Crash of a Harbin Yunsunji Y-12-II in Bom Jesus

Date & Time: Mar 4, 1995
Type of aircraft:
Operator:
Registration:
PNP-224
Flight Type:
Survivors:
Yes
MSN:
0072
YOM:
1993
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown, the twin engine airplane went out of control, veered off runway and came to rest 200 metres further. All eight occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Cessna 208B Grand Caravan in Gainesville: 2 killed

Date & Time: Mar 3, 1995 at 1943 LT
Type of aircraft:
Registration:
N227DM
Survivors:
No
Schedule:
Savannah - Gainesville
MSN:
208B-0364
YOM:
1993
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2005
Captain / Total hours on type:
201.00
Circumstances:
The flight was executing the non-precision NDB runway 04 approach, had reported procedure turn inbound, and was cleared to change to advisory frequency. Witnesses observed the airplane descend out of the base of the overcast clouds in a 10° nose down, 45° left wing down attitude. The airplane impacted terrain about 3/4 mile south-southeast of the airport. Witnesses in the area reported that the weather was ceilings of about 100 feet and visibility of about 500 feet in light rain and fog. The minimum descent altitude for the approach is 465 feet agl. Both pilots were killed.
Probable cause:
The pilots failure to maintain the minimum descent altitude during the approach. The weather and dark night light condition were factors.
Final Report:

Crash of a Mitsubishi MU-300 Diamond IA in Jasper

Date & Time: Mar 1, 1995 at 0920 LT
Type of aircraft:
Operator:
Registration:
C-GLIG
Survivors:
Yes
Schedule:
Williams Lake - Jasper
MSN:
76
YOM:
1984
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3500
Captain / Total hours on type:
360.00
Copilot / Total flying hours:
13500
Copilot / Total hours on type:
350
Aircraft flight hours:
3290
Circumstances:
The Mitsubishi MU-300 Diamond business jet was on an instrument flight rules (IFR) flight from Williams Lake, British Columbia, to Hinton, Alberta. There were two pilots and two passengers on board. Prior to issuing the descent clearance from flight level 270 (FL270), the Edmonton Area Control Centre (ACC) advised the crew of the Jasper townsite, Alberta, weather. The winds were reported as calm. The crew cancelled the IFR during the descent and continued for a visual approach and landing to runway 02 at the Jasper-Hinton Airport. During the approach, the crew encountered moderate turbulence on short final. The captain increased the reference airspeed (Vref) from 105 to 115 knots to allow for subsiding air and airspeed fluctuations. The crew noted that the wind sock for runway 02 was fully extended and was varying in direction frequently. They elected to continue the approach and landing on runway 02. Power was reduced to idle at 50 feet. The aircraft touched down at about 1,000 feet down the runway. During the landing roll, the captain first applied maximum braking and then, when he determined that the aircraft would not come to a stop in the remaining runway distance available, he initiated commanded swerving to assist in stopping the aircraft; the aircraft skidded to a position 255 feet off the end of the runway. The aircraft sustained substantial damage; however, the occupants were uninjured. The accident occurred at latitude 53°19'N, longitude 117°45'W, at an elevation of 4,016 feet above sea level (asl), at 0920 mountain standard time (MST), during the hours of daylight.
Probable cause:
The aircraft overran the runway because the crew landed with a 14- to 21-knot tailwind. Contributing to the occurrence were the crew's belief that the calm winds given to them by the Area Control Centre for Jasper townsite were for the Jasper-Hinton Airport, and their decision to continue with the straight-in approach procedure without overflying the airport.
Final Report:

Crash of a Beechcraft A100 King Air in Big Trout Lake

Date & Time: Feb 21, 1995 at 1248 LT
Type of aircraft:
Operator:
Registration:
C-GYQT
Survivors:
Yes
Schedule:
Sioux Lookout - Big Trout Lake
MSN:
B-189
YOM:
1974
Flight number:
BLS324
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5000
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
2300
Copilot / Total hours on type:
800
Aircraft flight hours:
13739
Circumstances:
The crew of the Beechcraft A100, C-GYQT, were conducting a scheduled flight from Sioux Lookout, Ontario, to Big Trout Lake, Ontario, as Bearskin (BLS) 324. BLS324 departed Sioux Lookout with nine passengers and a crew of two at 1133 central standard time (CST) and arrived in the vicinity of Big Trout Lake at approximately 1240. The captain briefed an instrument approach with a circling procedure to runway 14. On descent to the radio beacon, the crew reportedly encountered flight visibilities of one mile and were in visual contact with the ground. When the aircraft was less than five miles from the airport, the crew heard a position report from another aircraft completing an approach to the airport. To ensure safe separation from the aircraft ahead, the captain elected to fly under visual flight rules to the southwest of the airport. Air Traffic Services radar data was obtained from the Big Trout Lake radar source. The radar data indicated that the crew descended to about 150 feet above ground level (agl) approximately 4.5 miles from the end of the landing runway and maintained 200 to 300 feet agl for some 50 seconds prior to impact. Immediately prior to impact, the radar data indicated that the aircraft was about 3 1/2 miles from the runway at about 300 feet agl and descending at more than 1,200 feet per minute. Throughout the approach, the first officer flew the aircraft visually with occasional reference to his instruments, while the captain navigated and maintained terrain clearance by visual reference to the terrain and issued instructions to the first officer. At approximately five miles from the runway, the crew turned onto the extended centre line of the runway and received a radio report from the other aircraft of local visibilities of less than 1/2 mile. The aircraft flew inbound over a wide expanse of lake, and the captain lowered the flaps in preparation for landing. Shortly thereafter, the captain became concerned with the reducing visibility and looked in the Company Approach Procedures binder that he held on his lap. The captain was aware of the danger of whiteout and intended to revert to instrument flight if whiteout were encountered. He had not previously removed the approach chart for Big Trout Lake and clipped it in the approach chart holder because he had discovered that the binder rings were broken and taped shut when he had performed his initial approach briefing. He intended to provide new approach information to the first officer so that a full instrument approach could be initiated from their current position. When the captain looked up from the binder, he observed the altimeter indicating a descent through 1,000 feet above sea level (asl) and called to the first officer, "Watch your altitude." Before a recovery could be initiated, the aircraft struck the frozen surface of the lake and bounced into the air. The captain initiated a recovery and then, concerned with the airworthiness of the aircraft, reduced power and attempted to land straight ahead. The aircraft crashed onto the frozen surface of the lake about 3/4 mile beyond the initial impact location. All passengers and crew survived the accident. However, the crew and several passengers sustained serious injuries. Rescuers from the local community reached the aircraft about two hours after the crash and all survivors were rescued within four hours. The more seriously injured were experiencing the effects of hypothermia when rescued. The accident occurred at 1248 CST, approximately three miles northwest of Big Trout Lake Airport, at latitude 53°49'N, longitude 089°53'W, at an elevation of 690 feet asl.
Probable cause:
While the crew were manoeuvring the aircraft to land and attempting to maintain visual flying conditions in reduced visibility, their workload was such that they missed, or unknowingly discounted, critical information provided by the altimeters and vertical speed indicators. Contributing factors were the whiteout conditions and the crew's decision to fly a visual approach at low altitude over an area where visual cues were minimal and visibility was reduced.
Final Report:

Crash of a Piper PA-46-310P Malibu in Chippewa Falls: 2 killed

Date & Time: Feb 14, 1995 at 2250 LT
Operator:
Registration:
N9YP
Survivors:
Yes
Schedule:
Ithaca - Eau Claire
MSN:
46-08043
YOM:
1986
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2200
Captain / Total hours on type:
120.00
Aircraft flight hours:
1248
Circumstances:
The single engine airplane departed with two pilots, two passengers, baggage and equipment. At takeoff, the airplane was 955 pounds over the maximum allowable gross weight, and 2 inches beyond the aft c.g. Limit. After 4 hours of flying, the pilot elected to divert to another airport, due to icing conditions. During the descending left turn from base leg to final approach to runway 22, the airplane dropped, struck the ground, and slid 250 feet. The wings were separated from the airplane during the ground slide by two trees. A satisfactory postaccident engine run was completed. The airplane was calculated to be about 600 pounds over the maximum landing weight, and 2 inches beyond the aft c.g. Limit. The air induction lever was in the primary position, and not the required alternate position for icing conditions. The propeller and stall warning heat switches were off. The airplane had been flying in light freezing rain, which the poh stated should be avoided. Severe mixed icing was reported 25 miles northwest of the airport. Winds at the airport were from 150 degrees at 10 knots, gusting to 16 knots. Both pilots were killed and both passengers were seriously injured.
Probable cause:
The pilot's improper decision to depart into known adverse weather conditions, and the subsequent encounter with freezing drizzle, resulting in an inadvertent stall and collision with the terrain during an approach to land. Also causal to the accident was the pilot's failure to adhere to the airplane's weight and balance limitations, resulting in an overweight and out of balance flight condition, and his failure to comply with published procedures for flight into icing conditions.
Final Report:

Crash of a Cessna 414 Chancellor in McGregor

Date & Time: Feb 14, 1995 at 0108 LT
Type of aircraft:
Operator:
Registration:
N4643G
Flight Type:
Survivors:
Yes
Schedule:
Portales - McGregor
MSN:
414-0911
YOM:
1976
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
651
Captain / Total hours on type:
318.00
Aircraft flight hours:
4083
Circumstances:
The pilot was cleared for the VOR runway 17 approach. Field elevation and the minimum descent altitude were 590 and 980 feet respectively. The missed approach point was 10.4 miles outbound from the Waco VOR, which coincided with the runway threshold. The pilot stated that the passenger seated in the right front seat established visual contact with the airport. After confirming that the airport was in sight and the runway environment identified, the pilot continued his descent towards the runway to land on runway 17. The pilot further stated that 'I realized that there would not be adequate runway to safely land, and initiated a right turn to execute a missed approach.' The right wing of the airplane impacted the top of the trees. The FAA inspector at the scene reported that after impacting the trees, the airplane continued through the trees for approximately 400 feet on a track of 344 degrees prior to coming to rest on a heading of 230 degrees.
Probable cause:
The pilot's delayed initiation of the missed approach until well below the minimum descent altitude and beyond the published missed approach point. Factors were the dark night and the low ceiling and visibility.
Final Report:

Crash of a Rockwell Grand Commander 690A in Guthrie: 2 killed

Date & Time: Feb 12, 1995 at 1721 LT
Registration:
N69TM
Flight Type:
Survivors:
No
Schedule:
Wichita - Oklahoma City
MSN:
690-11322
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2870
Circumstances:
The airplane impacted terrain approx 14 miles from the destination during a descent. According to radar data and meteorological information, the airplane descended from 16,700 feet to 3,700 feet agl through clouds and icing conditions. During the descent, the airplane decelerated from 268 kts to 92 kts ground speed. The pilot reported to approach that he 'broke out' of the clouds at 5,400 feet. He subsequently informed approach that he had accumulated 'some clear and rime ice' during the descent. 13 seconds later the pilot made a distress call and stated, 'we're in trouble, we're going down.' The last radar track showed the airplane descending through 3,700 feet at a ground speed of 92 kts. A witness reported he observed that the airplane 'appeared to be doing tricks', and 'then headed straight down in a spin.' An airmet for icing conditions was in effect along the airplane's route of flight. Also, there were several pilot reports of icing encountered in the area of the accident. The pilot did not request a weather briefing prior to, or during the flight.
Probable cause:
The pilot's failure to maintain adequate airspeed due to airframe ice, which resulted in a loss of control. Factors contributing to the accident were the pilot's continued flight into adverse weather, his failure to obtain weather information either before or during the flight, and the icing conditions.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Tremonton: 2 killed

Date & Time: Feb 9, 1995 at 1821 LT
Operator:
Registration:
N57NW
Flight Type:
Survivors:
No
Site:
Schedule:
Pueblo – Tremonton
MSN:
61-0775-8063388
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4300
Aircraft flight hours:
2100
Circumstances:
The instrument-rated private pilot intended to land at an uncontrolled airport at night. The airport had no instrument approaches. The airplane was flying on an instrument flight rules (IFR) flight plan above an overcast layer of clouds. The pilot informed air traffic control (ATC) that he was going to try to find a 'hole' in the overcast and attempt a visual approach into the uncontrolled airport. The pilot then stated that he could not find a hole; he requested and received an IFR clearance to a larger controlled airport. On his way to the controlled airport, he stated that he found a 'hole' and attempted a visual approach to the uncontrolled airport. He received a cruise clearance from atc for 12,000 feet msl, and then descended at 2,280 feet per minute before impacting mountainous terrain at an elevation of 6,200 feet msl. Instrument meteorological conditions prevailed near the accident site. No distress calls from the airplane were recorded. An examination of the wreckage did not reveal any evidence of preimpact mechanical malfunctions. Both occupants were killed.
Probable cause:
The pilot's attempt to conduct visual flight into instrument meteorological conditions, and his failure to maintain altitude/clearance with the mountainous terrain. Factors were the clouds, and the dark night.
Final Report:

Crash of an Antonov AN-24B in Arkhangelsk

Date & Time: Feb 6, 1995 at 1852 LT
Type of aircraft:
Operator:
Registration:
RA-46564
Survivors:
Yes
Schedule:
Naryan-Mar - Arkhangelsk
MSN:
87304703
YOM:
1968
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
34
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Arkhangelsk-Vaskovo Airport, the crew encountered marginal weather conditions with snow showers. The captain lost visual contact with the runway but continued the approach when he realized, too late, that the aircraft was misaligned with the runway. This caused the aircraft to land to the right of the runway and to collide with a snow bank. All 38 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a Boeing 737-2A1 in São Paulo

Date & Time: Feb 2, 1995 at 0008 LT
Type of aircraft:
Operator:
Registration:
PP-SMV
Survivors:
Yes
Schedule:
São Paulo – Buenos Aires
MSN:
20968
YOM:
1974
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
121
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8000
Captain / Total hours on type:
6500.00
Copilot / Total flying hours:
4500
Copilot / Total hours on type:
2500
Circumstances:
Following a night takeoff from São Paulo-Guarulhos Airport, en route to Buenos Aires, the captain informed ATC about technical problems and was cleared to return for an emergency landing. The aircraft landed at a speed of 185 knots with flaps down to 15° on wet runway 09L. Unable to stop within the remaining distance, the aircraft overran, lost its undercarriage and came to rest 200 metres further. All 128 occupants were evacuated safely, among them two passengers were slightly injured. The aircraft was written off.
Probable cause:
It was determined that the n°3 leading edge flap actuator attachment fitting on the wing front spar had fractured due to corrosion. The actuator came away and caused the failure of some hydraulic lines and damage to the thrust control cables. Some 1981 Boeing Service Bulletins had not been complied with. One of these included the replacement of the aluminium leading edge flap actuator attachment fitting with a steel one; this had not been done. The following contributing factors were reported:
- Excessive workload on approach and landing due to the emergency situation,
- Poor approach planning,
- Lack of visibility due to the night,
- Poor crew coordination,
- Poor crew resources management,
- The crew forgot to lower the flaps electrically on approach, causing the speed to be 32 knots in excess,
- Poor aircraft maintenance and supervision,
- Failures in the supervision of the Company's operating sector.
Final Report: