Crash of a Britten Norman BN-2A Trislander III-1 on Great Barrier Island

Date & Time: Jul 5, 2009 at 1305 LT
Type of aircraft:
Operator:
Registration:
ZK-LOU
Flight Phase:
Survivors:
Yes
Schedule:
Great Barrier Island - Auckland
MSN:
322
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
868
Captain / Total hours on type:
28.00
Circumstances:
At about 1300 on Sunday 5 July 2009, ZK-LOU, a 3-engined Britten Norman BN2A Mk III Trislander operated by Great Barrier Airlines (the company), took off from Great Barrier Aerodrome at Claris on Great Barrier Island on a regular service to Auckland International Airport. On board were 10 passengers and a pilot, all of whom were wearing their seat belts. That morning the pilot had flown a different Trislander from Auckland International Airport to Claris and swapped it for ZK-LOU for the return flight because it was needed for pilot training back in Auckland. Another company pilot had that morning flown ZK-LOU to Claris from North Shore Aerodrome. He had completed a full engine run-up for the first departure of the day, as was usual, and said he noticed nothing unusual with the aeroplane during the approximate 30-minute flight. For the return flight the pilot said he completed the normal after-start checks in ZK-LOU and noticed nothing abnormal. He did not do another full engine run-up because it was not required. He taxied the aeroplane to the start of sealed runway 28, applied full power while holding the aeroplane on brakes and rechecked that the engine gauges were indicating normally before starting the take-off roll. The aeroplane took off without incident, but the pilot said when it was climbing through about 500 feet he heard an unusual “pattering” sound. He also heard the propellers going out of synchronisation, so he attempted to resynchronise them with the propeller controls. He checked the engine’s gauges and noticed that the right engine manifold pressure and engine rotation speed had dropped, so he adjusted the engine and propeller controls to increase engine power. At that time there was a loud bang and he heard a passenger scream. Looking back to his right the pilot saw that the entire propeller assembly for the right engine was missing and that there was a lot of oil spray around the engine cowling. The pilot turned the aeroplane left and completed the engine failure and shutdown checks. He transmitted a distress call on the local area frequency and asked the other company pilot, who was airborne behind him, to alert the local company office that he was returning to Claris. The company office manager and other company pilot noticed nothing unusual with ZK-LOU as it taxied and took off. The other pilot was not concerned until he saw what looked like white smoke and debris emanate from the aeroplane as though it had struck a flock of birds. Despite the failure, ZK-LOU continued to climb, so the pilot said he levelled at about 800 feet and reduced power on the 2 serviceable engines, completed a left turn and crossed over the aerodrome and positioned right downwind for runway 28. There was quite a strong headwind for the landing, so the pilot elected to do a flapless landing and keep the power and speed up a little because of the possibility of some wind shear. The pilot and other personnel said that the cloud was scattered at about 2500 feet, that there were a few showers in the area and that the wind was about 15 to 20 knots along runway 28. The visibility was reported as good. After landing, the pilot stopped the aeroplane on the runway and checked on the passengers before taxiing to the apron. At the apron he shut down the other engines and helped the passengers to the terminal, where they were offered drinks. The company chief executive, who lived locally, and a local doctor attended to the passengers. Three of the passengers received some minor abrasions and scrapes from shattered Perspex and broken interior lining when the propeller struck the side of the fuselage.
Probable cause:
Findings are listed in order of development and not in order of priority.
- The engine propeller assembly separated from the right engine of ZK-LOU in flight and struck the fuselage when the crankshaft failed at the flange that connected it to the propeller hub.
- High-cycle fatigue cracking on the flange that had developed during normal operations from undetected corrosion had reached a critical stage and allowed the flange to fail in overload.
- The crankshaft had inadvertently passed its overhaul service life by around 11% when the failure occurred, but the company had not realized this because of an anomaly in the recorded overseas service hours prior to importation of the engine to New Zealand. Ordinarily, the crankshaft would have been retired before a failure was likely.
- The crankshaft was an older design that has since been progressively superseded by those with flanges less prone to cracking.
- There was no requirement for a specific periodic crack check of the older-design crankshaft flanges, but this has been addressed by the CAA issuing a Continuing Airworthiness Notice on the issue.
- The CAA audit of the company had examined whether its engine overhaul periods were correct, but the audit could not have been expected to discover the anomaly in the overseas-recorded engine hours.
- This failure highlighted the need by potential purchasers of overseas components to follow the guidelines outlined in CAA Advisory Circular 00-1 to scrutinize overseas component records to ensure that the reported in-service hours are accurate.
Final Report:

