Crash of a Learjet 60 in Columbia: 4 killed

Date & Time: Sep 19, 2008 at 2353 LT
Type of aircraft:
Operator:
Registration:
N999LJ
Flight Phase:
Survivors:
Yes
Schedule:
Columbia - Van Nuys
MSN:
314
YOM:
2006
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3140
Captain / Total hours on type:
35.00
Copilot / Total flying hours:
8200
Copilot / Total hours on type:
300
Aircraft flight hours:
108
Aircraft flight cycles:
123
Circumstances:
On September 19, 2008, about 2353 eastern daylight time, a Bombardier Learjet Model 60, N999LJ, owned by Inter Travel and Services, Inc., and operated by Global Exec Aviation, overran runway 11 during a rejected takeoff at Columbia Metropolitan Airport, Columbia, South Carolina. The captain, the first officer, and two passengers were killed; two other passengers were seriously injured. Both pilots and two passengers were killed while two others were seriously injured. Both passengers who were admitted in a local hospital for high burns were DJ AM & Travis Barker of the Rock band called "Blink". They were travelling back to California after they gave a concert in South Carolina.
Probable cause:
The operator’s inadequate maintenance of the airplane’s tires, which resulted in multiple tire failures during takeoff roll due to severe underinflation, and the captain’s execution of a rejected takeoff (RTO) after V1, which was inconsistent with her training and standard operating procedures.
Contributing to the accident were:
- Deficiencies in Learjet’s design of and the Federal Aviation Administration’s (FAA) certification of the Learjet Model 60’s thrust reverser system, which permitted the failure of critical systems in the wheel well area to result in uncommanded forward thrust that increased the severity of the accident,
- The inadequacy of Learjet’s safety analysis and the FAA’s review of it, which failed to detect and correct the thrust reverser and wheel well design deficiencies after a 2001 uncommanded forward thrust accident,
- Inadequate industry training standards for flight crews in tire failure scenarios,
- The flight crew’s poor crew resource management (CRM).
Final Report:

Crash of a Gippsland GA8 Airvan in Cooinda

Date & Time: Sep 9, 2008 at 1500 LT
Type of aircraft:
Operator:
Registration:
VH-KNE
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cooinda - Cooinda
MSN:
GA8-08-128
YOM:
2008
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot was completing a local post maintenance test flight at Cooinda Airport. Shortly after takeoff, while in initial climb, the engine failed. The pilot attempted an emergency landing in the bush but the aircraft collided with a telephone pole and came to rest. The pilot escaped with minor injuries and the aircraft was damaged beyond repair.
Probable cause:
Engine failure for unknown reasons.

Crash of a Lockheed P2V-7 Neptune in Reno: 3 killed

Date & Time: Sep 1, 2008 at 1810 LT
Type of aircraft:
Operator:
Registration:
N4235T
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Reno - Reno
MSN:
726-7285
YOM:
1958
Flight number:
Tanker 09
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
9520
Copilot / Total flying hours:
2812
Aircraft flight hours:
10217
Circumstances:
Just after the airplane's landing gear was retracted during takeoff for a retardant drop mission, a ball of fire was observed coming out of the left jet engine before the airplane rolled steeply to the left and descended into the terrain. Prior to takeoff, the captain said he would make the takeoff and provided a takeoff briefing concerning the runway to be used and his intentions should an emergency develop. Shortly thereafter, the captain informed the co-pilot that this would actually be his (the co-pilot's) takeoff. On the cockpit voice recorder, the co-pilot stated "Same briefing (sound of laughter)". The co-pilot did not give an additional takeoff briefing beyond the one given by the captain and the captain did not ask the co-pilot to give one. During the initial climb, the captain said he detected a fire on the left side of the airplane and the copilot responded that he was holding full right aileron. At no point did either pilot call for the jettisoning of the retardant load as required by company standard operating procedures, or verbally enunciate the jet engine fire emergency checklist. Recorded data showed that the airplane's airspeed then decayed below the minimum air control speed, which resulted in an increased roll rate to the left and impact with terrain. The 11th stage compressor disc of the left jet engine failed in fatigue, which caused a catastrophic failure of the compressor section and the initiation of the engine fire. Metallurgical examination of the fracture identified several origin points at scratches in the surface finish of the disk. The scratches were too small to have been observed with the approved inspection procedures used by the company. A review of the FAA sanctioned Approved Aircraft Inspection Program, revealed no shortcomings or anomalies in the performance or documentation of the program. A post-accident examination of the airframe and three remaining engines revealed no anomalies that would have precluded normal operations.
Probable cause:
The failure of the flight crew to maintain airspeed above in-flight minimum control speed (Vmca) after losing power in the left jet engine during initial climb after takeoff. Contributing to the accident was the crew's inadequate cockpit resource management procedures, the failure of the captain to assume command of the airplane during the emergency, the flight crew's failure to carry out the jet engine fire emergency procedure, and the failure of the crew to jettison the retardant load.
Final Report:

