector was found with the 'Down' button pushed in, but the electric actuator that is switched by the selector was found in the fully up position; this actuator had not been disturbed during recovery operations. The landing gear indicator was found in the 'Day' (ie bright) setting. Examination and testing of relevant systems was carried out, except for the hydraulic generation system; this indicated that the landing gear operating and indication systems functioned normally.
Final Report:

Crash of a Britten-Norman BN-2A-21 Islander near Keflavik

Date & Time: Mar 17, 1996 at 1212 LT
Type of aircraft:
Registration:
N904WA
Flight Type:
Survivors:
Yes
Schedule:
Reykjavik - Narsarsuaq
MSN:
904
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot, sole on board, was completing a delivery flight from Europe to the US via Iceland and Greenland. Eight minutes after her departure from Reykjavik Airport, outbound to Narsarsuaq, the pilot informed ATC that her portable GPS fell on the ground and was not able to locate it. It such conditions, she decided to divert to Keflavik Airport when less than five minutes later, while descending, the right engine failed. For unknown reasons, she did not feather the propeller and did not elected to restart the engine. Due to drag and a loss of speed, the aircraft lost altitude and crashed near the village of Njarðvík, about 5 km east of Keflavik Airport. The aircraft was destroyed and the pilot was seriously injured.
Probable cause:
It was determined that the loss of power on the right engine was caused by the pilot who probably inadvertently reduced the mix ratio of the right engine while trying to find the portable GPS. For unknown reasons, she did not feather the propeller which increased drag and reduced speed and lift. A the time of the accident, the total weight of the aircraft was 297 kilos above MTOW, which was considered as a contributing factor.

Crash of a Cessna 402B off Punto Fijo: 8 killed

Date & Time: Mar 13, 1996 at 0815 LT
Type of aircraft:
Operator:
Registration:
P4-AVB
Survivors:
No
Schedule:
Oranjestad - Punto Fijo
MSN:
402B-1201
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
The twin engine aircraft was completing a charter flight from Oranjestad to Punto Fijo with seven passengers and one pilot on board. While descending to Punto Fijo-Josefa Camejo Airport, the pilot informed ATC about the failure of the left engine. Shortly later, the left engine caught fire and detached, causing a part of the left wing to be torn off. Out of control, the aircraft crashed in the sea about 29,5 km north of Punto Fijo Airport. All eight occupants were killed.
Probable cause:
Failure of the left engine as a result of a cracked exhaust manifold.