Crash of a Piper PA-46-310P Malibu in Pine Island

Date & Time: Dec 7, 1993 at 1530 LT
Registration:
N4391C
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Pine Island – Kendall-Tamiami
MSN:
46-8508053
YOM:
1985
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3700
Captain / Total hours on type:
125.00
Circumstances:
The pilot stated that he was attempting a takeoff on a 2,700 foot sod runway and hit a soft spot which decreased his groundspeed by 15 to 20 miles per hour. He continued the takeoff attempt and struck trees at the end of the runway. The airplane fell to the ground and burst into flames.
Probable cause:
The failure of the pilot-in-command to abort the takeoff. A contributing factor was the soft condition of the runway surface.
Final Report:

Crash of a Grumman G-21A Goose in Prince Rupert: 2 killed

Date & Time: Dec 4, 1993 at 1145 LT
Type of aircraft:
Operator:
Registration:
C-FUMG
Flight Phase:
Survivors:
Yes
Schedule:
Prince Rupert - Kincolith
MSN:
B145
YOM:
1945
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
12400
Captain / Total hours on type:
1600.00
Aircraft flight hours:
22683
Circumstances:
The Grumman G21A Goose (C-FUMG) departed from the Seal Cove floatplane base at Prince Rupert, British Columbia, on a charter flight to Kincolith. The aircraft carried one pilot, four passengers, and approximately 600 pounds of baggage and freight. This was the first flight of the day for the occurrence aircraft. Prior to take-off, the pilot contacted the Prince Rupert Flight Service Station (FSS)1 by radio and obtained local traffic and weather information. The aircraft took off from the water at approximately 1141 Pacific standard time (PST)2, and proceeded southbound, following the normal departure path. During the take-off and climb, one or both of the aircraft's engines did not sound as if they were operating normally. Shortly after take-off, the pilot radioed the company dispatcher at Seal Cove and reported that he was experiencing engine problems, and that he was returning to Seal Cove and would require assistance at the ramp. After the left propeller stopped rotating, the aircraft rolled to the left and descended steeply to the ground. The aircraft crashed into trees on a hillside, at an altitude of approximately 150 feet, approximately three nautical miles (nm)3 south of Seal Cove. The pilot and one passenger were fatally injured; the three other passengers received serious injuries. A search started approximately 45 minutes after the aircraft departed. The aircraft was discovered by a Coast Guard helicopter, which was able to rescue the survivors. The accident occurred during daylight hours at about 1145 PST, at latitude 54·17'N and longitude 134·14'W.
Probable cause:
The pilot encountered engine problems during the take-off and climb, and, after the left propeller was feathered, lost directional control of the aircraft. The aircraft rolled to the left, descended rapidly, and crashed to the ground.
Final Report:

Crash of a De Havilland DH.104 Dove 5 in Melbourne

Date & Time: Dec 3, 1993 at 2037 LT
Type of aircraft:
Operator:
Registration:
VH-DHD
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Melbourne - Melbourne
MSN:
04104
YOM:
1948
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18154
Captain / Total hours on type:
1500.00
Aircraft flight hours:
21259
Circumstances:
The pilot had planned to conduct a night charter flight over Melbourne and Port Phillip Bay, starting from and returning to Essendon Airport. Dinner was to be served in flight. The pilot gave a safety briefing to the passengers before starting the engines. He completed engine runups and pre-takeoff checks, including selecting 20° of flap. At 2036 ESuT, in daylight, the pilot initiated takeoff on runway 17 using standard take-off power setting of 7.5 lb/in2 of boost and 3,000 RPM. Wind conditions were light and variable, visibility was about 10 km and the temperature was 19°C. The aircraft became airborne and, just as it achieved the take-off safety speed of 84 kts, at a height not above 50 ft, the right engine lost power. The aircraft yawed right. The pilot reported to the investigation team that he briefly noticed a reading of 3 lb of boost on the MAP gauge and assessed the problem as a possible partial right engine failure. He then selected the landing gear up but it did not retract. He cycled the landing gear selector once and the gear then retracted. By this time several seconds had elapsed and the airspeed had decayed to 76 kts. The pilot then assessed the airspeed as too low to retract the flaps and left them at 20°. The airspeed continued to decay until VMCA, 72 kts, was reached. When indicated airspeed had further decayed to 68 kts, the pilot reduced power on the left engine to avoid an uncontrollable roll to the right. He was able to maintain wings level and attempted to track the aircraft toward a street but was unable to maintain height. The aircraft collided with powerlines and then struck the roofs of several houses before coming to rest, on its left side, against the front wall of a house. About one minute had elapsed from initiation of takeoff until the accident. The pilot and all but one of the passengers remained conscious throughout the accident sequence. All occupants were evacuated, some without assistance and others with the assistance of the pilot, other passengers, emergency services personnel or bystanders.
Probable cause:
The following factors were reported:
- The right engine fuel control unit fuel pump failed causing the engine to fail at a critical phase of flight.
- Maintenance inspections did not detect the abnormal wear on the thrust face of the right engine fuel control unit fuel pump.
- The landing gear did not retract on the first attempt and aircraft performance decayed while the pilot resolved this problem.
- The pilot was probably forced to abandon the emergency procedures to concentrate on maintaining control of the aircraft.
- The aircraft was unable to maintain altitude and airspeed with the right propeller windmilling and 20° of flap.
- The investigation identified organisational factors concerning deficiencies in the manuals and procedures available to, and used by, the operator for the operation and maintenance of the accident aircraft.
Final Report:

Crash of a Britten-Norman BN-2A-27 Islander near Tuktoyaktuk: 7 killed

Date & Time: Dec 3, 1993 at 1713 LT
Type of aircraft:
Registration:
C-GMOP
Flight Phase:
Survivors:
No
Schedule:
Tuktoyaktuk - Inuvik
MSN:
398
YOM:
1974
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
3224
Captain / Total hours on type:
848.00
Aircraft flight hours:
9391
Circumstances:
On 03 December 1993, a Britten-Norman BN2A-20 Islander, registration C-GMOP, owned and operated by Arctic Wings and Rotors, departed Tuktoyaktuk, Northwest Territories, on a night
visual flight rules (VFR) flight to the Inuvik townsite airstrip. On board were the pilot and six passengers. The pilot took off from runway 09 at 1706:34 mountain standard time (MST) , and had turned the aircraft to a southerly direction when the right engine (Textron Lycoming IO540-K1B5) lost all power. At 1710:40, the pilot reported to Tuktoyaktuk Flight Service Station (FSS) that he had an engine problem and was trying to get back to the airport. At 1711:44, he reported that he was "presently heading back to the airport at this time." At 1711:58, he reported "showing six miles back from the airport at this time." The FSS specialist asked if he was declaring an emergency, and the pilot's response was indecisive. During the last radio transmission, there were indications of stress in the pilot's voice; however, there was no further mention of the specific nature of the problem. The pilot did not report his altitude during the conversations with the FSS. The transmission lasted approximately 15 seconds and ended at 1713:03. When the aircraft did not return to the airport, an air and ground search was initiated. The aircraft was located on an ice-covered lake approximately eight miles southeast of the airport. The aircraft struck the ice in a steep nose-down attitude. The engines and front of the aircraft penetrated the approximately two-foot-thick layer of ice. The remainder of the fuselage, wings, and empennage remained on the ice surface. The seven occupants were fatally injured. The accident occurred during the hours of darkness at approximately 1713 MST, at latitude 69°20'N, longitude 132°56'W, at an elevation of approximately 50 feet above sea level (asl).
Probable cause:
A magneto impulse coupling, worn beyond the prescribed limits, resulted in the failure of the right engine. Following the engine failure, the pilot mistrimmed the rudder and was unable to maintain control of the aircraft.
Final Report:

Crash of a Piper PA-61P Aerostar (Ted Smith 601P) near Campeche

Date & Time: Nov 23, 1993 at 1435 LT
Operator:
Registration:
N32RG
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Campeche - New Orleans
MSN:
61P-0514-214
YOM:
1978
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Five minutes after takeoff from Campeche Airport, both engines started to surge and lost power. The pilot reduced his altitude and attempted an emergency landing when the aircraft crash landed about 16 km from Campeche. All four occupants were slightly injured and the aircraft was damaged beyond repair.
Probable cause:
It is believed that the engine failed after the aircraft was refueled with Jet A1 iso 100LL.

Crash of a Piper PA-31-350 Navajo Chieftain in Orlando: 1 killed

Date & Time: Nov 12, 1993 at 0629 LT
Registration:
N27687
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Orlando - Tampa
MSN:
31-7852107
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2465
Aircraft flight hours:
8393
Circumstances:
Cargo was not weighed and weight and balance calculations were not performed. The airplane was about 321 pounds over gross. While taxiing, a witness reported seeing black smoke trailing the left engine which had been worked on the night before the accident. Two cylinders were worked on and a fuel injector nozzle was cleaned. The climb after takeoff was 'low and slow' during which the airplane rolled left, pitched nose down, and impacted the ground coming to rest adjacent to a house. Examination of each engine revealed no evidence of internal mechanical failure or malfunction. Heat damage precluded testing of the magnetos, turbocharger components, and fuel servos of each engine. Examination of each propeller revealed no evidence of preimpact failure or malfunction. The fuel nozzles from the left engine were examined which revealed that they were blocked in various places due to contaminants. After the accident the faa performed a focused inspection of the operator revealing that the cargo was not being weighed, the chief pilot of the company was in name only, and load manifests were not being kept by the company. The pilot, sole on board, was killed.
Probable cause:
In flight loss of control for failure of the pilot-in-command to maintain vmc shortly after takeoff. Contributing to the accident was partial loss of engine power from the left engine due to partial blockage of several of the fuel injector nozzles. Also contributing to the accident was weight and balance exceeded by the pilot-in-command and inadequate surveillance by the company and by the FAA.
Final Report:

Crash of an Avro 748-234-2A in Sandy Lake: 7 killed

Date & Time: Nov 10, 1993 at 1805 LT
Type of aircraft:
Operator:
Registration:
C-GQTH
Flight Phase:
Survivors:
No
Schedule:
Winnipeg – Sandy Lake – Saint Theresa Point – Island Lake – Winnipeg
MSN:
1617
YOM:
1967
Flight number:
7N205
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
16000
Captain / Total hours on type:
4500.00
Copilot / Total flying hours:
6500
Copilot / Total hours on type:
1100
Aircraft flight hours:
29284
Circumstances:
The aircraft, a Hawker Siddeley 748 Series 2A Model 234 (HS 748) owned and operated by Air Manitoba Ltd. (Air Manitoba), took off from Winnipeg at 1438 central standard time (CST) , 10 November 1993, on scheduled flight NAM 205/ 206 that included stops at Sandy Lake, Ontario; St. Theresa Point, Manitoba; Island Lake, Manitoba; and return to Winnipeg, Manitoba. The flight was conducted in accordance with an instrument flight rules (IFR) flight plan and flight notification. On arrival at Sandy Lake at approximately 1549, the crew attempted to land but were unable to because of the low ceiling and visibility. They then diverted to St. Theresa Point, landing at 1630. A normal turnaround was completed; the number of passengers on departure was 26, and 2,086 pounds of fuel was uploaded to an estimated total of 6,700 pounds on board. The flight departed St. Theresa Point for Sandy Lake at 1720. The aircraft landed at approximately 1745 at Sandy Lake, where 22 passengers deplaned while four remained on board; the aircraft was not refuelled or otherwise serviced at Sandy Lake. During the stop, both engines were shut down. On take-off from Sandy Lake, there were two pilots, a flight attendant, and four passengers on board. The aircraft took off from runway 29 at Sandy Lake at approximately 1805 and entered a right turn. Witnesses indicate that the aircraft appeared to fly at a lower than normal height throughout the turn. After turning through approximately 120 degrees(°), the aircraft descended into 100-foot trees and crashed. The aircraft struck the ground about one nautical mile (nm) northwest of the airport. All seven occupants of the aircraft were fatally injured in the crash. The accident occurred during the hours of darkness. The wreckage was located at position latitude 53°04'71"N, longitude 93°21'38"W, at an elevation of approximately 940 feet above sea level (asl).
Probable cause:
After take-off, the crew most likely lost situational awareness and, as a result, did not detect the increasing deviation from their intended flight path. Contributing to the loss of situational awareness was the lack of AC power to some of the flight instruments; the reason for the lack of AC power could not be determined.
Final Report:

Crash of a De Havilland DHC-3 Otter off Thorne Bay

Date & Time: Nov 10, 1993
Type of aircraft:
Registration:
N98AT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Thorne Bay - Ketchikan
MSN:
181
YOM:
1956
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine airplane was returning to its base in Ketchikan following maintenance in Thorne Bay. Shortly after takeoff, while climbing, the engine lost power, forcing the pilot to attempt an emergency landing. While landing on water, a control wire snapped, causing the airplane to nose down in the water, coming to rest upside down. All three occupants were rescued by coastguard 20 minutes later and the aircraft sank.
Probable cause:
Loss of engine power on climb out for unknown reasons.

Crash of a Douglas DC-3-65TP in Lokichoggio

Date & Time: Nov 7, 1993
Type of aircraft:
Registration:
ZS-KCV
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
15268/26713
YOM:
1944
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was engaged in a humanitarian flight on behalf of Unicef. Shortly after takeoff, while climbing, it went out of control and crashed on a parking lot. It was destroyed and all four occupants were injured.
Probable cause:
It is believed that the crew forgot to unlock the tail prior to departure.

Crash of a Cessna 402B in Sugai Besi: 2 killed

Date & Time: Oct 13, 1993 at 1715 LT
Type of aircraft:
Operator:
Registration:
M27-03
Flight Phase:
Flight Type:
Survivors:
No
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Sungai Besi Airport, while in initial climb, the twin engine aircraft went out of control and crashed in a huge explosion about 3 km from the airfield. Both pilots were killed.