Crash of a Douglas DC-3A in Villavicencio: 7 killed

Date & Time: May 28, 1994 at 0738 LT
Type of aircraft:
Operator:
Registration:
HK-2213
Flight Phase:
Survivors:
Yes
Schedule:
Villavicencio – Puerto Carreño – La Primavera
MSN:
11752
YOM:
1942
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
26
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
Less than three minutes after takeoff from Villavicencio-Ernesto Cortissoz Airport, while climbing, the captain reported engine problems to ATC. While approaching an open field at low speed in an attempt to make an emergency landing, the crew lost control of the airplane that stalled and crashed. All three crew members and four passengers were killed while 21 others were injured. A passenger escaped uninjured. The aircraft was destroyed upon impact. It was reported that one of the engine lost power during initial climb and white smoke was coming out.
Probable cause:
Engine problems for unknown reasons.

Crash of a Beechcraft C90 King Air in Mindelheim: 1 killed

Date & Time: May 27, 1994 at 0700 LT
Type of aircraft:
Operator:
Registration:
D-IHNA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mindelheim - Berlin
MSN:
LJ-926
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Shortly after takeoff from Mindelheim-Mattsies Airport, while in initial climb, the pilot informed ATC about problems and elected to return. While completing a sharp turn to the right at a relative low altitude, the aircraft stalled and crashed in a field located less than 2 km from the airfield. The aircraft was destroyed and the pilot, sole on board, was killed. The aircraft was operated by Burkhart Grob Luft-und-Raumfahrt later renamed Grob Aerospace.
Probable cause:
It was determined that the fuel filler cap on the right fuel tank was missing and fuel was leaking, necessitating an emergency return. While completing a last turn to the right, the aircraft stalled because its speed was insufficient and the distance from the ground was too low to expect recovery.

Crash of a Douglas C-47A-1-DK in Bloemfontein

Date & Time: May 6, 1994
Operator:
Registration:
6816
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
12112
YOM:
1943
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After takeoff from Bloemfontein, the crew encountered engine problems. The aircraft lost height and crash landed in Bloemspruit, south of the airport. Both pilots were rescued and the aircraft was written off.

Crash of a Douglas C-47A-20-DK off Sydney

Date & Time: Apr 24, 1994 at 0910 LT
Registration:
VH-EDC
Flight Phase:
Survivors:
Yes
Schedule:
Sydney - Norfolk Island - Lord Howe Island
MSN:
12874
YOM:
1944
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9186
Captain / Total hours on type:
927.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
250
Aircraft flight hours:
40195
Circumstances:
This accident involved a DC-3 aircraft which was owned and operated by South Pacific Airmotive Pty Ltd, who were based at Camden, NSW. It was flown on commercial operations under an Air Operators Certificate held by Groupair, who were based at Moorabbin, Vic. The aircraft had been chartered to convey college students and their band equipment from Sydney to Norfolk Island to participate in Anzac Day celebrations on the island. A flight plan, submitted by the pilot in command, indicated that the aircraft was to proceed from Sydney (Kingsford-Smith) Airport to Norfolk Island, with an intermediate landing at Lord Howe Island to refuel. The flight was to be conducted in accordance with IFR procedures, with a departure time from Sydney of 0900. The aircraft, which was carrying 21 passengers, was crewed by two pilots, a supernumerary pilot and a flight attendant. Preparations for departure were completed shortly before 0900, and the aircraft was cleared to taxi for runway 16 via taxiway Bravo Three. The pilot in command occupied the left control position. The co-pilot was the handling pilot for the departure. The aircraft was cleared for takeoff at 0907:53. The crew subsequently reported to the investigation team that all engine indications were normal during the take-off roll and that the aircraft was flown off the runway at 81 kts. During the initial climb, at approximately 200 ft, with flaps up and the landing gear retracting, the crew heard a series of popping sounds above the engine noise. Almost immediately, the aircraft began to yaw left and at 0909:04 the pilot in command advised the TWR that the aircraft had a problem. The co-pilot determined that the left engine was malfunctioning. The crew subsequently recalled that the aircraft speed at this time had increased to at least 100 kts. The pilot in command, having verified that the left engine was malfunctioning, closed the left throttle and initiated propeller feathering action. During this period, full power (48 inches Hg and 2,700 RPM) was maintained on the right engine. However, the airspeed began to decay. The handling pilot reported that he had attempted to maintain 81 KIAS but was unable to do so. The aircraft diverged to the left of the runway centreline. The co-pilot and the supernumerary pilot subsequently reported that almost full right aileron had been used to control the aircraft. They could not recall the skid-ball indication. The copilot reported that he had full right rudder or near full right rudder applied. When he first became aware of the engine malfunction, the pilot in command assessed that, although a landing back on the runway may have been possible, the aircraft was capable of climbing safely on one engine. However, when he determined that the aircraft was not climbing, and that the airspeed had reduced below 81 kts, the pilot in command took control, and at 0909:38 advised the TWR that he was ditching the aircraft. He manoeuvred the aircraft as close as possible to the southern end of the partially constructed runway 16L. The aircraft was ditched approximately 46 seconds after the pilot in command first advised the TWR of the problem. The four crew and 21 passengers successfully evacuated the aircraft before it sank. They were taken on board pleasure craft and transferred to shore. After initial assessment, they were transported to various hospitals. All were discharged by 1430 that afternoon, with the exception of the flight attendant, who had suffered serious injuries.
Probable cause:
The following factors were considered significant in the accident sequence.
1. Compliance with the correct performance charts would have precluded the flight.
2. Clear and unambiguous presentation of CAA EROPs documentation should have precluded the flight.
3. The aircraft weight at takeoff exceeded the MTOW, the extent of which was unknown to the crew.
4. An engine malfunction and resultant loss of performance occurred soon after takeoff.
5. The operations manual take-off safety speed used by the crew was inappropriate for the overloaded condition of the aircraft.
6. The available single-engine aircraft performance was degraded when the co-pilot mishandled the aircraft controls.
7. The pilot in command delayed taking over control of the aircraft until the only remaining option was to conduct a controlled ditching.
8. There were organisational deficiencies in the management and operation of the DC-3 involving both Groupair and SPA.
9. There were organisational deficiencies in the safety regulation of both Groupair and SPA by the CAA district offices at Moorabbin and Bankstown.
10. There were organisational deficiencies relating to safety regulation of EROPS by the CAA.
Final Report:

