Crash of a Beechcraft 70 Queen Air in Leonora

Date & Time: Jun 24, 2000 at 1740 LT
Type of aircraft:
Registration:
VH-MWJ
Flight Phase:
Survivors:
Yes
Schedule:
Leonora – Laverton
MSN:
LB-29
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Beechcraft Queen Air and Rockwell Aero Commander were being used by a company to conduct private category passenger-carrying flights to transport its workers from Leonora to Laverton in Western Australia. The Aero Commander had departed and was established in the Leonora circuit area when the Queen Air took off. The pilot and one of the passengers of the Queen Air reported the take-off roll appeared normal until the aircraft crossed the runway intersection, when they felt a bump in the aircraft. The pilot reported hearing a loud bang and noticed that the inboard cowl of the right engine had opened. He also reported that he believed he had insufficient runway remaining to stop safely, so he continued the takeoff. The cowl separated from the aircraft at the time, or just after the pilot rotated the aircraft to the take-off attitude. He reported that although the aircraft had left the ground after the rotation, it then would not climb. The aircraft remained at almost treetop level until the pilot and front-seat passenger noticed the side of a tailings dump immediately in front of the aircraft. The pilot said that he pulled the control column fully back. The aircraft hit the hillside parallel to the slope of the embankment, with little forward speed. The impact destroyed the aircraft. Although the occupants sustained serious injuries, they evacuated the aircraft without external assistance. There was no post-impact fire. The aircraft-mounted emergency locator transmitter (ELT) did not activate.
Probable cause:
The examination of the Queen Air wreckage found no mechanical fault that may have contributed to the accident sequence other than the inboard cowl of the right engine detaching during the takeoff. The cowl latching mechanisms appeared to have been capable of operating normally. The two top hinges failing in overload associated with the lack of cowl latch damage suggested that the cowl was probably improperly secured before takeoff. The cowl appeared to have subsequently opened when it experienced the jolt when the aircraft crossed the runway intersection. The lack of any further cowl damage indicated that it detached cleanly and consequently its dislodgment should not have adversely affected the flying qualities of the aircraft.
Final Report:

Crash of a Learjet 55 Longhorn in Boca Raton: 3 killed

Date & Time: Jun 23, 2000 at 1141 LT
Type of aircraft:
Operator:
Registration:
N220JC
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Boca Raton - Fort Pierce
MSN:
55-050
YOM:
1982
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
15180
Aircraft flight hours:
8557
Circumstances:
The Learjet departed from an uncontrolled airport about 2 minutes before the accident on a on a VFR climb and was not talking to ATC. The Extra EA-300S departed VFR from a controlled airport and requested and received a frequency change from the control tower 2 minutes after departure. Review of radar data revealed that the Extra climbed to 2,500 feet on a heading of 346 degrees before descending to 2,400 at 1141:25. The Learjet was observed on radar in a right crosswind departure passing through 700 feet on a heading of 242 degrees at 1141:02. At 1141:16, the Learjet was at 1,400 feet heading 269. At 1141:30, the Extra is observed on radar at 2,400 feet, in a right turn heading 360 degrees. The Learjet is observed on radar at 1141:28 in a climbing left turn passing through 2,300 feet. The last radar return on both aircraft was at 1141:30.
Probable cause:
The failure of the pilot's of both airplanes to maintain a visual lookout (while climbing and maneuvering) resulting in an in-flight collision and subsequent collision with residences and terrain.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Hotnarko Lake: 3 killed

Date & Time: Jun 19, 2000 at 1630 LT
Type of aircraft:
Registration:
C-GAXE
Flight Phase:
Survivors:
Yes
Schedule:
Hotnarko Lake - Nimpo Lake
MSN:
841
YOM:
1955
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total hours on type:
150.00
Circumstances:
The de Havilland DHC-2 (Beaver) floatplane, serial number 841, departed Hotnarko Lake, British Columbia, at about 1630 Pacific daylight time. The pilot and six passengers were on board, with fishing gear and fish. Soon after take-off, the pilot entered a left turn. Before the turn was completed, the aircraft rolled, without command, further left to about 40 degrees of bank and the nose dropped. The aircraft did not respond to initial pilot inputs and continued in a left, diving turn toward the trees at the edge of the lake. The pilot tried to get the aircraft back onto the lake. The aircraft started to recover from the bank and the nose started to come up; however, the aircraft struck the lake surface before a level attitude could be regained. It broke apart on contact with the water and sank soon after. The pilot and four of the passengers managed to free themselves from the wreckage, but only three passengers and the pilot managed to swim to shore. One passenger slipped below the water surface before reaching the shore and drowned. Two passengers remained in the aircraft below the water surface, one secured by his seat belt, and drowned.
Probable cause:
Findings as to Causes and Contributing Factors:
1. When the pilot entered a turn, the combined effects of the increased g-forces, power reduction, the aircraft=s heavy weight, the aft CofG, retraction of the flaps, and the wind conditions resulted in
the aircraft stalling. The aircraft struck the lake surface before the pilot was able to re-establish a level-flight attitude.
2. The aircraft was operating in excess of 385 pounds above the maximum gross takeoff weight, and the CofG was about 2.7 inches aft of the aft limit. This loading configuration aggravated the stall characteristics of the aircraft.
3. The pilot reduced power and raised the flaps before the climb was complete, contrary to the Pilot Operating Handbook, thereby increasing the aircraft's stall speed.
Other Findings:
1. The shoulder harnesses worn by the pilot and the front passenger likely prevented serious head injuries.
2. The centre seat broke from its footings. This may have incapacitated the two passengers inside the aircraft or impeded their escape.
Final Report:

Crash of a Cessna 401 in La Romana: 1 killed

Date & Time: Jun 2, 2000 at 1240 LT
Type of aircraft:
Operator:
Registration:
HI-696CT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
La Romana - La Romana
MSN:
401-0021
YOM:
1967
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
On June 2, 2000, about 1240 Atlantic standard time, a Cessna 401, Dominican Republic registration HI-696CT, registered to and operated by Air Century, crashed shortly after takeoff from La Romana International Airport, La Romana, Dominican Republic, while on an instructional flight. Visual meteorological conditions prevailed at the time and no flight plan was filed. The aircraft was destroyed. The commercial-rated pilot received fatal injuries. The commercial-rated second pilot received serious injuries. The flight was originating at the time of the accident. Civil aviation authorities stated that the flight was an instructional flight. Shortly after takeoff on runway 12, the pilot simulated the failure of the left engine. Control of the aircraft was lost and the aircraft crashed 350 meters from the runway. Examination of the aircraft and engines showed no mechanical anomalies.

Crash of a Piper PA-46-310P Malibu in Hawthorne: 3 killed

Date & Time: May 28, 2000 at 1159 LT
Operator:
Registration:
N567YV
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hawthorne – Las Vegas
MSN:
46-8408016
YOM:
1984
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2550
Captain / Total hours on type:
1250.00
Circumstances:
The aircraft collided with the ground in a steep nose down descent angle while maneuvering to return to the runway during the takeoff initial climb from the airport. Pilot and mechanic witnesses on the airport described the engine sounds during the takeoff as abnormal. The takeoff ground roll was over 3,000 feet in length, and the airplane's climb out angle was much shallower than usual. Two other witnesses said the engine sounded "like a radial engine," and both believed that the power output was lower than normal. One mechanic witness said the engine was surging and not developing full power; he believed the symptoms could be associated with a fuel feed problem, a turbocharger surge, or an excessively lean running condition. The ground witnesses located near the impact site said the airplane began a steep left turn between 1/4- and 1/2-mile from the runway's end at a lower than normal altitude. The bank angle was estimated by the witnesses as 45 degrees or greater. The turn continued until the nose suddenly dropped and the airplane entered a spiraling descent to ground impact. The majority of these witnesses stated that they heard "sputtering" or "popping" noises coming from the airplane. Engineering personnel from the manufacturer developed a performance profile for a normal takeoff and climb under the ambient conditions of the accident and at gross weight. The profile was compared to the actual aircraft performance derived from recorded radar data and the witness observations. The ground roll was 1,300 feet longer than it should have been, and the speed/acceleration and climb performance were consistently well below the profile's predictions. Based on the radar data and factoring in the winds, the airplane's estimated indicated airspeed during the final turn was 82 knots; the stall speed at 45 degrees of bank is 82 knots and it increases linearly to 96 knots at 60 degrees of bank. No evidence was found that the pilot flew the airplane from December until the date of the accident. The airplane sat outside during the rainy season with only 10 gallons of fuel in each tank. Comparison of the time the fueling began and the communications transcripts disclosed that the pilot had 17 minutes 41 seconds to refuel the airplane with 120 gallons, reboard the airplane, and start the engine for taxi; the maximum nozzle discharge flow rate of the pump he used is 24 gallons per minute. Review of the communications transcripts found that a time interval of 3 minutes 35 seconds elapsed from the time the pilot asked for a taxi clearance from the fuel facility until he reported ready for takeoff following a taxi distance of at least 2,000 feet. During the 8 seconds following the pilot's acknowledgment of his takeoff clearance, he and the local controller carried on a non pertinent personal exchange. The aircraft was almost completely consumed in the post crash fire; however, extensive investigation of the remains failed to identify a preimpact mechanical malfunction or failure in the engine or airframe systems. The pistons, cylinder interiors, and spark plugs from all six cylinders were clean without combustion deposits. The cockpit fuel selector lever, the intermediate linkages, and the valve itself were found in the OFF position; however, an engineering analysis established that insufficient fuel was available in the lines forward of the selector to start, taxi, and perform a takeoff with the selector in the OFF position.
Probable cause:
A partial loss of power due to water contamination in the fuel system and the pilot's inadequate preflight inspection, which failed to detect the water. The pilot's failure to perform an engine run-up before takeoff is also causal. Additional causes are the pilot's failure to maintain an adequate airspeed margin for the bank angle he initiated during the attempted return to runway maneuver and the resultant encounter with a stall/spin. Factors in the accident include the pilot's failure to detect the power deficiency early in the takeoff roll due to his diverted attention by a non pertinent personal conversation with the local controller, and, the lack of suitable forced landing sites in the takeoff flight path.
Final Report:

Crash of a Piper PA-31-350 Panther II in Zurich: 1 killed

Date & Time: May 26, 2000 at 2023 LT
Operator:
Registration:
HB-LTC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Zurich - Geneva
MSN:
31-7952003
YOM:
1979
Flight number:
HBLTC
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1119
Captain / Total hours on type:
9.00
Aircraft flight hours:
8387
Circumstances:
On 25 and 26 May 2000 aircraft HB-LTC was used for a commercial flight from Zurich to Béziers (F) and back. To this end, the pilot made a positioning flight from Geneva to Zurich on 24 May 2000. The reconstruction of the following events is based on recorded radio conversations and witness statements. On 25 May 2000 at approx. 07:20 hrs, the pilot placed a telephone order with the refuelling service of Jet Aviation Zurich AG. According to statements from aircraft refuelling attendant A concerned, the pilot asked for the aircraft to be fully refuelled with aviation gasoline (AVGAS) for a flight to France. When aircraft refuelling attendant A arrived at the aircraft, the pilot was present. The refuelling attendant saw the winglets on the HB-LTC and asked the pilot whether the machine had been modified and therefore needed jet kerosene. Before the pilot could even answer, the refuelling attendant realised, from the square engine housings, that the machine was equipped with reciprocating engines. The pilot confirmed that HB-LTC had been modified but pointed out that this modification involved only the airframe and that the aircraft had not been converted to turboprop operation. Refuelling attendant A then filled the HB-LTC’s four fuel tanks with 372 l of AVGAS 100LL (low lead). The aircraft was therefore fully refuelled and at that time had 726 l of fuel. Refuelling attendant A later reported that he had not noticed markings which described the types of fuel permitted for this aircraft, either on the wing or on the tank seals. During the refuelling operation, which ended at approx. 07:30 hrs, the pilot was in the cockpit. Nobody observed him draining the tanks after refuelling. The seven passengers for the flight to Béziers (F) arrived on 25 May 2000 at about eight o’clock in the morning at the General Aviation Centre (GAC) at Zurich airport. At 08:18:42 hrs the pilot received start-up clearance from Zurich Apron (ZRH APR) and at 08:26:25 hrs indicated that he was ready to taxi. Taxi clearance was granted without delay and the aircraft taxied to the holding point of runway 28. Several passengers later stated that the pilot carried out a run up of the engines while the following time of waiting. At 08:32:01 hrs HB-LTC indicated to aerodrome control (Zurich Tower – ZRH TWR) that it was ready to take off. The aircraft was queued in the traffic and was cleared for take-off at 08:45:27 hrs. The aircraft landed in Béziers (F) some two hours later. On 26 May 2000 between 15:35 and 15:45 hrs HB-LTC was refuelled in Béziers with 107 l of AVGAS 100LL. The aircraft then flew with the same passengers from Béziers (F) back to Zurich, where it landed at 19:10 hrs. Before the flight back to Geneva, the pilot obviously decided to refuel. According to the statements of aircraft refuelling attendant B at approx. 19:45 hrs the pilot ordered “Kraftstoff JET-A1” by telephone. Unlike the telephone conversations of air traffic control at Zurich airport, incoming and outgoing telephone calls made to and from the refuelling service of Jet Aviation Zurich AG were not recorded. The precise wording of the pilot’s fuel order cannot therefore be established with certainty. Aircraft refuelling attendant B then forwarded the order by radio to his colleague, aircraft refuelling attendant C. A third aircraft refuelling attendant D heard on his radio how aircraft refuelling attendant B gave the instruction to aircraft refuelling attendant C to refuel aircraft HB-LTC with JET A-1 fuel. Then aircraft refuelling attendant C drove tanker FL 7 to HB-LTC, which was parked in GAC Sector 1. According to his statements, he positioned the tanker with its right-hand side in front of the aircraft so that he could reach the filler caps on both wings using the hose affixed to that side of the tanker. Then aircraft refuelling attendant C, still next to the tanker, began to complete the delivery note, while the pilot came up to him and indicated the desired quantity of fuel in English. The pilot gave him a credit card and aircraft refuelling attendant C then explained to him that after refuelling he would have to complete the transaction in the office. The pilot remarked that he had a slot. Aircraft refuelling attendant C later stated that this gave him to understand that the pilot did not have much time. The aircraft refuelling attendant replied to the pilot that he would only need an additional two or three minutes. Because it had started to rain shortly before refuelling, the pilot evidently withdrew into the aircraft after his conversation with aircraft refuelling attendant C. According to his partner, the pilot conducted a brief conversation with her from his mobile telephone during this phase. As the investigation showed, this telephone call took place between 19:50:06 and 19:51:28 hrs. In the meantime, aircraft refuelling attendant C had connected HB-LTC to the tanker and then pumped 50 l of JET A-1 fuel into each of the two inboard main cells. The aircraft refuelling attendant later stated that he had not noticed markings or labels which described the permitted types of fuel for this aircraft, either on the tank seals or in the vicinity of the tank openings. He then drove the tanker to the office, debited the credit card and returned it with the receipt and the delivery note to the aircraft. He presented the debit slip and the delivery note to the pilot for signature. In the process the aircraft refuelling attendant asked the pilot what aircraft type HB-LTC was. The pilot answered that his aircraft was a modified PA31. The aircraft refuelling attendant then entered “PA31” on the delivery note and then gave the pilot the carbon copy. At 20:08:44 hrs the pilot made radio contact with Zurich Clearance Delivery (ZRH CLD) air traffic control and received departure clearance with the instruction to change to the ZRH APR frequency for start-up clearance. The apron gave HB-LTC start-up clearance at 20:10:00 hrs. Three minutes and 50 seconds later the pilot requested taxi clearance and was then instructed to taxi to the holding point of runway 28. After the transfer to ZRH TWR at 20:15:02 hrs the pilot stated he was ready for take off at 20:17:30 hrs. A short time after this he was able to line up runway 28 and at 20:20:58 hrs ZRH TWR gave him take-off clearance. According to witness statements, HB-LTC took off normally and went into a climb. In the region of runway intersection 28/16 and at an altitude of approx. 50 m AGL the aircraft stopped climbing, maintained level flight briefly and began to descend slightly. At the same time, HB-LTC began to make a gentle right turn and overflew the woods to the north of runway 28. Because of this unusual flight pattern, the duty aerodrome controller (ADC) at 20:22:08 hrs asked the pilot whether everything was normal: “Tango Charlie, normal operations?” The pilot replied in the negative: “(Ne)gative, Hotel Tango Charlie!” In this phase, the aircraft began to make a left turn with a high bank angle and witnesses observed that the landing gear was lowered. At 20:22:21 hrs the pilot radioed that he was in an emergency situation: “Mayday, Mayday, Mayday, Hotel Tango Charlie”. During the first 90° of the turn, HB-LTC descended only slightly. After crossing the extended centerline of runway 28 the aircraft increasingly lost height in the tight left turn. When the aircraft had almost completed the full turn, its bank attitude began to reduce. At a height of approx. 10 m AGL HB-LTC collided with the trees in a copse. The aircraft passed through the copse and came to rest upside down in the “Glatt” river. The pilot was fatally injured on impact. Coordinates of the final position of the wreck: 682 700/256 700, elevation 420 m AMSL corresponding to 1378 ft AMSL.
Probable cause:
The investigation established the following causal factors for the accident:
• A misunderstanding occurred when the fuel was ordered.
• The refuelling attendant concerned did not notice the fuel grade rating placards attached to the aircraft.
• The refuelling attendant concerned did not realise that the aircraft was equipped with reciprocating engines.
• The pilot did not notice the fuel grade rating placards on the tanker vehicle.
• The pilot did not realise the incorrect refuelling on the receipt for the fuel provision.
The following factors allowed or favoured the occurrence of the accident:
• The delivery nozzle on the filler gun was of an outside diameter which allowed the aircraft involved in the accident to be refuelled.
• The level of training and knowledge of the refuelling personnel concerned was inadequate.
• The Federal Office for Civil Aviation never inspected the refuelling operation before the accident.
• Until the time of the accident, the Federal Office for Civil Aviation had issued no regulations on the training of refuelling personnel, the size of delivery nozzles and tank openings on aircraft or on the identification of filler guns and tank openings.
The following points may have exacerbated the outcome of the accident:
• The pilot decided on an about turn which brought him onto a collision course with obstacles.
• The retention mechanism of the safety belt was not working.
Final Report:

Crash of a Grumman E-2C Hawkeye at Point Mugu NAS

Date & Time: May 9, 2000
Type of aircraft:
Operator:
Registration:
164354
Flight Phase:
Survivors:
Yes
Schedule:
Point Mugu NAS - Point Mugu NAS
MSN:
A147
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after liftoff from Point Mugu NAS, the aircraft collided with a flock of pelicans. The crew attempted an emergency landing and the aircraft belly landed before coming to rest. All three crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Forced belly landing following a collision with pelicans after takeoff.

Crash of a Britten-Norman BN-2A-20 Islander in Bapi: 4 killed

Date & Time: Apr 29, 2000
Type of aircraft:
Operator:
Registration:
P2-ISA
Flight Phase:
Survivors:
No
MSN:
703
YOM:
1973
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
Shortly after takeoff from the Bapi grassy runway 14/32 which is 495 metres long, the twin engine aircraft collided with trees and crashed, bursting into flames. All four occupants were killed. It is believed that the pilot completed the rotation too late.

Crash of an Antonov AN-8 in Pepa: 24 killed

Date & Time: Apr 19, 2000
Type of aircraft:
Operator:
Registration:
TL-ACM
Flight Phase:
Survivors:
No
Schedule:
Pepa - Kigali
MSN:
9340706
YOM:
1959
Location:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
24
Circumstances:
Shortly after takeoff from Pepa Airport, while in initial climb, the aircraft collided with a flock of birds that struck both engines. The aircraft lost height and crashed past the runway end, bursting into flames. All 24 occupants were killed, among them several officers from the Rwanda Army, one major, two captains, two lieutenants and some soldiers who were returning to Kigali after taking part to a presidential ceremony.
Probable cause:
Loss of control during initial climb following a bird strike.

Crash of a Grumman US-2C Tracker in Reno: 3 killed

Date & Time: Apr 17, 2000 at 1035 LT
Type of aircraft:
Operator:
Registration:
N7046U
Flight Phase:
Survivors:
No
Schedule:
Reno - Reno
MSN:
27
YOM:
1957
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
8170
Copilot / Total flying hours:
3700
Circumstances:
During the takeoff climb, the airplane turned sharply right, went into a steep bank and collided with terrain. The airplane began a right turn immediately after departure and appeared to be going slow. A witness was able to distinguish the individual propeller blades on the right engine, while the left engine propeller blades were indistinguishable. The airplane stopped turning and flew for an estimated 1/4-mile at an altitude of 100 feet. The airplane then continued the right turn at a steep bank angle before disappearing from sight. Then the witness observed a plume of smoke. White and gray matter, along with two ferrous slivers, contaminated the chip detector on the right engine. The airplane had a rudder assist system installed. The rudder assist provided additional directional control in the event of a loss of power on either engine. The NATOPS manual specified that the rudder assist switch should be in the ON position for takeoff, landing, and in the event of single-engine operation. The rudder boost switch was in the off position, and the rudder boost actuator in the empennage was in the retracted (off) position. The owner had experienced a problem with the flight controls the previous year and did not fly with the rudder assist ON. The accident flight had the lowest acceleration rate, and attained the lowest maximum speed, compared to GPS data from the seven previous flights. It was traveling nearly 20 knots slower, about 100 knots, than the bulk of the other flights when it attempted to lift off. The airplane was between the 2,000- and 3,000-foot runway markers (less than halfway down the runway) when it lifted off and began the right turn. Due to the extensive disintegration of the airplane in the impact sequence, the seating positions for the three occupants could not be determined. One of the occupants was the aircraft owner, who held a private certificate with a single-engine land rating, was known to have previously flown the airplane on contract flights from both the left and right seats. A second pilot was the normal copilot for all previous contract flights; his certificates had been revoked by the FAA. The third occupant held an airline transport pilot certificate and had never flown in the airplane before. Prior to the accident flight, the owner had told an associate that the third occupant was going to fly the airplane on the accident flight.
Probable cause:
The flying pilot's failure to maintain directional control following a loss of engine power. Also causal was the failure of the flight crew to follow the published checklist and use the rudder assist system, and the decision not to abort the takeoff.
Final Report: