Crash of an Antonov AN-2 in Kenema: 1 killed

Date & Time: Apr 1, 1995
Type of aircraft:
Flight Phase:
Flight Type:
Survivors:
No
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Shortly after takeoff, the single engine aircraft collided with trees and crashed in a cotton field. The pilot, sole on board, was killed.

Crash of an Airbus A310-324 in Bucharest: 60 killed

Date & Time: Mar 31, 1995 at 0908 LT
Type of aircraft:
Operator:
Registration:
YR-LCC
Flight Phase:
Survivors:
No
Schedule:
Bangkok - Abu Dhabi - Bucharest - Brussels
MSN:
450
YOM:
1987
Flight number:
RO371
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
49
Pax fatalities:
Other fatalities:
Total fatalities:
60
Captain / Total flying hours:
14312
Captain / Total hours on type:
1735.00
Copilot / Total flying hours:
8988
Copilot / Total hours on type:
650
Aircraft flight hours:
31092
Aircraft flight cycles:
6216
Circumstances:
Tarom flight 371 was a scheduled passenger service from Bucharest Otopeni Airport (OTP) in Romania to Brussel Airport (BRU), Belgium. On board were 49 passengers and eleven crew members. The first officer was pilot flying, the captain was pilot monitoring. Following de-icing, the Airbus A310 taxied to runway 08R for departure. The flight was cleared via the Strejnic 'STJ' VOR/DME beacon and an initial climb to flight level 260. Takeoff was initiated at 09:04 hours local time. When airborne, the captain announced positive climb and co-pilot requested to retract the landing gear. At 09:07:20 the captain called the Otopeni Approach controller and received a clearance to turn left and proceed direct to STJ. The co-pilot asked the captain to select direct STJ on FMS. The captain confirmed a direct STJ selection and requested the co-pilot to move the control wheel slightly. At an altitude of 1700 feet and speed a 187 knots, with flaps 15/slats 15 and pitch angle of 17.6 degrees, the aircraft was turning left, with a bank angle of 12 degrees, flying towards STJ. At 09:07:36, when the aircraft crossed 2000 feet at 188 knots, an engine thrust asymmetry started developing with continuous decrease of the left engine thrust, approximately 1 degree TRA (throttle resolver angle)/second. At 09:07:53, when the aircraft was crossing 3300 feet altitude at 195 kts turning with a decreasing bank angle of 20 degrees, the first officer called "250 in sight" and asked the captain to retract the flaps. This was carried out. At that moment, the engine thrust asymmetry reached 14.5 TRA degrees and 0.19 for EPRs. The first officer then requested slats retraction, but this action which was not carried out by the captain. At this moment the aircraft was passing through 013 degrees magnetic heading, at 3800 feet altitude and a decreasing speed of 185 kts. The aircraft pitch angle was 16,5 degrees, decreasing, and the left bank angle was 18 degrees, also decreasing. At that time the thrust asymmetry reached was 28 TRA degrees and 0.27 for EPRs. At 09:08:02, the first officer asked the captain: "Are you all right?" The aircraft was passing through 330 degrees magnetic heading, 4200 ft altitude, a decreasing speed of 181 kts, and an increasing 17 degrees left bank angle. At 09:08:08, a noise like an uttering of pain or a metallic noise was heard. The aircraft was crossing 4460 ft altitude, 179 kts speed and an increasing bank angle of 22 degrees. At that time the engines thrust asymmetry reached 0.36 for EPRs. The bank angle continued to increase to 28 degrees and the engine thrust asymmetry reached 0.41 for EPRs. At 09:08:15, the first officer, with a stressed and agitated voice, requested engagement of autopilot no. 1. The aircraft was crossing 4620-ft altitude, continuing its turn at an increasing bank angle of 43 degrees and a steadily decreasing pitch angle of 3.5 degrees. One of the pilots attempted to engage autopilot no. 1 The aircraft started a descent with 45 degrees bank angle and the engine thrust asymmetry had reached the maximum value of 0.42 for EPRs, followed by a continuous thrust reduction of engine n°2. One second later, there was recorded autopilot disengagement followed by the aural warning a level 3 "cavalry charge" lasting several moments. From that moment on, the aircraft started diving, the speed increased and the aircraft performed a complete rotation around its roll axis. At 09:08.28, first officer cried out "THAT ONE HAS FAILED!" without any other comments. The aircraft was descending through 3600 ft at 258 kts speed and an increasing nose down pitch angle at 61.5 degrees. The aircraft continued until it impacted the ground at a nose down attitude of approximately 50 degrees pitch angle with both engines at idle power. The airplane was destroyed and all 60 occupants were sustained fatal injuries.
Probable cause:
The following factors were reported:
- Thrust asymmetry,
- Possible incapacitation of the captain,
- Insufficient corrective action from the copilot in order to cover the consequences of the first factors.
The French Ministry of Transport commented on the Romanian investigation report, stating that the pilot flying's actions that led to the loss of control could have been caused by the fact that the artificial horizon between Eastern and Western built aircraft is inverted in roll and that the first officer spent the majority of his career on Eastern-built aircraft.
Final Report:

Crash of a Beechcraft 65-A80-8800 Excalibur in Hamilton: 6 killed

Date & Time: Mar 29, 1995 at 1225 LT
Type of aircraft:
Operator:
Registration:
ZK-TIK
Flight Phase:
Survivors:
No
Schedule:
Hamilton – New Plymouth
MSN:
LD-249
YOM:
1965
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
1099
Captain / Total hours on type:
71.00
Copilot / Total flying hours:
587
Aircraft flight cycles:
10137
Circumstances:
The aircraft departed Hamilton Airport runway 36 on a scheduled service to New Plymouth on behalf of Eagle Airways. Six minutes after takeoff, while climbing to an altitude of 5,000 feet, the crew informed ATC about the failure of the left engine and was cleared to return for an emergency landing. Four minutes later, the right turn failed as well. The airplane lost height and crashed in an open field located 9 km from Hamilton Airport. All six occupants were killed.
Probable cause:
Failure of both engines after the crew failed to realize that the fuel selector was positioned on the wrong fuel tank. The following contributing factors were reported:
- After the second engine failure, the crew failed to plan effectively for a forced landing, and ultimately failed to maintain controlled flight,
- Probable factors contributing to these failures include: workload, time pressure, unfamiliarity with the situation in which they found themselves and inexperience on type.
Final Report:

Crash of a Cessna 207A Skywagon in Santa Cruz: 10 killed

Date & Time: Mar 28, 1995
Registration:
CP-1947
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Santa Cruz – Santa Ana del Yacuma
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
10
Circumstances:
Shortly after takeoff from El Trompillo Airport, while in initial climb, the single engine aircraft entered an uncontrolled descent, struck a tree and crashed onto several houses located in a populated area by the airport. Debris were found on a large area and all seven occupants were killed as well as three people on the ground. Five other people on the ground were injured.
Probable cause:
Loss of control following an engine failure for unknown reasons.

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: