Crash of a Douglas DC-3C in Lake Bondesir

Date & Time: Mar 23, 1995
Type of aircraft:
Operator:
Registration:
C-GCXD
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
14167/25612
YOM:
1944
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While taking off from the icy Lake Bondésir, the left ski struck an ice ridge on the ground. The main gear/ski collapsed and the aircraft came to rest. Both pilots escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Cessna 208 Caravan in Tawau

Date & Time: Mar 20, 1995 at 1730 LT
Type of aircraft:
Operator:
Registration:
9M-PMN
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tawau - Kota Kinabalu
MSN:
208B-0295
YOM:
1992
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft was completing a cargo flight to Kota Kinabalu, carrying two pilots and a load of 400 kilos of fish. After a course of 860 metres on runway 17, the aircraft lifted off and climbed to a height of about 3 metres when it landed back. It continued in a nose-up attitude, overran for 60 metres and came to rest down an embankment into several houses. Both occupants were slightly injured and the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-2 Beaver near Yea

Date & Time: Mar 16, 1995 at 1400 LT
Type of aircraft:
Operator:
Registration:
VH-IDB
Flight Phase:
Survivors:
Yes
Schedule:
Yea - Yea
MSN:
883
YOM:
1956
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1468
Captain / Total hours on type:
244.00
Circumstances:
The pilot reported that the flight departed from an agricultural strip located in a valley surrounded by hills. The aircraft carried a full load of superphosphate to be spread on a property approximately one mile from the strip. The pilot had previously surveyed the property and the flight path. He had selected a route that took him up through a valley between hills and then over a low ridge to the property. After take off the pilot set climb power and selected climb flap in order to follow his predetermined route to the property. The pilot advised that as the aircraft flew towards the low ridge it appeared to be descending rather than climbing. He elected to carryout a partial dump and to apply extra flap to clear a clump of trees. The speed deteriorated to 60 knots from the initial climb speed of 70 knots. The pilot did not increase power. Some 300 metres later another partial dump was carried out to clear another tree. As that tree was cleared the pilot again initiated a partial dump and turned to the right in an endeavour to escape from a rapidly deteriorating situation. Immediately the turn was initiated the right wing dropped and the aircraft stalled, impacting the ground onto the right wing and cartwheeled to a stop some 50 metres from the initial impact. The company chief pilot examined the accident site and advised that the flight path through the valley was in a classic false horizon situation whereby the surrounding hills caused the pilot to consider that the flight path was over flat terrain whilst in reality the terrain was rising approximately 5 degrees up to the ridge. The chief pilot also advised that the aircraft would not have been able to outclimb the terrain at high gross weight with only cruise power set.
Probable cause:
Examination of the wreckage did not disclose any pre-impact factors that may have contributed to the accident. Weather and pilot workload were not considered to be factors in this accident.
The pilot had flown approximately 1200 hours on agricultural operations and 244 hours on the type. His loss of situational awareness could be due in part to his relatively low experience.
The following factors were considered relevant to the development of the accident:
- At high weight, and with climb power applied, the pilot flew the aircraft on an inappropriate flight path into rising terrain.
- The pilot did not take appropriate remedial actions when the aircraft could not outclimb the terrain and the aircraft speed deteriorated.
- The pilot lost control of the aircraft while attempting a turn at low speed.
Final Report:

Crash of a Piper PA-46-310P Malibu in Cambridge: 1 killed

Date & Time: Mar 15, 1995 at 0512 LT
Operator:
Registration:
N166CP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Cambridge - Baltimore
MSN:
46-8408024
YOM:
1984
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
9600
Aircraft flight hours:
6089
Circumstances:
The airplane collided with trees shortly after takeoff and came to rest in a church yard. There were no witnesses to the crash; however, several local residents heard the airplane overfly their homes at a low altitude. One resident stated that he heard the airplane collide with the trees. Another resident stated that he heard the engine operating as the airplane flew low overhead. Both residents reported that reduced visibility hampered their ability to find the wreckage. One resident estimated that the visibility was about 50 to 60 feet. The prescribed takeoff minimums for that airport is 300 feet and 1 mile visibility. Examination of the airplane did not disclose evidence of mechanical malfunction. The pilot, sole on board, was killed.
Probable cause:
The commercial/instrument rated pilot's failure to obtain/maintain adequate altitude/clearance during the initial climb after takeoff. Related factors are the pilot's poor planning/decision making, and the fog.
Final Report:

Crash of a Cessna 402B in Tabora

Date & Time: Feb 27, 1995 at 0745 LT
Type of aircraft:
Operator:
Registration:
5H-TZB
Flight Phase:
Survivors:
Yes
MSN:
402B-0444
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Tabora Airfield, while in initial climb, the twin engine aircraft encountered difficulties to gain height, stalled and crashed 130 metres past the runway end. All six occupants were injured.

Crash of a Douglas DC-8-63CF in Kansas City: 3 killed

Date & Time: Feb 16, 1995 at 2027 LT
Type of aircraft:
Operator:
Registration:
N782AL
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kansas City - Westover
MSN:
45929
YOM:
1968
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
9741
Captain / Total hours on type:
4483.00
Copilot / Total flying hours:
4460
Copilot / Total hours on type:
218
Aircraft flight hours:
77096
Aircraft flight cycles:
22404
Circumstances:
The airplane crashed immediately after liftoff during a three-engine takeoff. Flightcrew had shortened rest break; rest periods not required for ferry flights. Flight crew fatigue from lack of rest, sleep, and disruption of circadian rhythms. Flightcrew did not have adequate, realistic training in three-engine takeoff techniques or procedures. Flight crew did not adequately understand three-engine takeoff procedures, including significance of vmcg. Flight engineer improperly determined vmcg speed, resulting in value 9 knots too low. During first takeoff attempt, captain applied power to asymmetrical engine too soon, was unable to maintain directional control, and rejected the takeoff. Captain agreed to modify procedure by allowing flight engineer to advance throttle, a deviation of prescribed procedure. FAA oversight of operator was inadequate because the poi and geographic inspectors were unable to effectively monitor domestic crew training and international operations. Existing far part 121 flight time limits & rest requirements that pertained to the flights that the flightcrew flew prior to the ferry flights did not apply to the ferry flights flown under far part 91. Current one-engine inoperative takeoff procedures do not provide adequate rudder availability for correcting directional deviations during the takeoff roll compatible with the achievement of maximum asymmetric thrust at an appropriate speed greater than ground minimum control speed. All three crew members were killed.
Probable cause:
The accident was the consequence of the following factors:
- The loss of directional control by the pilot in command during the takeoff roll, and his decision to continue the takeoff and initiate a rotation below the computed rotation airspeed, resulting in a premature liftoff, further loss of control and collision with the terrain.
- The flightcrew's lack of understanding of the three-engine takeoff procedures, and their decision to modify those procedures.
- The failure of the company to ensure that the flightcrew had adequate experience, training, and rest to conduct the nonroutine flight. Contributing to the accident was the inadequacy of Federal Aviation Administration oversight of air transport international and federal aviation administration flight and duty time regulations that permitted a substantially reduced flightcrew rest period when conducting a non revenue ferry flight under 14 code of federal regulations part 91.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Grand Canyon: 8 killed

Date & Time: Feb 13, 1995 at 1536 LT
Operator:
Registration:
N27245
Flight Phase:
Survivors:
Yes
Schedule:
Grand Canyon - Las Vegas
MSN:
31-7752121
YOM:
1977
Flight number:
6G45
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
5086
Captain / Total hours on type:
480.00
Aircraft flight hours:
13367
Circumstances:
The charter flight was on a return tour trip after landing at the Grand Canyon National Park Airport. No fueling or maintenance was performed on the airplane while it sat on the ground for three hours. Shortly after takeoff from runway 21, the pilot transmitted that he had a problem and was declaring an emergency. He then stated '...I'm single engine right now....' The airplane was observed to be 100-200 feet above the terrain at the time. It continued flying for about 6 minutes, turning onto a crosswind, downwind, and then a right base leg for runway 21 before colliding with trees about 2.5 miles northeast of the airport. The airport is located in terrain that slopes upward from south to north and west to east. Winds were gusting to 29 knots. The density altitude was 6,870 feet. Examination of the suspect left engine did not reveal any evidence of failures or malfunctions. The investigation revealed deficiencies in the Federal Aviation Administration's oversight of the airline's maintenance program, and in the airline's extension of the time-in-service interval of the engines. The airline's AAIP does not require a maximum rated power check of the engines as required by the engine manufacturer's service instruction. In addition, the TBO of the engines had been extended from 1,800 to 2,400 hours.
Probable cause:
A loss of power on one engine for an undetermined reason(s), and the pilot's improper decision to return to the departure airport for landing which necessitated maneuvering over increasingly higher terrain. Factors in the accident were: the high gusting wind, the high density altitude, the rising terrain, and the reduced single-engine performance capability of the airplane under these conditions.
Final Report:

Crash of a Fletcher FU-24-400 in Mangakino

Date & Time: Feb 9, 1995
Type of aircraft:
Operator:
Registration:
ZK-BIF
Flight Phase:
Survivors:
Yes
Schedule:
Mangakino - Mangakino
MSN:
33
YOM:
1956
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Mangakino, while climbing, the single engine aircraft collided with power cables and crashed in a field. The pilot was injured.

Crash of a Beechcraft 200 Super King Air in Cafunfo: 2 killed

Date & Time: Jan 28, 1995
Operator:
Registration:
D2-ECH
Flight Phase:
Survivors:
Yes
Schedule:
Luanda - Cafunfo
MSN:
BB-345
YOM:
1978
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
After landing at Cafunfo Airport and while taxiing to the ramp, the crew heard several explosions outside the airport as UNITA rebels were approaching the airstrip. In such conditions, the crew decided to return to Luanda and expedited a takeoff. After departure, while climbing, the twin engine aircraft was hit by a Stinger missile that struck the right engine. The crew lost control of the airplane that crashed few km from the airport, bursting into flames. Two passengers were killed while four other occupants were injured.
Probable cause:
Shot down by a Stinger missile.

Crash of an Antonov AN-26B in Sambailo

Date & Time: Jan 26, 1995
Type of aircraft:
Registration:
UN-26080
Flight Phase:
Survivors:
Yes
MSN:
117311709
YOM:
1981
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from Sambailo Airport, at a speed of 180 km/h, the pilot-in-command realized he could not takeoff so he initiated an emergency braking procedure. As a distance of 350 metres was remaining, the aircraft was unable to stop within the distance, overran and came to rest. All 24 occupants escaped unhurt.
Probable cause:
It was determined that the crew failed to prepare the flight according to published procedures and failed to follow the pre-takeoff checklist. The aircraft was unable to gain sufficient speed because the parking brake was not fully released.