Crash of a Curtiss C-46F Commando in Lokichoggio

Date & Time: Apr 23, 1994 at 0400 LT
Type of aircraft:
Operator:
Registration:
C-GIXZ
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
22495
YOM:
1945
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Just after liftoff, while climbing by night, the left engine lost power and failed. Its propeller was feathered and undercarriage and flaps were retracted. The aircraft lost height and crash landed near the runway end. Both pilots escaped uninjured while the aircraft was damaged beyond repair. It was chartered by Relief Air Transport.
Probable cause:
Failure of the left engine during initial climb for unknown reasons.

Crash of a Britten-Norman BN-2A-21 Islander in Weipa: 6 killed

Date & Time: Mar 21, 1994 at 1754 LT
Type of aircraft:
Registration:
VH-JUU
Flight Phase:
Survivors:
No
Schedule:
Weipa - Aurukun
MSN:
632
YOM:
1971
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
321
Captain / Total hours on type:
6.00
Circumstances:
On the day before the accident, the aircraft flew from Aurukun to Weipa with the chief pilot occupying the left pilot seat and the pilot involved in the accident occupying the right pilot seat. At Weipa the chief pilot left the aircraft, instructing the other pilot to fly some practice circuits before returning the aircraft to Aurukun. Before commencing the circuits and the return flight to Aurukun, the aircraft's two main tanks each contained 100 L of fuel and the two wing tip tanks each contained about 90 L of fuel. On the day of the accident the pilot added 200 L of fuel at Aurukun to the aircraft's tanks and then flew the aircraft and the passengers to Weipa. About 50 minutes before sunset, the aircraft taxied for departure from runway 30 for the 25-minute return flight to Aurukun. When the aircraft was about 300 ft above ground level after takeoff, a witness reported that all engine sounds stopped and that the aircraft attitude changed from a nose-high climb to a more level attitude. A short time later, the noise of engine power surging was heard. The aircraft rolled left and entered a spiral descent. It struck level ground some 350 m beyond the departure end of runway 30 and 175 m to the left of the extended centreline. All six occupants were killed.
Probable cause:
Significant factors:
- The pilot mismanaged the aircraft fuel system.
- Both engines suffered a total power loss due to fuel starvation.
- The right engine regained power probably as a result of a change in aircraft attitude.
- The pilot lost control of the aircraft.
- Recovery was not possible in the height available.
Final Report:

Crash of a Grumman G-73 Turbo Mallard off Key West: 2 killed

Date & Time: Mar 18, 1994 at 1143 LT
Type of aircraft:
Operator:
Registration:
N150FB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Key West Harbour - Key West
MSN:
J-51
YOM:
1950
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7725
Captain / Total hours on type:
3100.00
Aircraft flight hours:
17119
Circumstances:
The flightcrew had completed a 14 cfr part 135 charter flight and had landed in the harbor at Key West, Florida. They had moored the seaplane and departed. About an hour later, they reboarded the seaplane to fly it to an airport for refueling, then to return to the harbor to board the passengers. During takeoff, the seaplane was observed to pitch nose up, roll left, and crash nose down in the harbor. Due to the damage done by tidal flow and recovery attempts, the exact condition of the aft bilge drain plugs was unknown. During a check of the CVR recording, the crew was not heard to call out the bilge pumps during the before-takeoff checklist. After lift-off, both pilots made comments about keeping the nose down due to water in the aft portion of the aircraft. Both pilots were killed.
Probable cause:
Failure of the pilot-in-command to assure the bilges were adequately pumped free of water (adequately preflighted), which resulted in the aft center of gravity limit to be exceeded, and failure of the aircrew to follow the checklist. A factor related to the accident was: the water leak.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601P) in Pottstown: 2 killed

Date & Time: Mar 18, 1994 at 1126 LT
Operator:
Registration:
N36444
Flight Phase:
Survivors:
Yes
Schedule:
Pottstown - Salisbury
MSN:
61-0843-8163444
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
19950
Captain / Total hours on type:
7500.00
Aircraft flight hours:
4356
Circumstances:
At 0815 edt, N36444 landed with light snow falling and the temperature above freezing. Snow continued falling and the temperature dropped below freezing. At about 1100, the pilot filed an IFR flight plan and had a lineman brush snow from the wings. The lineman noted that patches of ice remained on the left wing, but the pilot declined to deice the plane. (At an airport 3 miles away, another flight was delayed due to ice that had formed below a snow cover on a plane that sat outside from 0945 to 1100.) The surviving passenger said that after takeoff, N36444 lost lift and yawed left. It appeared to recover, then vibrated, yawed, banked left, descended, and impacted the ground. After the accident, the engines were test run with no notable deficiencies. There was evidence the pilot was taking prescription medication. Tests of his blood showed 0.157 ug/ml of diazepam and 0.134 ug/ml of nordiazepam. Tests of his urine showed 0.152 ug/ml of nordiazepam and 0.167 ug/ml of oxazepam. On 3/2/90, the pilot had surgery for a tumor of (or near) the left optic nerve. In his last FAA medical application, he denied that he had medical treatment in the previous 5 years and did not report use of any medications. The aviation medical examiner had prescribed reserpine (for hypertension) and was aware of the surgery, but this was not reported in the pilot's faa medical record.
Probable cause:
The pilot's failure to ensure that ice was properly removed from the airplane before flight, possibly due to impairment of judgment caused by a prescription drug (valium) that was not approved for use while flying. Factors related to the accident were: the pilot's failure to properly report his medical history on his faa medical application, and failure of the designated medical examiner to report the pilot's known medical history.
Final Report:

Crash of a Douglas DC-3C in Spokane: 2 killed

Date & Time: Mar 18, 1994 at 0156 LT
Type of aircraft:
Operator:
Registration:
N3433Y
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Spokane - Portland
MSN:
43089
YOM:
1947
Flight number:
SAL2991
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3877
Captain / Total hours on type:
3114.00
Aircraft flight hours:
37190
Circumstances:
Shortly after takeoff, the copilot reported that the flight was returning with the right engine shut down. Seconds later, the tower controller saw a fire. The airplane collided with level terrain, 3,450 feet from the end of runway 21 in a 75° to 80° nose down attitude. The right engine propeller was found in the feathered position. The left engine indicated evidence that it was producing power at the time of impact. A fatigue crack was found that separated the head from the barrel on the number eight cylinder of the right engine. No other evidence was found to indicate a mechanical failure or malfunction. Both pilots were killed.
Probable cause:
The failure of the pilot-in-command to maintain airspeed. Factors to the accident were: cylinder fatigue, dark night and stall encountered.
Final Report:

Crash of a Cessna 402B in Jérémie

Date & Time: Mar 15, 1994 at 1220 LT
Type of aircraft:
Operator:
Registration:
N234AC
Flight Phase:
Survivors:
Yes
Schedule:
Jérémie - Port-au-Prince
MSN:
402B-0922
YOM:
1975
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
At liftoff, the twin engine went out of control and crashed by the runway. All nine occupants were injured, six of them seriously. The aircraft was destroyed.