Crash of a BAe 3201 Jetstream 31 at Salerno AFB

Date & Time: Jun 27, 2009
Type of aircraft:
Operator:
Registration:
N485UE
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
901
YOM:
1990
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Salerno AFB, the pilot-in-command decided to abandon the takeoff procedure for unknown reasons. The aircraft went out of control, veered off runway and came to rest. There were no injuries and the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-2 Beaver in Anchorage

Date & Time: Jun 7, 2009 at 1350 LT
Type of aircraft:
Operator:
Registration:
N915RC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Anchorage - Bulchitna Lake
MSN:
70
YOM:
1950
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
512
Captain / Total hours on type:
21.00
Aircraft flight hours:
2350
Circumstances:
The private pilot was taking off in the float plane from the lake's west waterway. The airplane was on step, gaining airspeed, and the takeoff run seemed normal to the pilot. The airplane was nearing takeoff speed, and proceeding directly down the waterway, when it encountered a right quartering tailwind gust that lifted up the right wing and float. The airplane veered to the left toward a steep bank, and the pilot was unable to correct the deviation with the rudder. He did not feel that he could reduce power as he would slam into the bank. The airplane lifted off, but the float collided with the top of the bank. The airplane cartwheeled about 160 degrees to the left before coming to rest on its right side. It sustained substantial damage to the wings, fuselage, and floats. The pilot reported that there were no mechanical malfunctions or failures. Reported wind at the airport approximately 3 minutes after the accident was from 020 degrees magnetic at 3 knots, with no recorded gusts.
Probable cause:
The pilot’s failure to maintain directional control during takeoff.
Final Report:

Crash of an Antonov AN-24T in Dire Dawa

Date & Time: May 18, 2009
Type of aircraft:
Registration:
EK-46839
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Dire Dawa - Bosaso
MSN:
7910201
YOM:
1967
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Dire Dawa-Aba Tenna Dejazmach Yilma Airport in foggy conditions, control was lost. The aircraft veered off runway and came to rest. All four crew members escaped with minor injuries and the aircraft was damaged beyond repair.

Crash of a Cessna 421C Golden Eagle III off Hamburg

Date & Time: Apr 28, 2009 at 1835 LT
Operator:
Registration:
D-IKST
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Hamburg – Altenburg – Thüringen
MSN:
421C-1024
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
175
Captain / Total hours on type:
28.00
Aircraft flight hours:
5482
Circumstances:
Shortly after take off from Hamburg-Fuhlsbüttel Airport, the pilot informed ATC that he lost all his navigational instruments and was cleared to divert to Hamburg-Finkenwerder Airport. On final, he encountered difficulties to lower the gears and eventually ditched the aircraft in the Elbe River. The aircraft came to rest upside down in 0,8 meter of water and was destroyed. The pilot escaped with minor injuries.
Final Report:

Crash of an Epic LT off Astoria

Date & Time: Apr 24, 2009 at 1645 LT
Type of aircraft:
Registration:
N653SB
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Astoria – Seattle
MSN:
025
YOM:
2008
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1550
Captain / Total hours on type:
75.00
Aircraft flight hours:
72
Circumstances:
The single engine aircraft departed Astoria Airport at 1637LT on a private flight to Seattle-Boeing Field, carrying one passenger (a female passenger aged 84) and one pilot. During a climb to en route cruise, the airplane's engine lost almost all power, and the pilot elected to ditch the airplane into the Columbia River off Astoria. The airplane crash landed eight minutes later, nosed down in water and came to rest partially submerged. Both occupants were quickly rescued and were uninjured. The aircraft was damaged beyond repair.
Probable cause:
The partial loss of engine power during climb to cruise due to the failure of the engine's fuel control unit. Contributing to the accident was the incorrect machining of an internal component of the fuel control unit, and the failure of the assembling technician to correctly inspect the unit's assembly.
Final Report:

