Crash of a Pilatus PC-6/B1-H2 Turbo Porter in Raeford

Date & Time: Jul 9, 1994 at 1015 LT
Operator:
Registration:
N111FX
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Raeford - Raeford
MSN:
701
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3000
Captain / Total hours on type:
108.00
Aircraft flight hours:
9960
Circumstances:
The pilot was performing the initial takeoff, when he observed a loss of power, associated with a torque indication of zero. He force landed the aircraft in a wooded area when he could not make an open field. A post accident inspection of the engine revealed that the fuel control unit arm was loose, and the lock wire was not in place. The arm was positioned so that a maximum power demand from the throttle would correspond to an idle power demand at the fuel control. The engine underwent a 100 hour inspection, by company maintenance personnel, 8 days prior to the accident. The inspection checklist called for examining the fuel control linkage for security.
Probable cause:
The improper inspection of the aircraft by company maintenance personnel, which resulted in an unsafetied and disconnected fuel control arm.
Final Report:

Crash of an Airbus A330-321 in Toulouse: 7 killed

Date & Time: Jun 30, 1994 at 1741 LT
Type of aircraft:
Operator:
Registration:
F-WWKH
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Toulouse - Toulouse
MSN:
42
YOM:
1993
Flight number:
BGA129
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
7713
Captain / Total hours on type:
345.00
Copilot / Total flying hours:
9558
Copilot / Total hours on type:
137
Aircraft flight hours:
360
Circumstances:
An Airbus A330-300 aircraft crashed during a test flight at the Toulouse-Blagnac Airport in France, killing all seven on board. The test flight was part of the preparation required to certify the autopilot, on this Airbus A330 equipped with Pratt and Whitney engines, to category III standards. The first part of the test flight was completed successfully when the aircraft landed on runway 15L. A 180 degree turn was made for takeoff from runway 33R. The second takeoff was to be performed under conditions similar to those of the first takeoff. For this test however, the autopilot would incorporate the modification under study. The takeoff was performed by the co-pilot with TOGA (Takeoff Go Around) power instead of Flex 49, a lower power setting which was specified in the test procedure. Rotation was positive and pitch input was stopped when the attitude changed from 12 to 18 degrees nose-up. Within 5 seconds after takeoff several attempts to engage the autopilot were unsuccessful. After it was engaged, activation was delayed by two seconds because the first officer was exerting a slight nose down input on the side stick. The aircraft, still trimmed at 2.2 degrees nose-up, pitched up to reach 29 degrees and the speed had decreased to 145 knots. The captain meanwhile reduced thrust on the no. 1 engine to idle and cut off the hydraulic system in accordance with the flight test order. Immediately after it activated, the autopilot switched to altitude acquisition mode. The altitude had been set at 2000 feet on the previous flight phase. This caused the pitch attitude to increase to 32 degrees in an attempt to reach 2000 feet. The speed decreased further to 100 knots, whereas the minimum control speed is 118 kts. Roll control was lost and the captain reduced no. 2 engine thrust to idle to recover symmetry on the roll axis. Bank and pitch attitudes had reached 112 degrees left and -43 degrees resp. before the pilot managed to regain control. It was however too late to avoid ground impact at a pitch attitude of around -15 degrees.
Probable cause:
At the present stage of its work, the commission estimates that the accident can be explained by a combination of several factors none of which, taken separately, would have led to an accident.
The initial causes are primarily related to the type of the test and its execution by the crew during the last takeoff:
1) choice of maximum power (TOGA) instead of Flex 49;
2) very aft CG for the last takeoff;
3) trim set in the takeoff range, but in too high a nose-up position;
4) selected altitude of 2000 feet;
5) imprecise and late definition of the test to be conducted and the tasks to be performed by the captain and first officer, respectively;
6) positive and very rapid rotation executed by the first officer;
7) the captain was busy with the test operations to be performed immediately after take off (engagement of the autopilot, reduce thrust on the engine and cut off the blue hydraulic system) which temporarily placed him outside the control loop;
8) in addition the absence of pitch attitude protection in the autopilot altitude acquisition mode played a significant role.
The following factors also contributed to the accident:
1) The inability of the crew to identify the mode in which the autopilot was placed;
2) the confidence of the crew in the expected reactions of the aircraft;
3) the late reaction from the flight test engineer when faced with a potentially hazardous change in parameters (speed in particular);
4) the time taken by the captain to react to an abnormal situation.

Crash of a PZL-Mielec AN-2P in Kirensk

Date & Time: Jun 25, 1994
Type of aircraft:
Operator:
Registration:
CCCP-70263
Flight Phase:
Survivors:
Yes
MSN:
1G139-22
YOM:
1972
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During initial climb, the engine failed. The aircraft stalled and crashed, bursting into flames. All eight occupants escaped uninjured (or with minor injuries) while the aircraft was destroyed.
Probable cause:
Engine failure during climb out for unknown reasons.

Crash of a Piper PA-31-325 Navajo C/R in Palm Beach: 2 killed

Date & Time: Jun 24, 1994 at 0905 LT
Type of aircraft:
Registration:
N27872
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Palm Beach - Palm Beach
MSN:
31-7912031
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1000
Captain / Total hours on type:
3.00
Circumstances:
The airplane was observed to rotate about 3,217 feet down the 3,746-feet runway. One or both engines were heard running rough. The airplane climbed to about 300 feet agl, banked left, pitched nose down and impacted the ground. During the investigation, the left engine operated to full rated rpm after replacement of the damaged ignition harness, adjustment of the turbocharger density controller, and adjustment of the magneto-to-engine timing. The right engine also operated normally after replacement of the magneto, ignition harness, and engine-driven fuel pump. The density controller required adjustment to obtain full rated rpm. The #3 cylinder fuel injector nozzle was also partially blocked by contaminant. The right engine magneto contact assemblies operationally checked ok. The capacitors were heat damaged. Right engine magneto-to-engine timing and internal timing of the magneto were not determined. Pilot's toxicological results were positive for butalbital (1.768 ug/ml blood, 0.553 ug/ml urine), and also positive for acetaminophen and salicylate (aspirin) in urine. Butalbital is a prescription medication (barbiturate) not approved for flying. Both occupants were killed.
Probable cause:
The pilot's impairment of judgment and performance due to drugs, his failure to abort the takeoff after experiencing reduced takeoff performance, and his failure to maintain minimum control speed. Factors in the accident were: a partial loss of engine power due to improper magneto-to-engine timing, and a partially blocked fuel nozzle.
Final Report:

Crash of a De Havilland DHC-3 Otter off Taku Lodge: 7 killed

Date & Time: Jun 23, 1994 at 2015 LT
Type of aircraft:
Operator:
Registration:
N13GA
Flight Phase:
Survivors:
Yes
Schedule:
Taku Lodge - Juneau
MSN:
179
YOM:
1956
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
12000
Captain / Total hours on type:
400.00
Aircraft flight hours:
7672
Circumstances:
Five aircraft departed a lodge, one behind the other. Fog and drizzle were encountered, and the pilot of the first aircraft radioed to the pilots of the other aircraft to cross the river to the east shoreline. A passenger in the fourth aircraft (N13GA) stated that when the aircraft was over the middle of the river, she could not see either shore due to fog. The pilot of N13GA (a floatplane) stated that he encountered deteriorating weather and started a descent, intending to make a precautionary landing. He began to level, expecting conditions to improve. Subsequently, the floatplane hit the surface of 'glassy water' and crashed. Seven passengers were killed and four other occupants were seriously injured. The aircraft was destroyed.
Probable cause:
VFR flight by the pilot into instrument meteorological conditions (IMC), and his failure to maintain altitude (clearance) above the surface of the river. Factors related to the accident were: the adverse weather conditions, and the surface condition of the river (glassy water).
Final Report:

Crash of a De Havilland DHC-2 Beaver near Hunter Point: 2 killed

Date & Time: Jun 23, 1994 at 1100 LT
Type of aircraft:
Operator:
Registration:
C-FDTI
Flight Phase:
Survivors:
No
Schedule:
Hunter Point – Sandspit
MSN:
37
YOM:
1949
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2586
Captain / Total hours on type:
1268.00
Aircraft flight hours:
11615
Circumstances:
The amphibious DHC-2 Beaver was being operated from the Harbour Air base at Sandspit, British Columbia, located on the Queen Charlotte Islands. On the first flight on the day of the accident, the aircraft carried baggage from the Sandspit Airport to a floating fishing resort at anchor in Givenchy Bay. This bay is located in the Kano Inlet on the west coast of the Queen Charlotte Islands, 28 nautical miles (nm) west of Sandspit. On board the aircraft with the pilot was a passenger who would remain with the flight for the return trip to Sandspit. The aircraft departed Sandspit under visual flight rules (VFR) at 1015 Pacific daylight time (PDT) and landed at the fishing resort at 1039. The pilot had taken the most direct route to the destination through a low pass and over Yakoun Lake. He advised the company dispatch on the company radio frequency that the weather was quite poor along that route and that he planned to take the Skidegate Channel for the return trip. On arrival at the Givenchy resort, the aircraft was loaded with the fish to be transported to Sandspit; it then departed Givenchy at 1051. When the aircraft did not arrive at Sandspit, a search was organized. The wreckage was located at 1245 at Hunter Point, about 7 nm from Givenchy, at latitude 53°15'N, longitude 132°42'W. The accident had occurred during the hours of daylight at approximately 1100. The aircraft was destroyed and the pilot and passenger were fatally injured upon impact.
Probable cause:
The aircraft likely stalled at an altitude insufficient to permit recovery. The reason why the aircraft may have stalled could not be determined.
Final Report:

Crash of a Cessna 441 Conquest in Fort Frances

Date & Time: Jun 18, 1994 at 0425 LT
Type of aircraft:
Operator:
Registration:
N441CA
Flight Phase:
Survivors:
Yes
Schedule:
Milwaukee – Fort Frances – God’s Lake Narrows
MSN:
441-0046
YOM:
1978
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4800
Captain / Total hours on type:
40.00
Aircraft flight hours:
2447
Circumstances:
The pilot of the Cessna 441 Conquest was conducting an international charter flight from General Mitchell International Airport in Milwaukee, Wisconsin, to Gods Lake Narrows, Manitoba. The pilot landed the aircraft at Fort Frances, Ontario, to clear customs and refuel, and then continued his visual flight rules (VFR) flight to Gods Lake Narrows. During the take-off at Fort Frances, the aircraft experienced a power loss in the left engine. The pilot elected to continue the take-off but was unable to control the aircraft after it became airborne. The aircraft veered to the left and crashed on the airfield. The accident occurred at 0425 central daylight time (CDT), at night, on the Fort Frances Municipal Airport. All seven occupants sustained minor injuries and the aircraft was damaged beyond repair.
Probable cause:
The pilot lost control of the aircraft during take-off when the left engine lost power as a result of bird ingestion. Contributing to the loss of aircraft control were a take-off weight in excess of the maximum allowable, and a centre of gravity aft of the centre of gravity limit.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Carlsbad: 2 killed

Date & Time: Jun 15, 1994 at 1434 LT
Registration:
N421AG
Flight Phase:
Survivors:
Yes
Schedule:
Carlsbad - Las Vegas
MSN:
421C-0843
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3340
Captain / Total hours on type:
1240.00
Aircraft flight hours:
2943
Circumstances:
About 2 minutes after takeoff, the pilot declared an emergency, stating that he had lost an engine and needed to return to the airport. The airplane descended into rough, brush-covered terrain and then struck a large dirt berm, about 1-1/2 miles northeast of the departure airport. Examination of the engines did not reveal any obvious mechanical malfunction. The fuel was correct. Combustion chamber signatures indicated that the engines were operated at a lean or mild detonation condition. The flaps were extended about 30 degrees and the landing gear was retracted. The surviving passenger could not recall any dramatic engine problems, only that the airplane could not maintain altitude. The pilot and front seat passenger were not wearing shoulder harnesses.
Probable cause:
A loss of engine power for undetermined reasons. The pilot's failure to raise the flaps and maintain altitude were factors in the accident.
Final Report:

Crash of a Tupolev TU-154M near Xi'an: 160 killed

Date & Time: Jun 6, 1994 at 0822 LT
Type of aircraft:
Operator:
Registration:
B-2610
Flight Phase:
Survivors:
No
Schedule:
Xi'an - §Guangzhou
MSN:
86A740
YOM:
1986
Flight number:
WH2303
Location:
Country:
Region:
Crew on board:
14
Crew fatalities:
Pax on board:
146
Pax fatalities:
Other fatalities:
Total fatalities:
160
Aircraft flight hours:
12507
Aircraft flight cycles:
6651
Circumstances:
Twenty-four seconds after takeoff, while climbing, the crew encountered controllability problems. The captain contacted ATC and reported uncommanded rolled left and right up to 30°. The aircraft continued to climb but reached a high angle of attack when it nosed up to 20°, activating the stall warning alarm. The aircraft reached the altitude of 4,717 metres then rolled to the left, pitched down to an angle of 65° and entered an uncontrolled descent. At a speed of 747 km/h, the aircraft descended to the altitude of 2,884 metres in 12 seconds then suffered structural deformation and failure before crashing in an open field located 29 km southeast of Xi'an Airport. The aircraft disintegrated on impact and all 160 occupants were killed.
Probable cause:
It was determined that the loss of control was the consequence of poor maintenance. The previous evening, the autopilot yaw-channel had been erroneously connected to the bank control and the bank-channel to the yaw control, after maintenance was completed at an unapproved facility.

Crash of a Rockwell Aero Commander 500B in Buenos Aires: 2 killed

Date & Time: Jun 2, 1994
Operator:
Registration:
LV-GXR
Flight Phase:
Flight Type:
Survivors:
No
MSN:
500-0962-17
YOM:
1960
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff, while in initial climb, the twin engine aircraft went out of control and crashed in a field located 2 km from the airport. Both pilots were killed. The aircraft was engaged in a cargo flight and was carrying a load of newspapers.