Crash of a Boeing E-3B Sentry at Elmendorf AFB: 24 killed

Date & Time: Sep 22, 1995 at 0747 LT
Type of aircraft:
Operator:
Registration:
77-0354
Flight Phase:
Survivors:
No
Schedule:
Elmendorf - Elmendorf
MSN:
21554
YOM:
1978
Flight number:
Yukla 27
Crew on board:
4
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
24
Circumstances:
The aircraft was dispatched out from Elmendorf AFB on an AWACS survey mission under call sign Yukla 27, carrying 20 passengers and four crew members. Shortly after takeoff from runway 05, while in initial climb, the aircraft collided with a flock of Canada geese that struck both left engines n°1 and 2. The aircraft climbed to a maximum height of about 250 feet when the engine n°1 failed and the engine n°2 exploded. The aircraft entered an uncontrolled left roll, causing the left wing to struck trees. Out of control, it crashed in a huge explosion in a wooded area located about a mile from the runway end. The aircraft disintegrated on impact and all 24 occupants were killed. Numerous dead geese were found at the crash site.
Probable cause:
It was determined that the loss of control and subsequent crash was the consequence of a collision with Canada geese during initial climb. Investigations revealed that a USAF Lockheed C-130 just took off from the same runway about two minutes prior to the accident. At that time, numerous geese were standing near the runway end and were probably disturbed by the C-130 low pass. All geese took off and remained hovering at low height. This phenomenon was spotted by the tower controller who failed to warn the Sentry crew accordingly. It was also determined that there was no efficient program to detect and deter bird hazard at Elmendorf AFB.

Crash of a Cessna 421B Golden Eagle II in Coldwater: 1 killed

Date & Time: Sep 21, 1995 at 1145 LT
Operator:
Registration:
N14A
Flight Phase:
Survivors:
No
Schedule:
Coldwater - Elkhart
MSN:
421B-0373
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1984
Captain / Total hours on type:
203.00
Aircraft flight hours:
5044
Circumstances:
The pilot obtained a preflight briefing and indicated that he would obtain an IFR clearance after becoming airborne; however, he took off and did not activate a flight plan. Witnesses observed the airplane flying north (away from the destination) about 200 to 300 feet above the ground below a low overcast sky condition. One witness said the airplane was flying very slow; he said he was almost able to keep up with it in his vehicle. The witnesses said they saw the airplane roll rapidly to the right and descend toward the ground. It collided with the ground in an approximate 50 degree pitch down attitude. An on-scene examination did not reveal any airframe or control anomaly that would have resulted in the accident. The engines and propellers were disassembled for inspection. Examination of the engines revealed they were capable of producing power. Examination of the propellers revealed both were operating at low pitch settings. About 25 miles north-northwest at Battle Creek, MI, the 1145 edt weather was, in part: 500 feet overcast, visibility 2 miles with fog, wind from 050 degrees at 10 knots.
Probable cause:
Failure of the pilot to maintain adequate airspeed, while maneuvering (turning) at low altitude, which resulted in an inadvertent stall and collision with the terrain. Factors relating to the accident were: the adverse weather conditions, and the lack of altitude for recovery from the stall.
Final Report:

Crash of a Mitsubishi MU-2B-35 Marquise in Smyrna

Date & Time: Sep 21, 1995 at 0425 LT
Type of aircraft:
Registration:
N309MA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Smyrna - Louisville
MSN:
602
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2140
Captain / Total hours on type:
112.00
Aircraft flight hours:
4304
Circumstances:
A witness stated he observed the airplane on climbout from runway 32. The airplane started a right turn estimated at about 30 to 45° angle of bank. The airplane stopped climbing and began descending. Subsequently, it collided with a tree line, while in a right bank, and then it impacted the ground. Weather conditions at the time of accident were described by the witness as very dark, with no ambient light or visible horizon. Examination of the airframe, flight control system, engine assembly, and propeller assembly revealed no evidence of a precrash failure or malfunction. The autopilot was found in the off position, and the autopilot circuit breakers were not tripped. The pilot and passenger were seriously injured and had no memory of the flight. A radio transcript revealed that after taking off, the flight had made one radio transmission to request an ifr clearance.
Probable cause:
Failure of the pilot to maintain a proper climb rate after takeoff, and his inadvertent entry in a descending spiral, which he failed to correct. Factors relating to the accident were: darkness, and the pilot becoming spatially disoriented during the initial climb while attempting to obtain an ifr clearance.
Final Report:

Crash of a Swearingen SA227AC Metro III in Tamworth: 2 killed

Date & Time: Sep 16, 1995 at 1957 LT
Type of aircraft:
Operator:
Registration:
VH-NEJ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tamworth - Tamworth
MSN:
AC-629B
YOM:
1985
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4132
Captain / Total hours on type:
1393.00
Copilot / Total flying hours:
1317
Copilot / Total hours on type:
1
Aircraft flight hours:
15105
Circumstances:
Two company pilots were undergoing first officer Metro III type-conversion flying training. Both had completed Metro III ground school training during the week before the accident. A company check-and-training pilot was to conduct the type conversions. This was his first duty period after 2 weeks leave. Before commencing leave, he had discussed the training with the chief pilot. This discussion concerned the general requirements for a co-pilot conversion course compared to a command pilot course but did not address specific sequences or techniques. The three pilots met at the airport at about 1530 EST on 16 September 1995. During the next 2 hours and 30 minutes approximately, the check-and-training pilot instructed the trainees in daily and pre-flight inspections, emergency equipment and procedures, and cockpit procedures and drills (including the actions to be completed in the event of an engine failure), as they related to the aircraft type. The briefing did not include detailed discussion of aircraft handling following engine failure on takeoff. The group began a meal break at 1800 and returned to the aircraft at about 1830 to begin the flying exercise. The check-and-training pilot was pilot in command for the flight and occupied the left cockpit seat. One trainee occupied the right (co-pilot) cockpit seat while the other probably occupied the front row passenger seat on the left side. This person had the use of a set of head-phones to listen to cockpit talk and radio calls. The aircraft departed Tamworth at 1852, some 40 minutes after last light. Witnesses described the night as very dark, with no moon. Under these conditions, the Tamworth city lighting, which extended to the east from about 2 km beyond the end of runway 12, was the only significant visual feature in the area. The co-pilot performed the takeoff, his first in the Metro III. For about the next 30 minutes, he completed various aircraft handling exercises including climbing, descending, turning (including steep turns), and engine handling. No asymmetric flight exercises were conducted. The check-and-training pilot then talked the co-pilot through an ILS approach to runway 30R with an overshoot and landing on runway 12L. The landing time was 1940. The aircraft had functioned normally throughout the flight. After clearing the runway, the aircraft held on a taxiway for 6 minutes, with engines running. During this period, the crew discussed the next flight which was to be flown by the same co-pilot. The check-and-training pilot stated that he was going to give the co-pilot a V1 cut. The co-pilot objected and then questioned the legality of night V1 cuts. The check-and-training pilot replied that the procedure was now legal because the company operations manual had been changed. The co-pilot made a further objection. The check-and-training pilot then said that they would continue for a Tamworth runway 30R VOR/DME approach and asked the co-pilot to brief him on this approach. The crew discussed the approach and the check-and-training pilot then requested taxi clearance. The aircraft was subsequently cleared to operate within a 15-NM radius of Tamworth below 5,000 ft. The crew then briefed for the runway 12L VOR/DME approach. The plan was to reconfigure the aircraft for normal two-engine operations after the V1 cut and then complete the approach. The crew completed the after-start checks, the taxi checks, and then the pre-take-off checks. The checks included the co-pilot calling for one-quarter flap and the check-and-training pilot responding that one-quarter flap had been selected. The crew briefed the take-off speeds as V1 = 100 kts, VR = 102 kts, V2 = 109 kts, and Vyse = 125 kts for the aircraft weight of 5,600 kg. Take-off torque was calculated as 88% and watermethanol injection was not required. The aircraft commenced the take-off roll at 1957.05. About 25 seconds after brakes release, the check-and-training pilot called 'V1', and less than 1 second later, 'rotate'. The aircraft became airborne at 1957.32. One second later, the check-and-training pilot reminded the co-pilot that the aircraft attitude should be 'just 10 degrees nose up'. After a further 3 seconds, the check-and-training pilot retarded the left engine power lever to the flight-idle position. Over the next 4 seconds, the recorded magnetic heading of the aircraft changed from 119 degrees to 129 degrees. The co-pilot and then the check-and-training pilot called that a positive rate of climb was indicated and the landing gear was selected up 15 seconds after the aircraft became airborne. The landing gear warning horn began to sound at approximately the same time. After 19 seconds airborne, and again after 30 seconds, the check-and-training pilot reminded the co-pilot to hold V2. Three seconds later, the check-and-training pilot said that the aircraft was descending. The landing gear warning horn ceased about 1 second later. By this time, the aircraft had gradually yawed left from heading 129 degrees, through the runway heading of 121 degrees, to 107 degrees. After being airborne for 35 seconds, the aircraft struck a tree approximately 350 m beyond, and 210 m left of, the upwind end of runway 12L. It then rolled rapidly left, severed power lines and struck other trees before colliding with the ground in an inverted attitude and sliding about 70 m. From the control tower, the aerodrome controller saw the aircraft become airborne. As it passed abeam the tower, the controller directed his attention away from the runway. A short time later, all lighting in the tower and on the airport failed and the controller noticed flames from an area to the north-east of the runway 30 threshold. Within about 30 seconds, when the emergency power supply had come on line, the controller attempted to establish radio contact with the aircraft. When no response was received, he initiated call-out of the emergency services.
Probable cause:
The following factors were reported:
1. There was no enabling legislative authority for AIP (OPS) para. 77.
2. CASA oversight, with respect to the company operations manual and specific guidance concerning night asymmetric operations, was inadequate.
3. The company decided to conduct V1 cuts at night during type-conversion training.
4. The check-and-training pilot was assigned a task for which he did not possess adequate experience, knowledge, or skills.
5. The check-and-training pilot gave the co-pilot a night V1 cut, a task which was inappropriate for the co-pilot's level of experience.
6. The performance of the aircraft during the flight was adversely affected by the period the landing gear remained extended after the simulated engine failure was initiated and by the control inputs of the co-pilot.
7. The check-and-training pilot did not recognise that the V1 cut exercise should be terminated and that he should take control of the aircraft.
Final Report:

Crash of a Beechcraft 65 Queen Air in West Point: 12 killed

Date & Time: Sep 10, 1995 at 1840 LT
Type of aircraft:
Registration:
N945PA
Flight Phase:
Survivors:
No
Site:
Schedule:
West Point - West Point
MSN:
LC-217
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
2980
Captain / Total hours on type:
462.00
Aircraft flight hours:
1530
Circumstances:
The airplane was loaded with 10 sport parachutists and one pilot. Later, investigators calculated that the maximum gross weight was exceeded by 149.6 pounds, and the center of gravity was 2.87 inches aft of the aft limit. The cabin door had been removed for parachuting operations; however, an altered Flight Manual Supplement had been used as authority for the door removal. The airplane was not on the FAA-approved eligible list for such removal. The airplane needed to be refueled before flight, but the quantity of fuel in the airport's underground storage tank was below the electric cutoff level. Fuel was pumped manually from the storage tank into plastic jugs, which were used to refuel the airplane. Before takeoff, samples of fuel were reported to have been drained from the airplane's fuel tanks (sumps). According to witnesses, they heard an engine misfiring during takeoff. They observed the airplane level off during the initial climb and start a shallow right turn. The bank angle gradually increased from shallow to steep as the nose dropped and the airplane descended. Other witnesses observed the airplane in a steep dive just before it crashed in the rear of a residence. One person in the residence was killed. A postaccident fire destroyed the accessory sections of both engines. Examination of the airplane disclosed evidence that the right engine had been shut down and the right propeller had been feathered; however, no preimpact mechanical failure was found. A sample of excess fuel was obtained from the tank that was used to refuel the airplane, but no observable quantity of water or contamination was found.
Probable cause:
The pilot's inadequate preflight/preparation, his failure to ensure proper weight and balance of the airplane, and his failure to obtain/maintain minimum control speed, which resulted in a loss of aircraft control after loss of power in one engine. A factor relating to the accident was: loss of power in the right engine for undetermined reason(s).
Final Report:

Crash of a Douglas C-47B-1-DL in Vancouver: 1 killed

Date & Time: Aug 19, 1995 at 0906 LT
Operator:
Registration:
C-GZOF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Vancouver – Whitehorse
MSN:
20833
YOM:
1944
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The DC-3 aircraft, with the captain, first officer, and an apprentice aircraft maintenance engineer on board, was to be ferried from Vancouver, British Columbia, to Whitehorse, Yukon. Just after take-off from runway 08, as the first officer was setting the engine power, the right propeller began to over-speed. The captain told the first officer to shut down and feather the right engine. The first officer did as instructed, and advised the Vancouver tower controller of the engine problem and that they would return to the airport to land on runway 08. The captain turned the aircraft to the right, onto downwind for runway 08; however, because the aircraft's altitude and airspeed were decreasing, the first officer advised the tower controller that they would land on runway 30. The aircraft continued to lose height, narrowly avoiding buildings in its path, and crashed to the ground, one mile short of runway 30. The three occupants were seriously injured during the impact and the post-crash fire; the captain died of his injuries eight days after the accident.
Probable cause:
The aircraft's right engine oil system malfunctioned for reasons that were not determined, and the right propeller did not completely feather during the emergency shutdown. The aircraft was unable to maintain flight because of the drag generated by the windmilling right propeller.

Crash of a Britten-Norman BN-2A Islander in Haifa

Date & Time: Aug 17, 1995
Type of aircraft:
Operator:
Registration:
4X-CCO
Flight Phase:
Survivors:
Yes
Schedule:
Haifa - Larnaca
MSN:
139
YOM:
1969
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll on runway 34, at a speed of 65 mph, the pilot pulled up on the control column to rotate. The nose gear lifted off briefly before touching down again. In such conditions, the pilot decided to abort the takeoff and initiated an emergency braking manoeuvre. Unable to stop within the remaining distance (the aircraft already rolled for 2/3 of the runway), the aircraft overran and came to rest in a rocky and bushy area. All 11 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
It was determined that the pilot failed to prepare the flight according to procedures. No weight & balance sheet was calculated prior to departure. At the time of the accident, the total weight of the aircraft was above MTOW and its CofG was too far forward the permissible limit.

Crash of a PZL-Mielec AN-2R in Mezhdurechensky

Date & Time: Aug 10, 1995
Type of aircraft:
Operator:
Registration:
RA-40371
Flight Phase:
Survivors:
Yes
Schedule:
Mezhdurechensky - Uray
MSN:
1G222-50
YOM:
1987
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
23
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Mezhdurechensky Airport, while on a forest patrol flight to Uray, the engine did not have sufficient power and the aircraft was unable to gain sufficient height. It struck power cables, stalled and crashed 2 km from the airfield. All 25 occupants were injured, four of them seriously, and the aircraft was damaged beyond repair.
Probable cause:
It was determined that 23 passengers, among them 10 children, embarked illegally, and the crew decided to take off despite the total weight of the aircraft was well above MTOW.

Crash of a Piper PA-31P-425 Pressurized Navajo in Madrid

Date & Time: Aug 9, 1995
Type of aircraft:
Operator:
Registration:
EC-FSF
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
31-7730012
YOM:
1977
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Madrid-Barajas Airport, while climbing, the crew lost control of the aircraft that crashed near a warehouse located in Paracuellos del Jarama, about 3 km east of the airport. The aircraft was destroyed and both pilots were seriously injured.

Crash of a PZL-Mielec AN-2R in Johannesburg: 3 killed

Date & Time: Aug 2, 1995
Type of aircraft:
Operator:
Registration:
RA-05708
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Johannesburg - Jamba
MSN:
1G153-21
YOM:
1974
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
After takeoff from Johannesburg-Rand Airport, while in initial climb, the single engine aircraft nosed up and stalled. It collided with power cables and crashed, bursting into flames. The aircraft was totally destroyed and all three occupants were killed.
Probable cause:
It was determined that the crew failed to prepare the flight according to published procedures as the cargo was not properly secured in the cabin and shifted after liftoff, causing the aircraft to stall and crash.