Crash of a Boeing E-3A Sentry in Preveza

Date & Time: Jul 14, 1996
Type of aircraft:
Registration:
LX-N90457
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Preveza - Geilenkirchen
MSN:
22852
YOM:
1984
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was completing a flight from Preveza to the Geilenkirchen NATO Air Base in Germany. During the takeoff roll at Preveza-Aktion Airport, after V1 speed, the pilot-in-command heard a loud noise. Thinking this was the consequence of a bird strike, he decided to abandon the takeoff procedure and started an emergency braking manoeuvre. Unable to stop within the remaining distance, the aircraft overran, struck a dyke and came to rest partially submerged in the sea. All 16 occupants escaped uninjured.
Probable cause:
Investigations revealed there were no indications of a possible bird striked during takeoff.

Crash of a Piper PA-46-310P Malibu in Hartford

Date & Time: Jul 12, 1996 at 1115 LT
Registration:
N234DM
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Hartford – Block Island
MSN:
46-8408043
YOM:
1984
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4918
Captain / Total hours on type:
488.00
Circumstances:
The pilot reported that he performed a rolling takeoff from the 2315 ft runway. He said that as soon as the airplane broke ground on the takeoff roll, he experienced a loss of engine power. The pilot said that he retracted the gear to help clear a 42 ft dike at the departure end of the runway. Also, he reported that after clearing the dike, he turned gradually to the left, and the left wing stalled. Two witnesses reported hearing loud, steady sounds from the airplane's engine and propeller. They said they saw the airplane in a high nose-up attitude, and watched the airplane descend behind the dike. The engine could be heard until the airplane contacted the river. During an operational check after the accident, the engine performed at recommended levels. According to performance data provided by the FAA, at the given takeoff weight, with a zero degree flap setting, the airplane required 2850 feet of runway to clear a 50 ft obstacle. The charts were based on full power before brake release.
Probable cause:
The pilot's inadequate preflight planning/preparation, and his failure to attain the proper liftoff airspeed, which resulted in a stall and collision with the terrain (river).
Final Report:

Crash of an Avro 748-402-2B in Ambon

Date & Time: Jul 11, 1996 at 0900 LT
Type of aircraft:
Operator:
Registration:
PK-IHN
Flight Phase:
Survivors:
Yes
Schedule:
Ambon - Manado
MSN:
1794
YOM:
1983
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
43
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Ambon-Pattimura Airport, just before Vr, one of the engine failed. The captain abandoned the takeoff procedure and initiated an emergency braking manoeuvre. Unable to stop with the remaining distance (the runway surface was wet), the aircraft overran and came to rest 180 metres further against a dyke. All 48 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a Beechcraft 65 Queen Air in Campbellsville

Date & Time: Jun 30, 1996 at 1240 LT
Type of aircraft:
Registration:
N3870C
Flight Phase:
Survivors:
Yes
MSN:
LC-212
YOM:
1966
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3500
Captain / Total hours on type:
100.00
Aircraft flight hours:
2549
Circumstances:
According to an FAA inspector, the airplane '...was unable to get airborne...' during the takeoff roll. He stated that after travelling the full length of the 4,997-foot runway, the airplane ran off the departure end of runway 5 and continued approximately 2,257 feet through an open field, a fence, a corn field and into a depression where it impacted terrain and came to rest. The pilot reported that during the takeoff roll he discovered that he had not removed the gust lock from the control column and that his attempts to remove it were unsuccessful. The pilot stated that the aircraft '...went off the end of the runway through a fence and impacted an earthen berm that collapsed the gear [and] blade strikes that stopped the engines.'
Probable cause:
The pilot's inadequate preflight preparation, his failure to remove the control lock, and his failure to abort the takeoff.
Final Report:

Crash of a Douglas DC-3A-S1C3G in Conroe

Date & Time: Jun 20, 1996 at 1408 LT
Type of aircraft:
Registration:
N23WT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Conroe - Conroe
MSN:
11650
YOM:
1943
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16500
Captain / Total hours on type:
707.00
Aircraft flight hours:
51307
Circumstances:
During initial takeoff climb the copilot who was manipulating the controls called for METO (maximum except takeoff) power. After the pilot-in-command set METO power, the left engine lost power. The PIC took the controls from the copilot and called for him to feather the left propeller. The copilot did not hear the call to feather the left propeller. Maintaining an indicated airspeed of 90 knots and wings level attitude, the airplane descended into trees and impacted a rural residential paved street. The cockpit area and main fuselage were consumed by a post crash fire. Examination of the throttle quadrant revealed the propeller control levers were forward, the mixture control levers were autorich, the throttle for the right engine was forward, and the throttle for the left engine was at idle. According to a FAA operations inspector maintaining 90 knots with the propeller not feathered would result in the aircraft descending. The pilot and copilot had not completed a proficiency check or flight check for the DC3 type aircraft within the previous 24 months. Examination of the left engine did not disclose any preexisting anomalies.
Probable cause:
The flight instructor's failure to use the single engine best angle of climb airspeed resulting in a loss of control of the aircraft. Factors were the loss of power to the left engine for undetermined reasons, the flight instructor not being qualified to be pilot-in-command in the DC3, his lack of recent experience in the DC3, and the lack of suitable terrain for the forced landing.
Final Report:

Crash of a PZL-Mielec AN-2TP in Georgetown

Date & Time: Jun 20, 1996 at 0950 LT
Type of aircraft:
Operator:
Registration:
N67AN
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Georgetown - Georgetown
MSN:
1G88-13
YOM:
1967
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7000
Captain / Total hours on type:
50.00
Circumstances:
During departure climb, the airplane experienced a loss of engine power. Emergency procedures were executed and a forced approach/landing was initiated to a field. While on the approach, the pilot observed a ditch running across the proposed landing pathway. He turned the airplane right to parallel the ditch. During the landing roll, the pilot attempted to avoid a building by intentionally ground looping the airplane. During this avoidance maneuver, the left wing struck the building. Examination of the airplane revealed that the engine had seized due to an internal failure. The reason for the engine's internal failure was not determined.
Probable cause:
Engine seizure for undetermined reasons. A factor was the lack of suitable terrain for the forced landing.
Final Report:

Crash of a Douglas DC-10-30 in Fukuoka: 3 killed

Date & Time: Jun 13, 1996 at 1208 LT
Type of aircraft:
Operator:
Registration:
PK-GIE
Flight Phase:
Survivors:
Yes
Schedule:
Fukuoka – Denpasar – Jakarta
MSN:
46685
YOM:
1979
Flight number:
GA865
Country:
Region:
Crew on board:
15
Crew fatalities:
Pax on board:
260
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
10263
Captain / Total hours on type:
2641.00
Copilot / Total flying hours:
3910
Copilot / Total hours on type:
1437
Aircraft flight hours:
46325
Circumstances:
During the takeoff roll at Fukuoka-Itazuke Airport runway 16, at a speed of 158 knots, the captain started the rotation. During initial climb, at a height of about 3 metres, the right engine suffered a loss of power after a fan blade located on the 1st stage of the high pressure compressor disk separated. The N1 dropped to 23,7% and five seconds later, the flight engineer informed the crew about the failure of the engine n°1. The captain decided to abort the takeoff and landed back on runway. The aircraft contacted ground with a vertical acceleration of 2,1 g then thrust reversers were deployed and ground spoilers were extended. Unable to stop within the remaining distance, the aircraft overran, crossed a road, skidded for about 620 metres before coming to rest in an open field, bursting into flames. Three passengers were killed.
Probable cause:
Although the CAS was well in excess of V1 and the aircraft had already lifted off from the runway, the takeoff was aborted. Consequently the aircraft departed the end of the runway, came to rest and caught fire. It is estimated that contributing to the rejection of the takeoff under this circumstance was the fact that the CAP's judgement in the event of the engine failure was inadequate. Investigation revealed that the turbine blade that failed, had operated for 30913 hours and 6182 cycles. General Electric had advised customers to discard blades after about 6000 cycles.
Final Report:

Crash of a Beechcraft E90 King Air in Wiscasset: 2 killed

Date & Time: Jun 10, 1996 at 0600 LT
Type of aircraft:
Registration:
N916PA
Flight Phase:
Survivors:
No
Schedule:
Wiscasset - Philadelphia
MSN:
LW-313
YOM:
1979
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
10516
Captain / Total hours on type:
1138.00
Aircraft flight hours:
6230
Circumstances:
The pilot took off on runway 07 and was cleared direct to the Wiscasset NDB, east of the airport. Shortly after takeoff, the airplane began turning to the left. The pilot then asked the controller, '. . . can you tell if I'm in a turn? I have a problem here.' Soon thereafter, the airplane collided with terrain in an uncontrolled descent, about 1.6 miles north of the airport. Investigation revealed that three days before the accident, a refueler had fueled the airplane's left wing with 840 pounds of fuel, then the fuel farm ran out of fuel. No further fueling was accomplished, and the pilot was not advised of the uneven fuel load. Procedures in the Beech E90 Pilot's Operating Manual (POM) included a check of the fuel tanks during preflight. The Beech C90 POM specified a maximum fuel imbalance of 200 pounds, but the E90 POM did not specify a maximum fuel imbalance. During examination of the wreckage, no preimpact malfunction or failure was found.
Probable cause:
Failure of the pilot to maintain control of the airplane while climbing after takeoff, due to spatial disorientation, which resulted in an uncontrolled descent and subsequent collision with terrain. Factors relating to the accident were: the improper refueling (servicing of the aircraft) by FBO personnel, and failure of the pilot to note the excessive lateral imbalance of the airplane during preflight.
Final Report:

