Crash of a Mitsubishi MU-2B-30 Marquise in Melbourne: 1 killed

Date & Time: Dec 21, 1994 at 0324 LT
Type of aircraft:
Registration:
VH-IAM
Flight Type:
Survivors:
No
Schedule:
Sydney – Melbourne
MSN:
517
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5000
Captain / Total hours on type:
150.00
Circumstances:
The aircraft departed Sydney for Melbourne International airport at 0130 on 21 December 1994. En-route cruise was conducted at flight level 140. Melbourne Automatic Terminal Information Service (ATIS) indicated a cloud base of 200 feet for the aircraft's arrival and runway 27 with ILS approaches, was in use. Air Traffic Control advised the pilot of VH-UZB, another company MU2 that was also en-route from Sydney to Melbourne, and the pilot of VH-IAM while approaching the Melbourne area, that the cloud base was at the ILS minimum and that the previous two aircraft landed off their approaches. VH-UZB was slightly ahead of VH-IAM and made a 27 ILS approach and landed. In response to an inquiry from the Tower controller the pilot of VH-UZB then advised that the visibility below the cloud base was 'not too bad'. This information was relayed by the Tower controller to the pilot of VH-IAM, who was also making a 27 ILS approach about five minutes after VH-UZB. The pilot acknowledged receipt of the information and was given a landing clearance at 0322. At 0324 the Approach controller contacted the Tower controller, who had been communicating with the aircraft on a different frequency, and advised that the aircraft had faded from his radar screen. Transmissions to VH-IAM remained unanswered and search-and-rescue procedures commenced. Nothing could be seen of the aircraft from the tower. A ground search was commenced but was hampered by the darkness and reduced visibility. The terrain to the east of runway 27 threshold, in Gellibrand Hill Park, was rough, undulating and timbered. At 0407 the wreckage was found by a police officer. Due to the darkness and poor visibility the policeman could not accurately establish his position. It took approximately another 15-20 minutes before a fire vehicle could reach the scene of the burning aircraft. The fire was then extinguished.
Probable cause:
The following factors were reported:
1. The company's training system did not detect deficiencies in the pilot's instrument flying skills.
2. The cloud base was low at the time of the accident and dark night conditions prevailed.
3. The pilot persisted with an unstabilised approach.
4. The pilot descended, probably inadvertently, below the approach minimum altitude.
5. The pilot may have been suffering from fatigue.
Final Report:

Crash of a Beechcraft B60 Duke in Oulu: 2 killed

Date & Time: Dec 20, 1994 at 1627 LT
Type of aircraft:
Operator:
Registration:
N911SG
Flight Type:
Survivors:
Yes
Schedule:
Bremerhaven – Oulu – Murmansk
MSN:
P-510
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2024
Captain / Total hours on type:
11.00
Aircraft flight hours:
3310
Circumstances:
The aircraft registered N911SG arrived in Oulu on a private flight from Bremerhaven, Germany (EDWB) on 20 December 1994, with the intention to continue the flight to Murmansk, Russia (ULMM). Landing time at Oulu airport was 15.03. The aircraft had one passenger in addition to the pilot-in-command and a representative of the operator company, who had been marked as a crew member. After the landing the pilot-in-command contacted air traffic control by radio and told that the aircraft needed refuelling, without mentioning the fuel type required. The ATC officer transmitted the information by telephone to the fuel company, saying that the aircraft would take JET. According to the delivery receipt, the aircraft was refuelled with 664 litres of jet fuel, JET A-1, whereas the proper fuel type for the aircraft would have been AVGAS 100LL. The aircraft was refuelled on a stand situated in front of the terminal building. The fuel was delivered by a tanker car used only for JET A-1 refuelling and equipped with labels clearly indicating the fuel type. The representative of the aircraft operator/possessor company, who had been registered as a crew member in the aircraft log book, was present during refuelling, and the tanks were filled up according to his instructions on the quantity of fuel needed. He also accepted the fuel sample presented to him and signed the delivery receipt. He paid for the fuel in cash. The fuel tanks had not been marked with the minimum fuel grade of aviation gasoline used, as provided for in the airworthiness requirements. The filling orifices were equipped with restrictors in order to prevent jet fuel nozzles from going in and thus to prevent incorrect refuelling. The tanker car replenishment nozzle had been manufactured with an expansion, which had been shaped and dimensioned to fulfil the requirements set for jet fuel nozzles in different standards. The expansion is intended to prevent jet fuel nozzles from fitting into the orifices of aviation gasoline tanks. However, after the expansion the nozzle tip had been shaped as a Camlock coupling, which was smaller in dimension than the expansion and thus fitted into the reduced filling orifices, making it possible to fill the aviation gasoline tanks with jet fuel. During refuelling, the pilot-in-command visited meteo and paid for the landing. The aircraft had an IFR flight plan drawn up by the pilot-in-command for the continued flight from Oulu to Murmansk. According to the plan, flight time was one hour and 35 minutes, alternate aerodrome Ivalo (EFIV) and endurance 5 hours. The aircraft left for this planned flight from Oulu, runway 30, at 16.19. It had been cleared to Murmansk and to climb after take-off to FL 160 with a right turn. According to the ATC officer who had monitored the take-off, the gradient of climb was rather low. Four minutes after take-off the ATC officer gave the departure time to the aircraft and asked the crew to change over to Rovaniemi Area Control Centre radio frequency. The crew acknowledged the frequency. Without contacting Rovaniemi ACC the crew called again at Oulu ATC frequency at 4 min 47 sec after take-off, stating that they wanted to return to the airport because they were having some problems. The ATC officer cleared the aircraft to call on final 12. Approximately 10 seconds after this transmission the ATC officer asked whether any emergency equipment was needed, and the answer was negative. At 16.25.25, when the ATC officer asked if the crew had the field in sight, the crew confirmed this and reported that their DME distance was 6 nm. At 16.26.11 the crew called mayday, stating that both engines were stopping. At 16.26.38 the mayday call was repeated and emergency landing reported. Rovaniemi ACC monitored the aircraft by radar, and the last reliable radar contact was established at 16.26.30. On the basis of recorded radar data, the crash site was estimated to be approximately 1 NM from Laanila NDB, in the direction of 60°. Rescue units found the aircraft in a forest at 17.06. It had struck into trees, turned upside down and been destroyed. The aircraft door was shut and the occupants were still inside. The passenger on the back seat had been thrown away from his seat and was found dead at the accident site. The pilot-in-command was on the left front seat, seriously injured and unconscious, with his seat belt fastened (he died from his injuries 10 days later on December 30). The right crew seat occupant was injured but conscious, and his seat belt was fastened as well. It came out during the investigation that he was actually a passenger.
Probable cause:
The accident was caused by incorrect refuelling. This was made possible by a series of human errors, which together with the fact that the technical defences failed, permitted the aircraft to be refuelled with Jet A-1 instead of Avgas 100LL. The incorrect fuel caused knocking, which resulted in engine damage and eventual stopping of both engines.
Final Report:

Crash of a Douglas C-47A-10-DK in Cerro Aicha: 7 killed

Date & Time: Dec 17, 1994 at 1030 LT
Type of aircraft:
Operator:
Registration:
YV-761C
Survivors:
Yes
MSN:
12476
YOM:
1944
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
While on approach to Cerro Aicha in good weather conditions, the aircraft was too low when it struck tree tops and crashed 2 km short of runway 15 threshold. Eight occupants were injured and seven others were killed, among them all three crew members.

Crash of a Learjet 35A in Fresno: 4 killed

Date & Time: Dec 14, 1994 at 1146 LT
Type of aircraft:
Operator:
Registration:
N521PA
Flight Type:
Survivors:
No
Schedule:
Fresno - Fresno
MSN:
35-239
YOM:
1979
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
7109
Captain / Total hours on type:
2747.00
Aircraft flight hours:
6673
Aircraft flight cycles:
5254
Circumstances:
At about 1146 pst, Learjet 35A, N521PA, operating as a public use aircraft, crashed in Fresno, CA. Operating with call sign Dart 21, the flightcrew had declared an emergency inbound to Fresno Air Terminal due to engine fire indications. They flew the airplane toward a right base for their requested runway, but the airplane continued past the airport. The flightcrew was heard on tower frequency attempting to diagnose the emergency conditions and control the airplane until it crashed, with landing gear down, on an avenue in fresno. Both pilots were fatally injured. Twenty-one persons on the ground were injured, and 12 apartment units in 2 buildings were destroyed or substantially damaged by impact or fire. Investigation revealed that special mission wiring was not installed properly, leading to a lack of overload current protection. The in-flight fire most likely originated with a short of the special mission power supply wires in an area unprotected by current limiters. The fire resulted in false engine fire warning indications to the pilots that led them to a shutdown of the left engine. An intense fire burned through the aft engine support beam, damaging the airplane structure and systems in the aft fuselage and may have precluded a successful emergency landing.
Probable cause:
The accident was the consequence of the following factors:
- Improperly installed electrical wiring for special mission operations that led to an in-flight fire that caused airplane systems and structural damage and subsequent airplane control difficulties,
- Improper maintenance and inspection procedures followed by the operator,
- Inadequate oversight and approval of the maintenance and inspection practice by the operator in the installation of the special mission systems.
Final Report:

Crash of a BAe 3201 Jetstream 32 in Raleigh: 15 killed

Date & Time: Dec 13, 1994 at 1834 LT
Type of aircraft:
Operator:
Registration:
N918AE
Survivors:
Yes
Schedule:
Greensboro – Raleigh
MSN:
918
YOM:
1990
Flight number:
AA3379
Crew on board:
2
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
15
Captain / Total flying hours:
3499
Captain / Total hours on type:
457.00
Copilot / Total flying hours:
3452
Copilot / Total hours on type:
677
Aircraft flight hours:
6577
Circumstances:
Flight 3379 departed Greensboro at 18:03 with a little delay due to baggage rearrangement. The aircraft climbed to a 9,000 feet cruising altitude and contacted Raleigh approach control at 18:14, receiving an instruction to reduce the speed to 180 knots and descend to 6,000 feet. Raleigh final radar control was contacted at 18:25 and instructions were received to reduce the speed to 170 knots and to descend to 3,000 feet. At 18:30 the flight was advised to turn left and join the localizer course at or above 2,100 feet for a runway 05L ILS approach. Shortly after receiving clearance to land, the n°1 engine ignition light illuminated in the cockpit as a result of a momentary negative torque condition when the propeller speed levers were advanced to 100% and the power levers were at flight idle. The captain suspected an engine flame out and eventually decided to execute a missed approach. The speed had decreased to 122 knots and two momentary stall warnings sounded as the pilot called for max power. The aircraft was in a left turn at 1,800 feet and the speed continued to decrease to 103 knots, followed by stall warnings. The rate of descent then increased rapidly to more than 10,000 feet/min. The aircraft eventually struck some trees and crashed about 4 nm southwest of the runway 05L threshold. Five passengers survived while 15 other occupants were killed.
Probable cause:
The accident was the consequence of the following factors:
- The captain's improper assumption that an engine had failed,
- The captain's subsequent failure to follow approved procedures for engine failure single-engine approach and go-around, and stall recovery,
- Failure of AMR Eagle/Flagship management to identify, document, monitor and remedy deficiencies in pilot performance and training.
Final Report:

Crash of a Cessna 402C in Koyuk: 5 killed

Date & Time: Dec 10, 1994 at 1900 LT
Type of aircraft:
Operator:
Registration:
N1238K
Survivors:
No
Schedule:
Nome - Koyuk
MSN:
402C-1019
YOM:
1985
Flight number:
XY2402
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
15804
Captain / Total hours on type:
828.00
Aircraft flight hours:
10722
Circumstances:
The airplane was on a flight at night from Nome to Koyuk, AK, when it crashed into a mountain at the 2,725 foot level. The accident site was directly on a course line between the Nome and Koyuk Airports. The ceiling at nome was 3,500 overcast at the time of departure. According to rescue personnel, weather at the accident area was: indefinable ceiling and poor visibility with heavy snow and blowing snow. The pilot had a hand held GPS on board that he had barrowed from another pilot. But the database could not be retrieved from the GPS. According to the owner of the GPS, he and the accident pilot programmed different waypoints. The pilot did not file a VFR or an ifr flight plan with the FAA.
Probable cause:
VFR flight by the pilot into instrument meteorological conditions (IMC), and his failure to maintain sufficient altitude or clearance from mountainous terrain. Factors related to the accident were: darkness and the adverse weather conditions.
Final Report:

