Crash of a De Havilland DHC-3 Otter near Points North Landing

Date & Time: May 1, 1999
Type of aircraft:
Operator:
Registration:
C-FASV
Flight Phase:
Survivors:
Yes
MSN:
23
YOM:
1953
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
20000
Captain / Total hours on type:
6400.00
Circumstances:
The wheel-ski equipped de Havilland DHC-3 Otter, C-FASV, serial number 23, was engaged in flying road construction crews from base camps to work sites in northern Saskatchewan. A five-man crew was moved from a base camp to a small lake, about 22 nautical miles (nm) from Points North Landing, Saskatchewan, the company's main base. The drop-off was made in the morning with a pick-up planned for late afternoon. The pilot then flew back to Points North Landing and filled the aircraft's fuel tanks from the company's main fuel supply. When the pilot returned for the pick-up, the ambient temperature was about seven degrees Celsius, and there were between five and six inches of slush on the ice surface. The pilot loaded the passengers and attempted a take-off. The aircraft accelerated slowly in the slush, and the pilot rejected the take-off. He selected a different take-off run, moved a passenger to a forward seat, and attempted a second take-off. The pilot continued beyond his previously selected rejection distance. The engine revolutions per minute (rpm) then reportedly decreased by about 150 rpm. The aircraft did not become airborne, and it ran into the low shoreline and crashed, skidding to a stop about 300 feet from the shore. An intense fire broke out immediately. The passengers and pilot evacuated the aircraft. Only one passenger suffered minor burns during the evacuation. Flames engulfed the main fuselage and engine, destroying the aircraft.
Probable cause:
The pilot continued the take-off run with the left ski firmly adhering to the slushy surface beyond a point at which a reject could have been made safely. Contributing to the occurrence was the decrease in engine rpm during take-off.
Final Report:

Crash of a De Havilland DHC-5 Buffalo in Mandera: 1 killed

Date & Time: May 1, 1999
Type of aircraft:
Operator:
Registration:
KAF207
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
75
YOM:
1977
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
During the takeoff roll, the captain decided to abort for unknown reasons. Unable to stop within the remaining distance, the aircraft overran and collided with a building. All five occupants escaped uninjured while one people on the ground was killed.

Crash of a Beriev BE-103 in Straubing: 1 killed

Date & Time: Apr 29, 1999 at 1833 LT
Type of aircraft:
Registration:
RA-03002
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Straubing - Straubing
MSN:
30 02
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
A testflight for the purpose of vibration measurements on the propellers was to be carried out with the a.m. aircraft. The Beriev BE103 is the prototype of a 6 seater, twin engine amphibious aircraft of russian design. It was powered by two piston engines Teledyne Continental IO-360 E5 which operated hydraulic variable pitch propellers. In the course of the russian type certification the vibration behavior and the stiffness of the propeller blades had to be proven. Therefore a test propeller, fitted with wire strain gauges was attached to the L/H engine at the propeller manufacturer’s facilities in Straubing. The transducers and transmitters were fitted instead of the spinner by means of special brackets. The data recording system was installed in the aircraft’s cabin. As during the testflights a maximum of 105% of the maximum allowable rpm had to be achieved the L/H propeller governor was adjusted to 2940 rpm. Furthermore the R/H propeller and governor were changed from prototypes to the serial components. After these modifications several engine test runs were carried out for calibration of the test equipment and data recording. The testflight was recorded on a camcorder. The film showed that the pilot in command taxied to the far end of the 940 m long pavement runway, adjusted the engines while standing and thereafter commenced his take-off run which should have been approx. 300 m long with view to the aircraft weight according to information gained from the a/c manufacturer. The a/c, however, taxied far beyond the ½ marking of the runway, rotated fairly long and went airborne after approx. 700 m with a high angle of attack. After gaining 10 to 15 m of altitude the pilot in command retracted the landing gear. Right after that the a/c entered a shallow descend in a nose-up attitude and turned to the left before it left the camera view some seconds before the impact. During the entire flight a constant and normal engine noise was audible. Approx. 600 m behind the runway end the aircraft hit the bank of a street and caught fire. The pilot in command was fatally injured, the aircraft was destroyed by the impact and the post impact fire.
Probable cause:
The accident was caused by the pilot in command trying to depart at an extremely reduced power setting and not aborting the take-off in time. Technical causes were not determined. The wrong power setting was related to a misinterpretation of the function and procedures in connection with the constant speed propeller system. Although these are part of the basic knowledge of a pilot on aircraft of this category they were explained to him by employees of the propeller manufacturer and the aircraft manufacturer’s test flight engineer as part of the preflight briefing. With a high probability the pilot did not understand these explanations in all details. The service of an interpreter was refused by him. The planned testflights wouldn’t have led to a power reduction when accomplished properly.
Final Report:

Crash of a Pilatus PC-6/B1-H2 Turbo Porter in Haifa: 4 killed

Date & Time: Apr 24, 1999
Operator:
Registration:
4X-AIY
Flight Phase:
Survivors:
Yes
Schedule:
Haifa - Haifa
MSN:
729
YOM:
1971
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
After takeoff from Haifa Airport, while climbing to a height of about 300 feet, the engine lost power then failed. The aircraft lost height and crashed on the top of a hill near the airport. The pilot and three skydivers were killed while six other occupants were injured.
Probable cause:
Engine failure for unknown reasons.

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

Date & Time: Apr 23, 1999 at 1023 LT
Registration:
N48MD
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ruidoso – North Las Vegas
MSN:
61-0492-201
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3681
Captain / Total hours on type:
597.00
Aircraft flight hours:
4526
Circumstances:
The pilot departed on runway 06 with zero degrees of flaps. A witness said that she noticed that the airplane appeared to wobble and shudder, and immediately went into a steep right bank turn right after takeoff. The airplane then went into the clouds which were 200 to 400 feet agl. Radar data indicated that the airplane made several 90 degree turns prior to impacting the mountainous terrain 2.55 nm from the departure end of the runway. The pilot normally used 20 degrees of flaps for takeoff. A test pilot said that the airplane handles significantly different during takeoff if zero degrees of flaps are used verses 20 degrees of flaps. The upper cabin's entry door was found, with the locking handle and locking pins, in the closed position. No preimpact engine or airframe anomalies, which might have affected the airplane's performance, were identified.
Probable cause:
The pilot's failure to maintain aircraft control for undetermined reason. A factor was the low ceiling IMC weather condition.
Final Report:

Crash of a McDonnell Douglas MD-11F in Shanghai: 8 killed

Date & Time: Apr 15, 1999 at 1604 LT
Type of aircraft:
Operator:
Registration:
HL7373
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Shanghai - Seoul
MSN:
48409
YOM:
1992
Flight number:
KE6316
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
12898
Captain / Total hours on type:
4856.00
Copilot / Total flying hours:
1826
Copilot / Total hours on type:
1152
Aircraft flight hours:
28347
Aircraft flight cycles:
4463
Circumstances:
On April 15, 1999, Korean Air cargo flight KE6316, a McDonnell Douglas MD-11F, Korean registration HL7373, departed from runway 18 at Shanghai-Hongqiao International Airport, for Seoul, Korea with 2 pilots and 1 flight technician on board at 16:01:35 Beijing local time (08:01:35 UTC time). The autopilot was off 1 minute 7 seconds (at 16:02:42) after takeoff. The airplane maneuvered first to the right, and then kept level flight at approximately 200° track for more than 30 seconds, and maneuvered back to the left. The crew was subsequently cleared to climb to 1,500 meters (4,900 feet) during which the airplane turned to NHW** at 900 meters (3,000 feet). The airplane passed 1,310 meters at 16:04:15, the airplane suddenly executed a very rapid descent after reaching 1,370 meters (4,500 feet) at 16:04:19 and then the airplane disappeared from the airport SSR screen. The airplane crashed into the ground at 16:04:35 according to Shanghai Seismic Bureau's measurement. The distance from the accident site to the airport runway is 11.6 kilometers, the site azimuth is 165° from the center of the runway centerline. The aircraft was totally destroyed and all three crew members were killed as well as five people on the ground. Thirty-six other people were injured, four seriously.
Probable cause:
The joint investigative team determines that the probable cause of the Korean Air flight KE 6316 accident was the flight crew's loss of altitude situational awareness resulting from altitude clearance wrongly relayed by the first officer and the crew's overreaction with abrupt flight control inputs.
Final Report:

Crash of a PAC Fletcher FU-24-954 near Riversdale: 1 killed

Date & Time: Mar 27, 1999 at 1435 LT
Type of aircraft:
Operator:
Registration:
ZK-EMV
Flight Phase:
Survivors:
No
Schedule:
Riversdale - Riversdale
MSN:
276
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8175
Captain / Total hours on type:
4500.00
Aircraft flight hours:
8837
Circumstances:
After completing the first run at the heavier weight, the pilot of ZK-EMV indicated to the loader driver that the load be increased by an additional hundredweight after the next run. The pilot of the second aircraft remained at 22 hundredweight, though he had moved his loading point back a short distance to provide additional take-off distance. The second pilot was still encountering “some sink” after take off, coinciding with the raising of flap. On completion of the second run at 22 hundredweight, the pilot of ZK-EMV positioned the aircraft for loading about 25 m to the east of his previous loading point. ZK-EMV was regarded by some personnel in the company to have had slightly better performance than other similar model aircraft. Consequently the increase to 23 hundredweight, while of interest, did not raise any concerns by the loader driver. Despite being unable to observe the departure of ZK-EMV, the loader driver was still able to hear the aircraft’s engine noise and recalled nothing unusual as the aircraft departed after loading. On returning from his run, the pilot of the second aircraft saw ZK-EMV to his lower right, in a steep climb, estimated to be about 45 to 50°. As it continued to climb the aircraft rolled slowly to the left, peaking at a height equivalent to “3 times power pole height”. Objects were seen falling from the aircraft during this time. Once inverted the aircraft descended rapidly, striking the ground. The aircraft hit the ground approximately 350 m from the strip, near where the power lines crossed a bend in the road and a small intersection. The pilot of the second aircraft landed and informed the two loader drivers. Together the group headed for the accident site in the loader truck. While en route a member of the group alerted emergency services by the use of a cellular telephone. The accident was also observed by the driver of a truck who had recently deposited a load of fertiliser in the bin at the airstrip. The driver had stopped the truck on a narrow gravel road below the airstrip to check the tailgate of the trailer. He then heard an aircraft begin its take-off run and decided to stay and watch the departure as the aircraft would fly over the road close to where the truck was parked. The driver saw ZK-EMV leave the end of the strip and “sag down a long way”, appearing to “drop like a stone”. The aircraft was observed to be in a high nose or climbing attitude as it continued to descend in a slight left turn towards a fence next to the road. The aircraft was then seen to strike the fence and balloon up, dropping fertiliser as it climbed. The aircraft then rolled left and descended in the direction of the truck driver, who quickly sought cover underneath the trailer. The aircraft struck the ground in a paddock next to the road, stopping about 5 m from the truck. With 15 years of working near agricultural aircraft, the truck driver considered himself to be familiar with their operations. The driver observed no items falling from the aircraft before it struck the fence, or anything hit the aircraft. He considered the engine to be at “full song” or maximum power the whole time and heard no change in pitch or beat. After the accident the truck driver went quickly to the upturned aircraft and attempted unsuccessfully to locate the pilot. The driver then headed for the airstrip in the truck, meeting the loader drivers and second pilot on their way to the aircraft. On reaching ZK-EMV the bucket on the loader was used to lift the aircraft to gain access to the cockpit. However, no assistance could be given to the pilot who had died on impact.
Probable cause:
The following findings were identified:
- The pilot was appropriately licensed, rated and experienced for the agricultural operation.
- The aircraft had a valid Certificate of Airworthiness and its records indicated that it had been maintained correctly.
- There was no evidence of any malfunction with the aircraft.
- The topography of the area should have presented no unusual problems for the pilot.
- The weather conditions at the time were suitable for sowing.
- A light tailwind component degraded the take-off and departure performance of the aircraft.
- Any ground effect benefits would have been lost immediately after take-off.
- The pilot was unable to establish a positive climb gradient after take-off.
- The aircraft was probably overweight for the prevailing variable weather conditions at the time of the last take-off.
- The pilot’s jettisoning of the load was too late to prevent the aircraft from striking the fence.
- As a result of striking the fence, the aircraft became uncontrollable.
Final Report:

Crash of a Beechcraft A90 King Air in Franca: 2 killed

Date & Time: Mar 23, 1999 at 1910 LT
Type of aircraft:
Registration:
PT-OUL
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Franca – Ribeirão Preto
MSN:
LJ-125
YOM:
1966
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3500
Captain / Total hours on type:
650.00
Copilot / Total flying hours:
206
Circumstances:
Less than a minute after takeoff from Franca Airport, while climbing in poor weather conditions, the twin engine aircraft nosed down and crashed in a huge explosion about 1,500 metres past the runway end. The aircraft was destroyed and both pilots were killed. They were completing a cargo flight to Ribeirão Preto, carrying documents on behalf of Banco do Brasil.
Probable cause:
The following findings were identified:
- The crew was in a hurry to take off in order to avoid poor weather approaching the airport,
- The crew took off from an intersection with a taxiway,
- Immediately after takeoff, the aircraft entered clouds,
- Approximately one minute after liftoff, the aircraft impacted ground,
- After the first impact, the aircraft flew for another 200 metres and again collided with the ground and exploded,
- The aircraft was totally destroyed by a post crash fire,
- The pilot had a hearing problem that was stabilized and was being researched by HASP. Considering the relationship between ear and ear balance, spatial disorientation in the pilot in
in the face of the adverse conditions it experienced: flight conditions by instruments associated with “windshear”. Since the search could not be completed above mentioned, this aspect remains undetermined,
- Individual characteristics contributed due to the habits acquired by the pilot and his eventual practice of taking off from the taxiway, delaying the point from which the aircraft would achieve the best characteristics flight performance,
- Poor weather conditions with CB's, sudden changes in wind, strong turbulence and rain, were conducive to the emergence of the phenomenon of “Windshear”, representing a real risk to the operation of any aircraft, being that voluntary entry or not, in this type of training, results almost always in the loss of control of the aircraft with unforeseeable consequences. The crew faced these conditions when the aircraft took off,
- It was evident from the witness statements that the pilot was in a hurry to take off, in addition to having used runway 23 from the intersection and towards the sector most affected by poor weather.
Final Report:

Crash of a Rockwell Aero Commander 500B off Shelter Cove

Date & Time: Mar 18, 1999 at 1835 LT
Registration:
C-FBCR
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Shelter Cove - Willits
MSN:
500-1376-135
YOM:
1963
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5400
Captain / Total hours on type:
32.00
Aircraft flight hours:
11635
Circumstances:
Prior to departure the pilot believed that his airplane contained between 30 and 40 gallons of fuel, adequate for a 15-minute-long flight to another airport where he could purchase additional fuel. The pilot reported the fuel gauge registered 40 gallons, so he departed. During initial climb upon reaching an altitude of about 400 feet above the ocean, both engines simultaneously lost power. The pilot rocked the airplane's wings and experienced a 'short surge of power.' However, it lasted only a brief moment and all engine power was again totally lost. The pilot turned toward the shoreline, reduced airspeed, and ditched about 0.25 miles off shore. The overnight tide/wave action subsequently beached most of the airplane. In the pilot's report, he did not indicate having experienced any mechanical malfunctions. The Federal Aviation Administration (FAA) coordinator examined recovered portions of the airframe and engines. In pertinent part, the FAA reported finding no physical evidence of any mechanical malfunction with the examined components. However, because of the airframe damage sustained during immersion in the salt water and the subsequent destruction to components, the Safety Board was unable to document the integrity of the fuel quantity indicator system.
Probable cause:
Fuel exhaustion due to the pilot's failure to ensure that an adequate fuel supply was onboard. A contributing factor was the lack of suitable terrain for the forced landing.
Final Report:

Crash of a Beechcraft C-45G Expeditor in Detroit: 1 killed

Date & Time: Mar 11, 1999 at 0051 LT
Type of aircraft:
Registration:
N234L
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Detroit - Detroit
MSN:
AF-447
YOM:
1958
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1305
Aircraft flight hours:
7073
Circumstances:
The aircraft declared an emergency following departure from runway 03R at Detroit Metropolitan Wayne County Airport, Romulus, Michigan. The aircraft was resting on a magnetic heading of 055 degrees located approximately 3,400 feet from and 1,900 feet to the left of the departure end and centerline of runway 03R at DTW. Inspection of the forward section of the fuselage door and surrounding fuselage, a circular impression with no exposure of the underlying metal was noted approximately 2 feet 6-1/2 inches from the door hinge line. The door was opened to a point nearly flush with the aircraft's fuselage. The door handle was found to match the circular impression in position and shape. There was no tearing or fracturing of the forward fuselage door pin tips or its door pin holes. Inspection of the door's latching mechanism revealed a brown colored nail connecting the handle and vertical latches. Both engine supercharger turbine wheels displayed scoring and deformation of the impeller blades in the plane of rotation. Aileron, elevator and rudder flight control continuity was established. The elevator trim was in the neutral position. The trailing edge flaps were in the retracted positions. Both engine oil screens showed no evidence of metal contamination.
Probable cause:
The aircraft control not maintained and the inadvertent stall by the pilot while maneuvering to the landing area. The open door was a contributing factor.
Final Report: