Crash of a Swearingen SA227AC Metro III off Sydney: 1 killed

Date & Time: Apr 9, 2008 at 2327 LT
Type of aircraft:
Operator:
Registration:
VH-OZA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sydney – Brisbane
MSN:
AC-600
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4873
Captain / Total hours on type:
175.00
Aircraft flight hours:
32339
Aircraft flight cycles:
46710
Circumstances:
On 9 April 2008, at 2325 Eastern Standard Time, a Fairchild Industries Inc. SA227-AC (Metro III) aircraft, registered VH-OZA, departed Sydney Airport, New South Wales on a freight charter flight to Brisbane, Queensland with one pilot on board. The aircraft was subsequently observed on radar to be turning right, contrary to air traffic control instructions to turn left to an easterly heading. The pilot reported that he had a ‘slight technical fault’ and no other transmissions were heard from the pilot. Recorded radar data showed the aircraft turning right and then left, followed by a descent and climb, a second right turn and a second descent before radar returns were lost when the aircraft was at an altitude of 3,740 ft above mean sea level and descending at over 10,000 ft/min. Air traffic control initiated search actions and search vessels later recovered a small amount of aircraft wreckage floating in the ocean, south of the last recorded radar position. The pilot was presumed to be fatally injured and the aircraft was destroyed. Both of the aircraft’s on-board flight recorders were subsequently recovered from the ocean floor. They contained data from a number of previous flights, but not for the accident flight. There was no evidence of a midair breakup of the aircraft.
Probable cause:
Contributing Safety Factors:
- It was very likely that the aircraft’s alternating current electrical power system was not energised at any time during the flight.
- It was very likely that the aircraft became airborne without a functioning primary attitude reference or autopilot that, combined with the added workload of managing the ‘slight technical fault’, led to pilot spatial disorientation and subsequent loss of control.
Other Safety Factors:
- The pilot’s Metro III endorsement training was not conducted in accordance with the operator’s approved training and checking manual, with the result that the pilot’s competence and ultimately, safety of the operation could not be assured. [Significant safety issue].
- The chief pilot was performing the duties and responsibilities of several key positions in the operator’s organisational structure, increasing the risk of omissions in the operator’s training and checking requirements.
- The conduct of the flight single-pilot increased the risk of errors of omission, such as not turning on or noticing the failure of aircraft items and systems, or complying with directions.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 200 in Comodoro Rivadavia

Date & Time: Apr 4, 2008
Operator:
Registration:
T-84
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
214
YOM:
1969
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Comodoro Rivadavia Airport, while climbing, the crew encountered an unexpected situation and was forced to attempt an emergency landing. The aircraft crash landed in a desert area located about 10 km from the airport. While all six occupants escaped uninjured, the aircraft was damaged beyond repair.

Crash of a Cessna F406 Caravan II in Mwanza: 2 killed

Date & Time: Apr 3, 2008 at 1624 LT
Type of aircraft:
Operator:
Registration:
5H-AWK
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mwanza - Mwanza
MSN:
406-0030
YOM:
1989
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2900
Captain / Total hours on type:
600.00
Circumstances:
The crew consisting of one instructor and one pilot under supervision departed Mwanza for a local training flight with approaches and touch-and-go manoeuvres. Shortly after takeoff from runway 12, while climbing to an altitude of 800 feet, the twin engine aircraft rolled to the right then entered a right turn and an uncontrolled descent before crashing on the top of a small hill located 890 metres from the runway 30 threshold. The aircraft was totally destroyed and both pilots were killed, a British instructor and an Australian citizen pilot under training.
Probable cause:
The crew was supposed to conduct several touch-and-go maneuvers and the instructor wanted to simulate an engine failure. Shortly after takeoff from runway 12, the aircraft rolled to the right while the right engine was turning at low RPM, presumably as a result of the instructor's decision to reduce the engine power. Due to a poor reaction by the pilot under supervision and an insufficient altitude to regain control, the aircraft lost altitude and crashed. The crew was supposed to initiate a left turn during initial climb, according to ATC instructions, but due to the power reduction on the right engine, the aircraft banked right then turned right and entered an uncontrolled descent. A wind from 090 gusting at 18 knots remained a contributing factor as it contributed to the aircraft rolling to the right.

Crash of a Cessna 500 Citation I in Biggin Hill: 5 killed

Date & Time: Mar 30, 2008 at 1438 LT
Type of aircraft:
Registration:
VP-BGE
Flight Phase:
Survivors:
No
Site:
Schedule:
Biggin Hill – Pau
MSN:
500-0287
YOM:
1975
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
8278
Captain / Total hours on type:
18.00
Copilot / Total flying hours:
4533
Copilot / Total hours on type:
70
Aircraft flight hours:
5844
Aircraft flight cycles:
5352
Circumstances:
Pilot B arrived at Biggin Hill Airport, Kent, at about 1100 hrs for the planned flight to Pau, France. At about 1130 hrs he helped tow the aircraft from its overnight parking position on the Southern Apron to a nearby handling agent whose services were being used for the flight. A member of staff employed by the handling agent saw Pilot B carry out what was believed to be an external pre-flight check of the aircraft. Pilot B also asked another member of staff to provide a print out of the weather information for the flight. Pilot A arrived at about 1145 hrs and joined Pilot B at the aircraft. Witnesses described nothing unusual in either pilots’ demeanour. Three passengers arrived at the handling agent at about 1300 hrs and waited in a lounge whilst their bags were taken to the aircraft and loaded into the baggage hold in the nose. A member of the handling agency, who later took the passengers to the aircraft, reported that Pilot B met them outside the aircraft. After they had all boarded, the agent heard Pilot B say that he would give them a safety brief. Pilot B then closed the aircraft door. Pilot A called for start at 1317 hrs. He called for taxi at 1320 hrs and the aircraft was cleared to taxi to the holding point A1. No one could be identified as a witness to the aircraft’s start or subsequent taxi to the holding point. At 1331 hrs ATC cleared the aircraft to line up on Runway 21 and at 1332 hrs cleared it to take off. Both clearances were acknowledged by Pilot A. The takeoff was observed by the tower controller who stated that everything appeared normal. No transmissions were made between the aircraft and ATC until one minute after takeoff when, at 1334 hrs, the following exchange was made. Numerous witnesses reported seeing the aircraft at around this time flying over a built-up area, about 2 nm north-north-east of Biggin Hill Airport, where it was observed flying low, passing over playing fields and nearby houses. Witnesses reported that the aircraft was maintaining a normal flying attitude with some reporting that the landing gear was up and others that it was down. Some described seeing it adopt a nose-high attitude and banking away from the houses just before it crashed. Some witnesses stated that there was no engine noise coming from the aircraft whilst others stated that they became aware of the aircraft as it flew low overhead due to the loud noise it was making, as if the engines were at high thrust. Two witnesses described hearing the aircraft make a pulsing, intermittent noise. The location of witnesses and the description of the aircraft noise they heard are also shown in Figure 1. Having flown over several houses at an extremely low height the aircraft’s left wing clipped a house which bordered a small area of woodland. The aircraft then impacted the ground between this and another house and caught fire. There were no injuries to anyone on the ground but all those on board the aircraft were fatally injured.
Probable cause:
The following contributory factors were identified:
1. It is probable that a mechanical failure within the air cycle machine caused the vibration which led to the crew attempting to return to the departure airfield.
2. A missing rivet head on the left engine fuel shut-off lever may have led to an inadvertent shut-down of that engine.
3. Approximately 70 seconds prior to impact neither engine was producing any thrust.
4. A relight attempt on the second engine was probably started before the relit first engine had reached idle speed, resulting in insufficient time for enough thrust to be developed to arrest the aircraft’s rate of descent before ground impact.
Final Report:

Crash of a Cessna 500 Citation I in Oklahoma City: 5 killed

Date & Time: Mar 4, 2008 at 1515 LT
Type of aircraft:
Operator:
Registration:
N113SH
Flight Phase:
Survivors:
No
Schedule:
Oklahoma City - Mankato
MSN:
500-0285
YOM:
1975
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
6100
Copilot / Total flying hours:
1378
Copilot / Total hours on type:
2
Aircraft flight hours:
6487
Circumstances:
On March 4, 2008, about 1515 central standard time, a Cessna 500, N113SH, registered to Southwest Orthopedic & Sports Medicine Clinic PC of Oklahoma City, Oklahoma, entered a steep descent and crashed about 2 minutes after takeoff from Wiley Post Airport (PWA) in Oklahoma City. None of the entities associated with the flight claimed to be its operator. The pilot, the second pilot, and the three passengers were killed, and the airplane was destroyed by impact forces and post crash fire. The flight was operated under 14 Code of Federal Regulations (CFR) Part 91 with an instrument flight rules flight plan filed. Visual meteorological conditions prevailed. The flight originated from the ramp of Interstate Helicopters (a 14 CFR Part 135 on demand helicopter operator at PWA) and was en route to Mankato Regional Airport, Mankato, Minnesota, carrying company executives who worked for United Engines and United Holdings, LLC.
Probable cause:
Airplane wing-structure damage sustained during impact with one or more large birds (American white pelicans), which resulted in a loss of control of the airplane.
Final Report:

Crash of a PZL-Mielec AN-2R in Orenburg

Date & Time: Feb 29, 2008
Type of aircraft:
Operator:
Registration:
RA-43990
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
1G211-09
YOM:
1985
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Orenburg-Tsentralny Airport, while climbing with a tailwind component, the skis collided with a concrete perimeter wall. The aircraft lost height and crashed 20 metres further. All 4 crew escaped unhurt while the aircraft was damaged beyond repair.

Crash of an ATR42-300 in Mérida: 46 killed

Date & Time: Feb 21, 2008 at 1700 LT
Type of aircraft:
Operator:
Registration:
YV1449
Flight Phase:
Survivors:
No
Site:
Schedule:
Mérida – Caracas
MSN:
28
YOM:
1986
Flight number:
BBR518
Location:
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
43
Pax fatalities:
Other fatalities:
Total fatalities:
46
Circumstances:
After takeoff from Mérida-Alberto Carnevalli Airport runway 25, the aircraft climbed in clouds when it collided with a mountain located 10 km northwest of the airport. The aircraft disintegrated on impact and all 46 occupants were killed. The wreckage was found at an altitude of 4,100 metres.
Probable cause:
After departure from runway 25, the crew planned to use an unpublished procedure. Climbing through clouds a 180-degree turn was initiated. Using the unreliable magnetic compass, the flight made a 270 degree turn, heading towards rising terrain. The captain took over control from the copilot. When visual contact with terrain was regained, the crew noted they were heading for mountains. The captain tried to avoid rising terrain but the aircraft impacted the side of a mountain at 4,100 metres.

Crash of an ATR72-212 in Putao

Date & Time: Feb 19, 2008
Type of aircraft:
Operator:
Registration:
XY-AIE
Flight Phase:
Survivors:
Yes
Schedule:
Putao - Myitkyina
MSN:
458
YOM:
1995
Flight number:
JAB252
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
53
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll, the captain noticed an asymmetrical engine thrust and decided to reject takeoff. Unable to stop within the remaining distance, the aircraft overran, rolled for about 30 metres and collided with an embankment, coming to rest broken in two. All 57 occupants evacuated safely.

Crash of a Cessna 414 Chancellor in Benton: 2 killed

Date & Time: Feb 16, 2008 at 1845 LT
Type of aircraft:
Operator:
Registration:
N41LP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Benton - Wichita
MSN:
414-0491
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
565
Captain / Total hours on type:
52.00
Aircraft flight hours:
6656
Circumstances:
According to witnesses, the airplane departed runway 35 and was observed flying in and out of the clouds. Several of the witnesses observed the airplane initiate a turn to the west. One witnesses commented that it was dark but he could still see the silhouette of the airplane. He observed the airplane descend below the trees. All of the witnesses reported flames and "fireballs." On scene evidence was consistent with the airplane impacting trees in a left turn. The airplane was destroyed. An examination of the airplane, flight controls, engines, and remaining systems revealed no anomalies. Weather observations and radar data depicted low clouds, and restricted visibility due to rain and mist, in the vicinity of the airport. Toxicological examination revealed cetirizine, an antihistamine, consistent with use within the previous 12 hours. Most studies have not found any significant impairment from the medication, though it is reported to cause substantial sedation in some individuals.
Probable cause:
The pilot's failure to maintain clearance from the trees. Contributing to the accident was the pilot's flight into known adverse weather conditions and the low clouds and visibility.
Final Report:

Crash of a Canadair RegionalJet CRJ-100ER in Yerevan

Date & Time: Feb 14, 2008 at 0415 LT
Operator:
Registration:
EW-101PJ
Flight Phase:
Survivors:
Yes
Schedule:
Yerevan - Minsk
MSN:
7316
YOM:
1999
Flight number:
BRU1834
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
15563
Aircraft flight cycles:
14352
Circumstances:
A Canadair CRJ100ER passenger jet, operated by Belavia, was destroyed when crashed and burned on takeoff from Yerevan-Zvartnots Airport (EVN), Armenia. All three crew members and eighteen passengers survived the accident. The airplane arrived as flight BRU1833 from Minsk-2 International Airport (MSQ), Belarus at 02:05. Refueling was carried out in preparation for the return flight and the crew conducted the flight planning. After refueling the pilot carried out a tactile and visual inspection of all critical surfaces of the wing and visual inspection of the tail assembly. All the planes were clean and dry. The weather reported for the 04:00 was: wind 110 degrees at the ground 1 m/sec, visibility 3500 meters, haze, small clouds, vertical visibility of 800 meters, scattered clouds at 3000 m, a temperature of minus 3° C, dew point minus 4° C, pressure 1019 hPa. At 04:08 both engines were started. The engine air intake heating (cowl anti-ice) was switched on but the wing anti-icing system was not switched on. The crew taxied to runway 27 and were cleared for departure. During takeoff the airplane progressively banked left until the left wing tip contacted runway. The airplane went off the side with the airplane rolling the right. The right hand wing broke off and spilled fuel caught fire. The airplane came to rest upside down.
Probable cause:
The accident involving aircraft CRJ-100LR registration number EW-101PJ was the result of an asymmetric loss of lift of the wing during take-off, which led to the toppling of the aircraft immediately after liftoff from the runway, the left wing tip contacting the ground, the subsequent destruction and fire. The reason for the loss of lift of the wing at the actual weather conditions, was the formation of frost, which "pollutes" the surface of the wing. The cause of formation of frost, most likely, was the fuel icing, while the aircraft was parked at the airport and during taxiing for the return flight, resulting in a difference in temperature of the surrounding air and cold fuel in the tanks after the flight. The situation could be aggravated when exceeding the values recommended by the operations manual of the angular velocity when lifting the nose wheel during takeoff with "contaminated" wings when it is impossible to monitor this parameter instrumentally. Existing procedural methods of control of the aerodynamic surfaces of the aircraft before departure, along with the inefficiency, during takeoff, the existing system of protection from stalling due to increased sensitivity of the wing, even to a slight contamination of the leading edge, can not fully guarantee the prevention of similar accidents in future. An Airworthiness Directive on the need to include anti-icing systems on the wing in the final stage of taxiing at the actual weather conditions was issued by Transport Canada after the accident. This probably could have prevented the accident.