Crash of an Ilyushin II-76MD in Kinshasa: 10 killed

Date & Time: Jun 6, 1996
Type of aircraft:
Operator:
Registration:
UR-76539
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kinshasa - Athens
MSN:
00334 42234
YOM:
1983
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
10
Aircraft flight hours:
2134
Aircraft flight cycles:
1358
Circumstances:
While taxiing backwards at Kinshasa-N'Djili Airport, the crew used thrust reversers and failed to extend the flaps prior to takeoff. During the takeoff roll, the pilot-in-command started the rotation when the nose gear lifted off. Despite the aircraft failed to take off, the crew did not reject the takeoff procedure and continued. The aircraft adopted a high nose up attitude and a super critical angle of attack. It rolled for about 3,800 metres, overran, rolled for another 800 metres when it struck irregularities on the ground. On impact, the right wing was torn off and the aircraft crashed, bursting into flames. All 10 occupants were killed. The aircraft was on its way to Athens, carrying a load consisting of engine and spare parts.
Probable cause:
The crew failed to prepare the flight according to published procedures and failed to extend flaps prior to takeoff. The following contributing factors were reported:
- Poor flight preparation,
- Poor crew coordination,
- Misunderstanding by the crew about the aircraft configuration,
- The pilot-in-command failed to reject takeoff.
- Crew's fatigue,
- The aircraft was not equipped with an alarm in case of wrong flaps' position.

Crash of a Learjet 25C in Ribeirão Preto: 2 killed

Date & Time: Jun 4, 1996 at 1320 LT
Type of aircraft:
Registration:
PT-KBC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
São Paulo – Uberaba – Ribeirão Preto
MSN:
25-165
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3500
Captain / Total hours on type:
250.00
Copilot / Total flying hours:
2000
Copilot / Total hours on type:
420
Circumstances:
The crew departed São Paulo on a training flight to Ribeirão Preto with an intermediate stop in Uberaba. On approach to Ribeirão Preto-Leite Lopes Airport, the instructor decided to reduce power on the left engine to simulate a failure and to complete a touch-and-go manoeuvre. After touchdown, the left engine power lever remained in the idle position so the captain took over control and attempted to take off as he judged it impossible to stop on the remaining runway. The aircraft took off but landed back about 92 metres past the runway end. Out of control, it collided with a truck and a tree and came to rest, bursting into flames. A man in the truck as well as one pilot were killed while three other pilots were injured. The aircraft was destroyed.
Probable cause:
The following findings were reported:
- There are indications of the presence of psychological variables that may have influenced the instructor's decision to perform the touch-and-go manoeuvre.
- There was inadequate supervision, at the technical and operational level, by the aircraft operating company, due to the lack of training, inadequate instruction and absence of flight simulator training.
- There was an error made by the pilots due to the inadequate use of the crew resources in the cockpit intended for the operation of the aircraft, due to an ineffective fulfillment of the tasks assigned to each of the crew and the non-observance of the operational rules.
- Even though the crew was qualified for the type of flight, there was inadequate planning regarding the absence of a takeoff and landing briefing.
- There was an error made by the copilot, when the delay in reducing the power levers, as soon as the locking of the left engine lever was established during the dash on the ground, with an inadequate assessment of the situation in this regard.
- There was the participation of the training process received, due to quantitative and qualitative deficiency, which did not attribute to pilots the full technical conditions to be developed in the activity, regarding the lack of simulator training, lack of a company training program that included CRM and local flights, among others.
- There are indications that the difficulties reported by the pilots in relation to the throttle were caused by the rupture of fibers in the cable that transfers its control to the FCU. This cable slides inside a corrugated cover and can be jammed if any fiber in the cable breaks.
Final Report: