Crash of a Fletcher FU-24-950 in Raetihi

Date & Time: Sep 28, 1999 at 1750 LT
Type of aircraft:
Operator:
Registration:
ZK-DLS
Flight Phase:
Survivors:
Yes
MSN:
182
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was taking off on the final sowing sortie, after which the pilot was to return to home base. The pilot reported that, on the takeoff roll, the engine appeared to overspeed and that the aircraft failed to get airborne. It subsequently sank into a shallow gully off the end of the strip. After the accident, one propeller blade was found to be free to rotate about its feathering axis. Metallurgical analysis indicated that the pitch change knob on the subject blade failed as the result of ductile overload. A second pitch change knob was also bent and cracked but had not separated from the blade. The overload sustained by the pitch change knobs was determined to have occurred at impact, not in flight. No reason was established for the failure to become airborne.

Crash of a Cessna 404 Titan II in Glasgow: 8 killed

Date & Time: Sep 3, 1999 at 1236 LT
Type of aircraft:
Registration:
G-ILGW
Flight Phase:
Survivors:
Yes
Schedule:
Glasgow – Aberdeen
MSN:
404-0690
YOM:
1980
Flight number:
Saltire 3W
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
4190
Captain / Total hours on type:
173.00
Copilot / Total flying hours:
2033
Copilot / Total hours on type:
93
Aircraft flight hours:
6532
Circumstances:
The aircraft had been chartered to transport an airline crew of nine persons from Glasgow to Aberdeen. The aircraft was crewed by two pilots and, so far as could be determined, its take-off weight was between 8,320 and 8,600 lb. The maximum permitted take-off weight was 8,400 lb. ATC clearance for an IFR departure was obtained before the aircraft taxied from the business aviation apron for take-off from runway 23, with a take-off run available of 2,658 metres. According to survivors, the take-off proceeded normally until shortly after the aircraft became airborne when they heard a thud or bang. The aircraft was then seen by external witnesses at low height, to the left of the extended runway centerline, in a wings level attitude that later developed into a right bank and a gentle descent. Witnesses reported hearing an engine spluttering and saw at least one propeller rotating slowly. There was a brief 'emergency' radio transmission from the commander and the aircraft was seen entering a steep right turn. It then entered a dive. A witness saw the wings levelled just before the aircraft struck the ground on a northerly track. Three survivors were helped from the wreckage by a nearby farm worker before flames from a severe post-impact fire engulfed the cabin.
Probable cause:
The following causal factors were identified:
- The left engine suffered a catastrophic failure of its accessory gear train leading to a progressive but complete loss of power from that engine,
- The propeller of the failed engine was not feathered and therefore the aircraft was incapable of climbing on the power of one engine alone,
- The commander feathered the propeller of the right-hand engine, which was mechanically capable of producing power resulting in a total loss of thrust,
- The commander attempted to return to the departure airfield but lost control of the aircraft during a turn to the right.
Final Report:

Crash of a Boeing 737-204C in Buenos Aires: 65 killed

Date & Time: Aug 31, 1999 at 2054 LT
Type of aircraft:
Operator:
Registration:
LV-WRZ
Flight Phase:
Survivors:
Yes
Schedule:
Buenos Aires – Córdoba
MSN:
20389
YOM:
1970
Flight number:
MJ3142
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
95
Pax fatalities:
Other fatalities:
Total fatalities:
65
Captain / Total flying hours:
6500
Captain / Total hours on type:
1710.00
Copilot / Total flying hours:
4085
Copilot / Total hours on type:
560
Aircraft flight hours:
67864
Aircraft flight cycles:
41851
Circumstances:
LAPA flight 3142 was scheduled to depart from Buenos Aires-Jorge Newbery Airport at 20:36 for a 1 hour and 15 minute flight to Córdoba, Argentina. The first officer and cabin crew were the first to arrive at the Boeing 737-200. The first officer notified one of the mechanics that the total fuel requirement was 8,500 kg, all to be stored in the wing tanks. The mechanic noticed there was still some fuel in the central tank and commenced transferring the fuel from the central to the wing tanks. At that moment the captain boarded the flight. He threw his paperwork on the ground, showing annoyance, confirming that attitude by later shutting off the fuel transfer between the main tank and the wing tanks. During their first four minutes on board, the captain, the co-pilot and the purser talked about trivial matters in good spirits, focusing on the purser's personal issues. When the purser left the cockpit, the conversation changed tone as they discussed a controversial situation about the family problems of the captain. The captain said that he was "going through bad times", to which the copilot replied that he was also having a bad day. Without interrupting the conversation, the crew began working the checklists, mixed with the personal issues that worried them and that led them to misread the checklist. In the process they omitted to select the flaps to the appropriate takeoff position. This confusing situation, in which the checklist procedure was mixed with conversation irrelevant to the crew's task, persisted during push back, engine start and taxiing, up to the moment of take-off, which was delayed by other aircraft waiting ahead of the LAPA flight and heavy arriving traffic. During this final wait, the crew members were smoking in the cockpit and continued their conversation. Take-off was started on runway 13 at 20:53 hours. During the takeoff roll the Take-off warning system sounded because the flaps had not been selected. The crew ignored the warning and continued the takeoff. After passing Vr, the pilot attempted to rotate the aircraft. The stick shaker activated as the aircraft entered a stall. It successively impacted the ILS antenna, the perimeter fence, a waiting shelter for buses, two automobiles, two excavators and an embankment where it stopped. Immediately a fire erupted. Three flight crew members, 60 passengers and two persons inside an automobile were killed.
Probable cause:
The JIAAC considers as an immediate cause of the accident that the flight crew of the LAPA 3142 forgot to extend the flaps for takeoff and dismissed the alarm sound that warned about the lack of configuration for that maneuver.
The contributing factors were:
- Lack of discipline of the crew that did not execute the logical reaction of aborting the takeoff and verification of the failure when the alarm began to sound when adding engine power and continued sounding until the rotation attempt.
- Excess of conversations foreign to the flight and for moments of important emotional intensity between the pilots, that were mixed with the execution of the check lists, arriving at omitting the part of these last ones where the extension of flaps for takeoff had to be completed.
- Personal and/or family and/or economic and/or other problems of both pilots, which affected their operational behavior.
- Insufficiency of the psychic control system, which did not allow to detect when the pilots were suffering personal and/or family problems and/or of another type that influenced their operational capacity when diminishing their psychic stability.
- Knowledge and treatment of very personal and extra-occupational issues among the pilots and even with the onboard commissioner, who facilitated the atmosphere of scarce seriousness and concentration in the operational tasks.
- Background of negative flight characteristics of the commander that surfaced before his personal situation and relationship in the cockpit before and during the emergency.
- Background of flight characteristics of the co-pilot, which manifested themselves during compliance with the procedural checklists in a cockpit where its components participated with a completely dispersed attention to particular interests outside the flight.
- No immediate recognition or verification of both pilots, of the relationship between the type of intermittent audible alarm that indicated failure in the configuration for takeoff, with the absence of flaps in the position for this maneuver.
- Design of the take-off configuration alarm system that does not allow, in this type of aircraft, a simple check by the crews to ensure periodic listening to this type of intermittent alarm.
Final Report:

Crash of a Cessna 414 Chancellor in Alpine

Date & Time: Aug 28, 1999 at 1021 LT
Type of aircraft:
Operator:
Registration:
N67JM
Flight Phase:
Survivors:
Yes
Schedule:
Alpine - Lajitas
MSN:
414-0066
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
383
Captain / Total hours on type:
24.00
Aircraft flight hours:
5581
Circumstances:
The pilot had the main and auxiliary fuel tanks filled and performed an abbreviated preflight prior to departing the Alpine Airport. The pilot did not perform an engine run-up prior to takeoff. The pilot stated that while the airplane was climbing through 100 feet agl, the left engine 'started to surge.' The pilot reported that he knew the airplane would not be able to climb at field elevation with one engine inoperative. The pilot switched the left engine's boost pump from low to high; however, the left engine continued to surge while the airplane lost altitude. The pilot initiated a forced landing with the landing gear and flaps retracted and the left propeller unfeathered. The airplane impacted the ground left wing tip first and a fire erupted, which damaged the left wing and left side of the fuselage. The left engine's spark plugs were found covered with thick black soot. The left engine's magnetos were rotated using an electric hand-held drill, and the left magneto did not produce any spark and the right magneto produced a spark in three of its six distributor cap posts. The left magneto's primary winding resistance and capacitor leakage were found to be beyond the manufacturer's specified limits. The internal components of both magnetos were covered in a dark oil and debris. The maximum takeoff weight for the accident airplane was 6,350 pounds; however, the takeoff weight at the time of the accident was calculated to be 6,509 pounds. The aircraft's single engine performance charts indicated that the airplane would obtain a 29 fpm climb at maximum gross weight with the inoperative engine feathered. The pilot operating handbook's supplement section indicated that the auxiliary fuel pump should only be used when the engine-driven fuel pump failed. A caution statement states in bold print, 'If the auxiliary fuel pump switches are placed in the HIGH position with the engine-driven fuel pump(s) operating normally, total loss of engine power may occur.'
Probable cause:
The pilot's improper use of the emergency fuel boost pump, which resulted in excessive fuel flow to the engine and subsequent total loss of left engine power. Factor's were the high density altitude, the pilot exceeding the airplane's weight and balance, the partial loss of left engine power as a result of the faulty magnetos, and the pilot's inadequate preflight inspection by not performing an engine run-up.
Final Report:

Crash of a Cessna 208 Caravan I in Hillsborough

Date & Time: Aug 13, 1999 at 1311 LT
Type of aircraft:
Registration:
N193GE
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Manchester - Denver
MSN:
208-0193
YOM:
1991
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10530
Captain / Total hours on type:
3000.00
Aircraft flight hours:
6132
Circumstances:
With an auxiliary fuel tank system installed, the pilot filled the tanks and departed. A few minutes later, he noticed fuel on the floor of the cabin, and tried to reach an airport. However, the fuel fumes were so strong he elected to land in an open field. After touchdown, the airplane passed through a ditch the pilot had not observed from the air. The nose landing gear collapsed and the airplane nosed over. An airborne witness reported the pilot exited the airplane after about 5 minutes, and about 5 minutes later, the airplane caught fire and burned. The post crash fire consumed the cabin. In an interview, the pilot reported that he had not initiated use of the auxiliary fuel tank system when the accident occurred. He also reported he could not see where the fuel was coming from. The investigation revealed the tank installation did not match the FAA Form 337, the instructions for use of the ferry tank system were inadequate, and the pilot had reported that the auxiliary fuel pumps were secured to a board which was not secured to the airplane.
Probable cause:
An inadequate auxiliary fuel tank installation which resulted in a leak of undetermined origin.
Final Report:

Crash of a Short SC.7 Skyvan 3 Variant 100 in Surkhet

Date & Time: Aug 7, 1999 at 0635 LT
Type of aircraft:
Operator:
Registration:
RAN-19
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
1884
YOM:
1970
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll on runway 20, the aircraft started to skid. Halfway down, the crew decided to abandon the takeoff procedure but the aircraft was unable to stop within the remaining distance. It overran and came to rest in a ravine. Both pilots escaped uninjured and the aircraft was damaged beyond repair. Weather conditions were good at the time of the accident with an OAT of 18° C. and light wind. The Surkhet Airport runway 20/02 is grass and is 3,400 feet long. It was reported that at the time of the accident, the turf was quit high and wet due to the morning dew which was considered as a contributing factor.

Crash of a Beechcraft C90 King Air in Marine City: 10 killed

Date & Time: Jul 31, 1999 at 0825 LT
Type of aircraft:
Operator:
Registration:
N518DM
Flight Phase:
Survivors:
No
Schedule:
Marine City - Marine City
MSN:
LJ-251
YOM:
1967
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
9700
Aircraft flight hours:
8986
Circumstances:
The airplane impacted the terrain approximately 2,065 feet south of the departure end of runway 22. Damage to the cockpit section of the wreckage indicated a nose down crush angle of approximately 80 degrees. The wreckage path was on a 208 degree heading, and the distance from the initial impact to the location of the empennage was about 142 feet. The cockpit and cabin were destroyed by post impact fire. Examination of the engines and propellers revealed no preexisting failures or conditions that would have prevented normal operation. The engines exhibited indications of rotation, and the witness marks on both sets of propellers were consistent with the propellers operating in the governing range at impact. Control continuity was established from the right aileron, elevator, and rudder. Witnesses reported the airplane seem to be operating normally during taxi and takeoff, but that it entered a steep left bank after clearing a 100 foot powerline located about 1,800 feet from the departure end of runway 22. After entering the steep left turn, the nose of the airplane dropped and the airplane impacted the ground. There was no evidence in the airplane's maintenance records of any annual maintenance inspection since August, 1997, although an airframe and powerplant mechanic reported that he had completed an inspection on June 30, 1999. There was no record in the airplane's maintenance records of compliance with five airworthiness directives applicable to the airplane.
Probable cause:
The pilot's failure to maintain adequate airspeed, which resulted in a stall, inflight loss of control, and collision with the ground.
Final Report:

Crash of an Ilyushin II-76TD in Irkutsk

Date & Time: Jul 26, 1999 at 1346 LT
Type of aircraft:
Operator:
Registration:
RA-76819
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tianjin – Irkutsk – Perm – Moscow
MSN:
10134 09274
YOM:
1991
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
2882
Aircraft flight cycles:
1177
Circumstances:
The aircraft departed Tianjin on a cargo flight to Moscow with intermediate stops in Irkutsk and Perm, carrying a load of 49,750 kilos of various goods and seven crew members. At Irkutsk-Intl Airport, 38 tons of fuel were uplifted and the crew calculated 30,040 kilos for the cargo, giving a total weight of 170 tons, about 4 tons below the MTOW. During the takeoff roll, after a course of 2,000 metres, at a speed of 225 km/h, the captain started the rotation. The aircraft lifted up and flew for about 4 seconds when the captain requested gear up. At a speed of 250 km/h, the aircraft passed the runway end and adopted a 16° angle of attack. Then the aircraft' speed decreased when the flight engineer reduced the power on all four engines and activated the thrust reverser systems on both left engines n°1 and 2. The aircraft rolled to the left, collided with a building containing an electrical transformer and came to rest 1,476 metres past the runway end, bursting into flames. All seven occupants were injured, two seriously. The aircraft was destroyed.
Probable cause:
It was determined that the total weight of the aircraft at the time of the accident was 198-200 tons which means 24-26 tons above MTOW. The cargo manifest showed a total weight of 49,750 kilos of various goods upon departure from Tianjin Airport but only 30,040 kilos upon departure from Irkutsk Airport while no cargo was unloaded. The following contributing factors were identified:
- A miscalculation of the mass and balance,
- Poor flight planning,
- Poor crew coordination.

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

Date & Time: Jul 23, 1999 at 1113 LT
Registration:
N345LS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Oklahoma City – San Angelo
MSN:
61-0315-085
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1500
Captain / Total hours on type:
100.00
Aircraft flight hours:
2945
Circumstances:
During takeoff, the twin-engine airplane was observed to roll left, pitch nose down, and impact terrain shortly after the pilot reported to ATC that he had a problem. Witnesses reported that the left engine was producing black smoke during the takeoff roll. One witness stated that the airplane had slowed to approximately 60-70 mph prior to rolling to the left. A mechanic, who worked on the airplane prior to the accident, stated that the pilot reported being unable to maintain manifold pressure (MP) with the left engine. The mechanic found that the left engine's rubber interconnect boot, which routes induction air between the turbocharger controller elbow and the fuel servo, was 'gaping open.' The mechanic reseated the boot and tightened the clamp. The pilot flew the airplane and reported no problems. During a second flight, the pilot reported that the left engine was again unable to maintain MP. Prior to the accident flight, the pilot informed the mechanic that the 'hose had slid off again' and that it had been reinstalled and he 'felt sure it was o.k.' A witness stated that he saw the pilot working on the left engine the morning of the accident. At the accident site, the left engine's interconnect boot was found disconnected. The clamp securing the boot was not located. No other preimpact anomalies were found with the engines, propellers, turbochargers, or fuel servos.
Probable cause:
The pilot's failure to maintain the minimum controllable airspeed. A factor was the disconnected rubber interconnect boot, which resulted in the partial loss of left engine power.
Final Report:

Crash of a Boeing 727-243F in Kathmandu: 5 killed

Date & Time: Jul 7, 1999 at 1951 LT
Type of aircraft:
Operator:
Registration:
VT-LCI
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Katmandu – New Delhi – Sharjah
MSN:
22168
YOM:
1981
Flight number:
LCI8533
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Aircraft flight hours:
43000
Aircraft flight cycles:
25000
Circumstances:
The aircraft departed Kathmandu-Tribhuvan Airport on a cargo flight to Sharjah with an intermediate stop in New Delhi, carrying five crew members and a load of 21 tons of woolen carpets. After takeoff from runway 20, the crew continued to climb but failed to realize his altitude was insufficient. The aircraft struck the slope of Mt Champadevi located 11 km southwest of the airport and disintegrated on impact. All five crew members were killed.
Probable cause:
The accident occurred as the crew after take off did not adhere to the published Standard Instrument Departure (SID) procedure for runway 20 at Kathmandu, Nepal.
The following contributory factors were identified:
- Incomplete departure briefing given by P1 while other cockpit activities were in progress,
- The unexpected airspeed decay to V 2 -3 during initial right climbing turn South of the VOR which occurred while P2 was busy with ATC,
- The improper power and climb profile used by P1 after rolling the aircraft out on a southwest heading following the initial airspeed loss,
- The inadequate intra cockpit crew coordination and communication as the aircraft proceeded to and across the KTM VOR 4 DME arc before recommencing a shallow right turn, and
- The incorrect and slow response to the initial and subsequent GPWS activation prior to the collision with the terrain.