Crash of a Cessna 208B Grand Caravan in Canaima: 1 killed

Date & Time: Apr 17, 2009 at 1545 LT
Type of aircraft:
Operator:
Registration:
YV1181
Flight Phase:
Survivors:
Yes
Schedule:
Canaima – Ciudad Bolívar
MSN:
208B-0695
YOM:
1998
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3404
Captain / Total hours on type:
1021.00
Copilot / Total flying hours:
269
Copilot / Total hours on type:
59
Aircraft flight hours:
15753
Circumstances:
After takeoff from runway 36 at Canaima Airport, while in initial climb, the single engine aircraft encountered difficulties to gain height. It collided with power lines and crashed in bushes located 80 metres past the runway end. A young boy aged 6 was killed while all other occupants were injured, seven seriously. The aircraft was destroyed.
Probable cause:
The accident occurred as a result of the inability of the aircraft to take off, affected by the tailwind and water puddles that covered part of the runway, which did not allow speed to build up, crashing into the ground. It is considered that the most likely cause of the accident was mismanagement by the crew, in the sense of failing to make adequate planning and analysis, coupled with overconfidence and lack of identification of hazardous conditions at that time of takeoff. Based on our [JIAAC] investigations, we can infer that there were several contributing causes for the occurrence of this accident. In this order, we can state the following:
- Adverse weather and tailwind conditions associated with the phenomenon.
- Incorrect management by the crew to use only the last third of the runway with the meteorological conditions prevailing at that time.
- Failure of the aerodrome administration to identify and correct poor drainage of the runway.
- Failure of the Autoridad Aeronáutica to monitor safety.
- Rejection by the crew of the concatenated form in which the factors involved in this event developed.
After all the analysis to different causes involved in this accident, we can point to as the main Causal Factor: Human Factor, due to the mismanagement by the flight crew upon takeoff in these conditions. Physical and Material factors included everything related to the prevailing weather conditions, road conditions and lack of services at the aerodrome by the authorities; all of them are considered Contributing Factors.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Fort Lauderdale: 1 killed

Date & Time: Apr 17, 2009 at 1115 LT
Operator:
Registration:
N1935G
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Fort Lauderdale - Fernandina Beach
MSN:
421B-0836
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
23000
Captain / Total hours on type:
5000.00
Circumstances:
Prior to the accident flight witnesses observed the pilot "haphazardly" pouring oil into the right engine. The pilot then ran the engines at mid-range power for approximately 20 minutes. The airplane subsequently taxied out of the ramp area and departed. Fire was observed emanating from the right engine after rotation. The airplane continued in a shallow climb from the runway, flying low, with the right engine on fire. The airplane then banked right to return to the airport and descended into a residential area. Examination of the right engine revealed an exhaust leak at the No. 4 cylinder exhaust riser flange. Additionally, one of the flange boltholes was elongated, most likely from the resulting vibration. The fuel nozzle and B-nut were secure in the No. 4 cylinder; however, its respective fuel line was separated about 8 inches from the nozzle. No determination could be made as to when the fuel line separated (preimpact or postimpact) due to the impact and postcrash fire damage. Examination of the right engine turbocharger revealed that the compressor wheel exhibited uniform deposits of an aluminum alloy mixture, consistent with ingestion during operation, and most likely from the melting of the aluminum fresh air duct. Additionally, the right propeller was found near the low pitch position, which was contrary to the owner's manual emergency procedure to secure the engine and feather the propeller in the event of an engine fire.
Probable cause:
The pilot's failure to maintain aircraft control and secure the right engine during an emergency return to the airport after takeoff. Contributing to the accident was an in-flight fire of the right engine for undetermined reasons.
Final Report:

Crash of a Tupolev TU-134AK at Dolinsk-Sokol AFB

Date & Time: Mar 26, 2009
Type of aircraft:
Operator:
Registration:
RA-65981
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
63250
YOM:
1980
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On take off roll at dusk during heavy snow falls, the aircraft veered off runway to the left and collided with a snow mound (1,2 meter high). The nose gear was torn off while both main gears collapsed. All occupants escaped uninjured while the aircraft was damaged beyond repair. It was used for the Far East Command.
Probable cause:
It appears that runway was not properly cleaned from snow prior to takeoff.

Crash of an Ilyushin II-76T off Entebbe: 11 killed

Date & Time: Mar 9, 2009 at 0515 LT
Type of aircraft:
Operator:
Registration:
S9-SAB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Entebbe - Mogadishu
MSN:
0734 10301
YOM:
1977
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
Shortly after takeoff from Entebbe Airport runway 17, while climbing by night, the aircraft entered an uncontrolled descent and crashed in the Lake Victoria, some 10 km south from Entebbe airport. The aircraft disintegrated on impact and all 11 occupants were killed, among them 3 Army Officer from Burundi and one Army Officer from Uganda. They were flying to Mogadishu on behalf of the Amisom, the African Union Mission In Somalia. The aircraft was chartered by the US Company Dynacorp to carry tents and water purification equipments.