Crash of a Convair CV-580 in Columbus: 3 killed

Date & Time: Sep 1, 2008 at 1206 LT
Type of aircraft:
Operator:
Registration:
N587X
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Columbus - Mansfield
MSN:
361
YOM:
1956
Flight number:
HMA587
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
16087
Copilot / Total flying hours:
19285
Aircraft flight hours:
71965
Circumstances:
The accident flight was the first flight following maintenance that included flight control cable rigging. The flight was also intended to provide cockpit familiarization for the first officer and the pilot observer, and as a training flight for the first officer. About one minute after takeoff, the first officer contacted the tower and stated that they needed to return to land. The airplane impacted a cornfield about one mile southwest of the approach end of the runway, and 2 minutes 40 seconds after the initiation of the takeoff roll. The cockpit voice recorder (CVR) indicated that, during the flight, neither the captain nor the first officer called for the landing gear to be raised, the flaps to be retracted, or the power levers to be reduced from full power. From the time the first officer called "rotate" until the impact, the captain repeated the word "pull" about 27 times. When the observer pilot asked, "Come back on the trim?" the captain responded, "There's nothing anymore on the trim." The inspection of the airplane revealed that the elevator trim cables were rigged improperly, which resulted in the trim cables being reversed. As a result, when the pilot applied nose-up trim, the elevator trim system actually applied nose-down trim. The flight crew was briefed on the maintenance work that had been performed on the airplane; therefore, when the captain’s nose-up trim inputs were affecting his ability to control the airplane, at a minimum, he should have stopped making additional inputs and returned the airplane to the configuration it was in before the problem worsened. An examination of the maintenance instruction cards used to conduct the last inspection revealed that the inspector's block on numerous checks were not signed off by the Required Inspection Item (RII) inspector. The RII inspector did not sign the item that stated: "Connect elevator servo trim tab cables and rig in accordance with Allison Convair [maintenance manual]...” The item had been signed off by the mechanic, but not by the RII inspector. The card also contained a NOTE, which stated in bold type, "A complete inspection of all elevator controls must be accomplished and signed off by an RII qualified inspector and a logbook entry made to this effect." The RII inspector block was not signed off.
Probable cause:
The improper (reverse) rigging of the elevator trim cables by company maintenance personnel, and their subsequent failure to discover the misrigging during required post-maintenance checks. Contributing to the accident was the captain’s inadequate post-maintenance preflight check and the flight crew’s improper response to the trim problem.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in North Las Vegas: 1 killed

Date & Time: Aug 28, 2008 at 1238 LT
Operator:
Registration:
N212HB
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
North Las Vegas - Palo Alto
MSN:
31-8152072
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3195
Captain / Total hours on type:
100.00
Aircraft flight hours:
6373
Circumstances:
During climb a few minutes after takeoff, a fire erupted in the airplane's right engine compartment. About 7 miles from the departure airport, the pilot reversed course and notified the air traffic controller that he was declaring an emergency. As the pilot was proceeding back toward the departure airport witnesses observed fire beneath, and smoke trailing from, the right engine and heard boom sounds or explosions as the airplane descended. Although the pilot feathered the right engine's propeller, the airplane's descent continued. The 12-minute flight ended about 1.25 miles from the runway when the airplane impacted trees and power lines before coming to rest upside down adjacent to a private residence. A fuel-fed fire consumed the airframe and damaged nearby private residences. The airplane was owned and operated by an airplane broker that intended to have it ferried to Korea. In preparation for the overseas ferry flight, the airplane's engines were overhauled. Maintenance was also performed on various components including the engine-driven fuel pumps, turbochargers, and propellers. Nacelle fuel tanks were installed and the airplane received an annual inspection. Thereafter, the broker had a ferry pilot fly the airplane from the maintenance facility in Ohio to the pilot's Nevada-based facility, where the ferry pilot had additional maintenance performed related to the air conditioner, gear door, vacuum pump, and idle adjustment. Upon completion of this maintenance, the right engine was test run for at least 20 minutes and the airplane was returned to the ferry pilot. During the following month, the ferry pilot modified the airplane's fuel system by installing four custom-made ferry fuel tanks in the fuselage, and associated plumbing in the wings, to supplement the existing six certificated fuel tanks. The ferry pilot held an airframe and powerplant mechanic certificate with inspection authorization. He reinspected the airplane, purportedly in accordance with the Piper Aircraft Company's annual inspection protocol, signed the maintenance logbook, and requested Federal Aviation Administration (FAA) approval for his ferry flight. The FAA reported that it did not process the first ferry pilot's ferry permit application because of issues related to the applicant's forms and the FAA inspector's workload. The airplane broker discharged the pilot and contracted with a new ferry pilot (the accident pilot) to immediately pick up the airplane in Nevada and fly it to California, the second ferry pilot's base. The contract specified that the airplane be airworthy. In California, the accident pilot planned to complete any necessary modifications, acquire FAA approval, and then ferry the airplane overseas. The discharged ferry pilot stated to the National Transportation Safety Board (NTSB) investigator that none of his airplane modifications had involved maintenance in the right engine compartment. He also stated that when he presented the airplane to the replacement ferry pilot (at most 3 hours before takeoff) he told him that fuel lines and fittings in the wings related to the ferry tanks needed to be disconnected prior to flight. During the Safety Board's examination of the airplane, physical evidence was found indicating that the custom-made ferry tank plumbing in the wings had not been disconnected. The airplane wreckage was examined by the NTSB investigation team while on scene and following its recovery. Regarding both engines, no evidence was found of any internal engine component malfunction. Notably, the localized area surrounding and including the right engine-driven fuel pump and its outlet port had sustained significantly greater fire damage than was observed elsewhere. According to the Lycoming engine participant, the damage was consistent with a fuel-fed fire originating in this vicinity, which may have resulted from the engine's fuel supply line "B" nut being loose, a failed fuel line, or an engine-driven fuel pumprelated leak. The fuel supply line and its connecting components were not located. The engine-driven fuel pump was subsequently examined by staff from the NTSB's Materials Laboratory. Noted evidence consisted of globules of resolidified metal and areas of missing material consistent with the pump having been engulfed in fire. The staff also examined the airplane. Evidence was found indicating that the fire's area of origin was not within the wings or fuselage, but rather emanated from a localized area within the right engine compartment, where the engine-driven fuel pump and its fuel supply line and fittings were located. However, due to the extensive pre- and post-impact fires, the point of origin and the initiating event that precipitated the fuel leak could not be ascertained. The airplane's "Pilot Operator's Handbook" (POH), provides the procedures for responding to an in-flight fire and securing an engine. It also provides single-engine climb performance data. The POH indicates that the pilot should move the firewall fuel shutoff valve of the affected engine to the "off" position, feather the propeller, close the engine's cowl flaps to reduce drag, turn off the magneto switches, turn off the emergency fuel pump switch and the fuel selector, and pull out the fuel boost pump circuit breaker. It further notes that unless the boost pump's circuit breaker is pulled, the pump will continuously operate. During the wreckage examination, the Safety Board investigators found evidence indicating that the right engine's propeller was feathered. However, contrary to the POH's guidance, the right engine's firewall fuel shutoff valve was not in the "off" position, the cowl flaps were open, the magneto switches were on, the emergency fuel pump switches and the fuel selector were on, and the landing gear was down. Due to fire damage, the position of the fuel boost pump circuit breaker could not be ascertained. Calculations based upon POH data indicate that an undamaged and appropriately configured airplane flying on one engine should have had the capability to climb between 100 and 200 feet per minute and, at a minimum, maintain altitude. Recorded Mode C altitude data indicates that during the last 5 minutes of flight, the airplane descended while slowing about 16 knots below the speed required to maintain altitude.
Probable cause:
A loss of power in the right engine due to an in-flight fuel-fed fire in the right engine compartment that, while the exact origin could not be determined, was likely related to the right engine-driven fuel pump, its fuel supply line, or fitting. Contributing to the accident was the pilot's failure to adhere to the POH's procedures for responding to the fire and configuring the airplane to reduce aerodynamic drag.
Final Report:

Crash of a Lockheed L-100-20 Hercules off Davao City: 11 killed

Date & Time: Aug 25, 2008 at 2055 LT
Type of aircraft:
Operator:
Registration:
4593
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Davao City – Iloilo City
MSN:
4593
YOM:
1975
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The four engine aircraft departed Davao City Airport at 2051LT on a flight to Iloilo City where members of the Presidential Security Group should be picked up for Manila. During initial climb, the crew was cleared to climb to 18,000 feet when the aircraft entered an uncontrolled descent and crashed in the sea about 4 minutes after takeoff. The aircraft was destroyed and all 11 occupants were killed.

Crash of a Beechcraft A100 King Air in Moab: 10 killed

Date & Time: Aug 22, 2008 at 1750 LT
Type of aircraft:
Registration:
N601PC
Flight Phase:
Survivors:
No
Schedule:
Moab - Cedar City
MSN:
B-225
YOM:
1975
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
1818
Captain / Total hours on type:
698.00
Aircraft flight hours:
9263
Circumstances:
The twin engine aircraft, owned by the Red Canyon Aesthetics & Medical Spa, a dermatology clinic headquartered in Cedar City, was returning to its base when shortly after take off, the pilot elected to make an emergency landing due to technical problem. The aircraft hit the ground, skidded for 300 meters and came to rest in flames in the desert, near the Arches National Park. All 10 occupants, among them some cancer specialist who had traveled to Moab early that day to provide cancer screening, cancer treatment, and other medical services to citizens in Moab, were killed.
Probable cause:
The pilot’s failure to maintain terrain clearance during takeoff for undetermined reasons.
Final Report:

Crash of a Cessna 207 Skywagon in Poesoegroenoe

Date & Time: Aug 21, 2008
Registration:
PZ-TRR
Flight Phase:
Survivors:
Yes
Schedule:
Poesoegroenoe – Paramaribo
MSN:
207-0313
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Poesoegroenoe Airstrip, while in initial climb, the single engine aircraft stalled and crashed in a wooded area. All six occupants escaped with minor injuries while the aircraft was damaged beyond repair.
Probable cause:
It is believed that the accident was the consequence of an engine failure for unknown reasons.

Crash of a McDonnell Douglas MD-82 in Madrid: 154 killed

Date & Time: Aug 20, 2008 at 1424 LT
Type of aircraft:
Operator:
Registration:
EC-HFP
Flight Phase:
Survivors:
Yes
Schedule:
Madrid - Las Palmas
MSN:
53148/2072
YOM:
1993
Flight number:
JKK5022
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
166
Pax fatalities:
Other fatalities:
Total fatalities:
154
Captain / Total flying hours:
8476
Captain / Total hours on type:
5776.00
Copilot / Total flying hours:
1276
Copilot / Total hours on type:
1054
Aircraft flight hours:
31963
Aircraft flight cycles:
28133
Circumstances:
An MD-82 passenger plane, registered EC-HFP, was destroyed when it crashed on takeoff at Madrid-Barajas Airport (MAD), Spain. Of the aircraft’s occupants, 154 were killed, including all six crew members. Eighteen passengers were seriously injured. The MD-82 aircraft operated Spanair flight JK5022 from Madrid-Barajas (MAD) to Gran Canaria (LPA). The estimated departure time was 13:00. The aircraft was authorized by control for engine start-up at 13:06:15. It then taxied to runway 36L from parking stand T21, which it occupied on the apron of terminal T2 at Barajas. The flaps were extended 11°. Once at the runway threshold, the aircraft was cleared for takeoff at 13:24:57. The crew informed the control tower at 13:26:27 that they had a problem and that they had to exit the runway. At 13:33:12, they communicated that they were returning to the stand. The crew had detected an overheating Ram Air Temperature (RAT) probe. The aircraft returned to the apron, parking on remote stand R11 of the terminal T2 parking area. The crew stopped the engines and requested assistance from maintenance technicians to solve the problem. The mechanic confirmed the malfunction described in the ATLB, checked the RAT probe heating section of the Minimum Equipment List (MEL) and opened the electrical circuit breaker that connected the heating element. Once complete, it was proposed and accepted that the aircraft be dispatched. The aircraft was topped off with 1080 liters of kerosene and at 14:08:01 it was cleared for engine start-up and to taxi to runway 36L for takeoff. The crew continued with the tasks to prepare the airplane for the flight. The conversations on the cockpit voice recorder revealed certain expressions corresponding to the before engine start checklists, the normal start list, the after start checklist and the taxi checklist. During the taxi run, the aircraft was in contact with the south sector ground control first and then with the central sector. On the final taxi segment the crew concluded its checks with the takeoff imminent checklist. At 14:23:14, with the aircraft situated at the head of runway 36L, it was cleared for takeoff. Along with the clearance, the control tower informed the aircraft that the wind was from 210° at 5 knots. At 14:23:19, the crew released the brakes for takeoff. Engine power had been increased a few seconds earlier and at 14:23:28 its value was 1.4 EPR. Power continued to increase to a maximum value of 1.95 EPR during the aircraft’s ground run. The CVR recording shows the crew calling out "V1" at 14:24:06, at which time the DFDR recorded a value of 147 knots for calibrated airspeed (CAS), and "rotate" at 14:24:08, at a recorded CAS of 154 knots. The DFDR recorded the signal change from ground mode to air mode from the nose gear strut ground sensor. The stall warning stick shaker was activated at 14:24:14 and on three occasions the stall horn and synthetic voice sounded in the cockpit: "[horn] stall, [horn] stall, [horn] stall". Impact with the ground took place at 14:24:23. During the entire takeoff run until the end of the CVR recording, no noises were recorded involving the takeoff warning system (TOWS) advising of an inadequate takeoff configuration. During the entire period from engine start-up while at parking stand R11 to the end of the DFDR recording, the values for the two flap position sensors situated on the wings were 0°. The length of the takeoff run was approximately 1950 m. Once airborne, the aircraft rose to an altitude of 40 feet above the ground before it descended and impacted the ground. During its trajectory in the air, the aircraft took on a slight left roll attitude, followed by a fast 20° roll to the right, another slight roll to the left and another abrupt roll to the right of 32°. The maximum pitch angle recorded during this process was 18°. The aircraft’s tail cone was the first part to impact the ground, almost simultaneously with the right wing tip and the right engine cowlings. The marks from these impacts were found on the right side of the runway strip as seen from the direction of the takeoff, at a distance of 60 m, measured perpendicular to the runway centerline, and 3207.5 m away from the threshold, measured in the direction of the runway. The aircraft then traveled across the ground an additional 448 m until it reached the side of the runway strip, tracing out an almost linear path at a 16° angle with the runway. It lost contact with the ground after reaching an embankment/drop-off beyond the strip, with the marks resuming 150 m away, on the airport perimeter road, whose elevation is 5.50 m lower than the runway strip. The aircraft continued moving along this irregular terrain until it reached the bed of the Vega stream, by which point the main structure was already in an advanced state of disintegration. It is here that it caught on fire. The distance from the initial impact site on the ground to the farthest point where the wreckage was found was 1093 m.
Probable cause:
The crew lost control of the airplane as a consequence of entering a stall immediately after takeoff due to an improper airplane configuration involving the non-deployment of the slats/flaps following a series of mistakes and omissions, along with the absence of the improper takeoff configuration warning.
The crew did not identify the stall warnings and did not correct said situation after takeoff. They momentarily retarded the engine throttles, increased the pitch angle and did not correct the bank angle, leading to a deterioration of the stall condition.
The crew did not detect the configuration error because they did not properly use the checklists, which contain items to select and verify the position of the flaps/slats, when preparing the flight. Specifically:
- They did not carry out the action to select the flaps/slats with the associated control lever (in the "After Start" checklist);
- They did not cross check the position of the lever or the status of the flap and slat indicating lights when executing the" After Start" checklist;
- They omitted the check of the flaps and slats during the "Takeoff briefing" item on the "Taxi" checklist;
- The visual check done when executing the "Final items" on the "Takeoff imminent" checklist was not a real check of the position of the flaps and slats, as displayed on the instruments in the cockpit.
The CIAIAC has identified the following contributing factors:
- The absence of an improper takeoff configuration warning resulting from the failure of the TOWS to operate, which thus did not warn the crew that the airplane's takeoff configuration was not appropriate. The reason for the failure of the TOWS to function could not be reliably established.
- Improper crew resource management (CRM), which did not prevent the deviation from procedures in the presence of unscheduled interruptions to flight preparations.
Final Report:

Crash of a Cessna 501 Citation I/SP off Santo Domingo: 1 killed

Date & Time: Aug 18, 2008 at 2029 LT
Type of aircraft:
Registration:
N223LC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Santo Domingo - San Juan
MSN:
501-0055
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft departed Santo Domingo-Las Améericas Airport at 2026LT on a positioning flight to San Juan, Porto Rico. While climbing in night conditions, the pilot lost control of the airplane that crashed in the sea few km offshore. SAR operations were initiated but no trace of the aircraft nor the pilot was found.