Crash of a Beechcraft E18S in Kansas City: 1 killed

Date & Time: Dec 8, 1994 at 2038 LT
Type of aircraft:
Registration:
N5647D
Flight Type:
Survivors:
No
Schedule:
Sedalia - Kansas City
MSN:
BA-364
YOM:
1958
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2523
Captain / Total hours on type:
500.00
Circumstances:
During arrival at night in fog and drizzle, the pilot was cleared for an ILS runway 1l approach. While on the approach, she reported encountering moderate rime ice. Radar data showed that the airplane continued inbound on the localizer until it neared the middle marker, then it deviated about 20° left and collided with the ground, about 300 feet short and 300 feet left of the threshold. According to witnesses, the airplane stopped its descent and slowed down, shortly before entering a steep descent and a spin. An on-scene investigation revealed no preimpact airframe, control system, or powerplant anomalies. The wings had 1/4 inch of ice on the leading edge and a 1/2 inch high ridge of ice, parallel to the deicing boots, about 3 inches aft of the boots. The cockpit and windshield heating system were found in the 'off' position. The pilot's logbook was not available for inspection. Company records showed she had passed a 14 cfr part 135 checkride on may 20, 1994. The faa checkride form was administered and signed by the chief pilot. However, other records/information showed the chief pilot would not have been able to have given the checkride on that date.
Probable cause:
Failure of the pilot to maintain adequate airspeed on final approach, which resulted in an inadvertent stall/spin. Factors related to the accident were: the adverse weather (icing) conditions, the accumulation of airframe/wing ice, the pilot's improper use of the anti-ice/deice equipment, inadequate training of the pilot concerning flight in icing conditions, and inadequate surveillance of the operation by the chief pilot (company/operator management).
Final Report:

Crash of an ATR72-202 in Oyem

Date & Time: Dec 8, 1994 at 1040 LT
Type of aircraft:
Operator:
Registration:
F-OHOC
Survivors:
Yes
Schedule:
Bitam - Oyem
MSN:
318
YOM:
1992
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following a normal visual approach, the aircraft landed 500 metres past the runway 21 threshold. The crew applied reverse thrust when the aircraft started to deviate to the right. The crew decided to abandon the landing procedure and initiate a go-around maneuver when the aircraft went out of control, veered off runway, struck a ditch and came to rest against trees. All 21 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Dornier DO.28D Skyservant in Nuuk

Date & Time: Dec 5, 1994 at 1223 LT
Type of aircraft:
Operator:
Registration:
D-IDNG
Flight Type:
Survivors:
Yes
Schedule:
Reykjavik - Goose Bay
MSN:
4112
YOM:
1971
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft was on a delivery flight from Germany to Colombia via Iceland and Canada, carrying one passenger and one pilot. On the leg from Reykjavik to Goose Bay, about 20 minutes into the flight, the right engine failed. As the pilot was unable to restart it, he decided to divert to Nuuk for an emergency landing. On short final, at a height of about 100 metres, the aircraft entered a right turn and struck the ground. Upon impact, the undercarriage were torn off and the aircraft came to rest against an embankment. Both occupants were slightly injured and the aircraft was damaged beyond repair.
Probable cause:
The exact cause of the engine failure could not be determined. Except the fact that a hinge pin was missing in the injector air heating system, no technical malfunction was found. It was reported that the pilot was not certified to perform such flight and the passenger was not allowed to take part to such mission according to the provisional airworthiness certificate that was valid till the day of the occurrence. The possible presence of windshear on final approach was not ruled out and it was also reported that the approach was completed with a speed that was approximately 10 to 15 knots below the prescribed approach speed.

Crash of a Fokker F28 Fellowship 4000 in Semarang

Date & Time: Nov 30, 1994 at 1845 LT
Type of aircraft:
Operator:
Registration:
PK-GKU
Survivors:
Yes
Schedule:
Jakarta - Semarang
MSN:
11210
YOM:
1984
Flight number:
MZ422
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
79
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The approach to Semarang-Ahmad Yani Airport was completed by night and poor weather conditions with heavy rain falls and strong winds. The aircraft landed too far down a wet runway and was unable to stop within the remaining distance. It overran and came to rest in a ravine, broken in three. All 85 occupants were evacuated, among them three passengers were injured.
Probable cause:
Following a wrong approach configuration, the crew landed the aircraft too far down a wet runway. In such conditions, the aircraft could not be stopped within the remaining distance. The following contributing factors were reported:
- The crew failed to follow the approach checklist,
- Poor crew coordination,
- Lack of discipline,
- The crew failed to initiate a go-around procedure,
- Poor approach planning,
- The runway surface was wet and the braking action was poor,
- Aquaplaning,
- Poor weather conditions.