Takeoff (climb)

Shortly after take off from Lomé international Airport, while on a cargo flight to Amsterdam, the crew declared an emergency and was cleared for an immediate return. The approach and landing were considered as normal and the aircraft returned safely to the apron. While all three crew members were uninjured, the aircraft was damaged beyond repair due to bulkhead destruction.

The instrument-rated private pilot departed on an instrument flight rules (IFR) cross-country flight plan in near-zero visibility with mist, light freezing rain, and moderate mixed and clear icing. After departure, and as the airplane entered a climbing right turn to a track of about 260 degrees, the pilot reported to air traffic control that she was at 1,000 feet, climbing to 10,000 feet. The flight remained on a track of about 260 degrees and continued to accelerate and climb for 38 seconds. The pilot then declared an emergency, stating that she had an attitude indicator failure. At that moment, radar data depicted the airplane at 3,500 feet and 267 knots. Thirteen seconds later, the pilot radioed she wasn't sure which way she was turning. The transmission ended abruptly. Radar data indicated that at the time the transmission ended the airplane was in a steep, rapidly descending left turn. The fragmented airplane wreckage, due to impact and subsequent explosive forces, was located in a wooded area about 6 miles south-southwest of the departure airport. Examination of the accident site revealed a near vertical high-speed impact consistent with an in-flight loss of control. The on-site examination of the airframe remnants did not show evidence of preimpact malfunction. Examination of recovered engine remnants revealed evidence that both engines were producing power at the time of impact and no preimpact malfunctions with the engines were noted. The failure, single or dual, of the attitude indicator is listed as an abnormal event in the manufacturer's Pilot's Abbreviated Emergency/Abnormal Procedures. The airplane was equipped with three different sources of attitude information: one incorporated in the primary flight display unit on the pilot's side, another single instrument on the copilot's side, and the standby attitude indicator. In the event of a dual failure, on both the pilot and copilot sides, aircraft control could be maintained by referencing to the standby attitude indicator, which is in plain view of the pilot. The indicators are powered by separate sources and, during the course of the investigation, no evidence was identified that indicated any systems, including those needed to maintain aircraft control, failed. The pilot called for a weather briefing while en route to the airport 30 minutes prior to departure and acknowledged the deteriorating weather during the briefing. Additionally, the pilot was eager to depart, as indicated by comments that she made before her departure that she was glad to be leaving and that she had to go. Witnesses indicated that as she was departing the airport she failed to activate taxi and runway lights, taxied on grass areas off taxiways, and announced incorrect taxi instructions and runways. Additionally, no Federal Aviation Administration authorization for the pilot to operate an aircraft between 29,000 feet and 41,000 feet could be found; the IFR flight plan was filed with an en route altitude of 38,000 feet. The fact that the airplane was operating at night in instrument meteorological conditions and the departure was an accelerating climbing turn, along with the pilot's demonstrated complacency, created an environment conducive to spatial disorientation. Given the altitude and speed of the airplane, the pilot would have only had seconds to identify, overcome, and respond to the effects of spatial disorientation.

Shortly after takeoff from a remote terrain located in Te Uku, near Raglan, the pilot lost control of the aircraft that collided with a fence and crashed, bursting into flames. The pilot escaped uninjured while the aircraft was destroyed by fire.

The commercial pilot departed on a night instrument flight rules flight in actual instrument meteorological in-flight conditions. Less than 2 minutes after the airplane departed the airport, the controller observed the airplane in a right turn and instructed the pilot to report his altitude. The pilot responded he thought he was at 3,500 feet and he thought he had lost the gyros. The pilot said he was trying to level out, and when the controller informed the pilot he observed the airplane on radar making a 360-degree right turn , the pilot said "roger." Three minutes and 23 seconds after departure the pilot said "yeah, I'm having some trouble right now" and there were no further radio communications from the flight. The on scene investigation disclosed that both wings and the tail section had separated from the airframe. All fractures of the wing and wing skin were typical of ductile overload with no evidence of preexisting failures such as fatigue or stress-corrosion. The deformation of the wings indicated an upward failure due to positive loading. No anomalies were noted with the gyro instruments, engine assembly or accessories

The airline transport pilot and nine passengers were departing in a twin-engine airplane on a 14 Code of Federal Regulations Part 135 air taxi flight from a runway adjacent to an ocean bay. According to the air traffic control tower specialist on duty, the airplane became airborne about midway down the runway. As it approached the end of the runway, the pilot said he needed to return to the airport, but gave no reason. The specialist cleared the airplane to land on any runway. As the airplane began a right turn, it rolled sharply to the right and began a rapid, nose- and right-wing-low descent. The airplane crashed about 200 yards offshore and the fragmented wreckage sank in the 10-foot-deep water. Survivors were rescued by a private float plane. A passenger reported that the airplane's nose baggage door partially opened just after takeoff, and fully opened into a locked position when the pilot initiated a right turn towards the airport. The nose baggage door is mounted on the left side of the nose, just forward of the pilot's windscreen. When the door is opened, it swings upward, and is held open by a latching device. To lock the baggage door, the handle is placed in the closed position and the handle is then locked by rotating a key lock, engaging a locking cam. With the locking cam in the locked position, removal of the key prevents the locking cam from moving. The original equipment key lock is designed so the key can only be removed when the locking cam is engaged. Investigation revealed that the original key lock on the airplane's forward baggage door had been replaced with an unapproved thumb-latch device. A Safety Board materials engineer's examination revealed evidence that a plastic guard inside the baggage compartment, which is designed to protect the door's locking mechanism from baggage/cargo, appeared not to be installed at the time of the accident. The airplane manufacturer's only required inspection of the latching system was a visual inspection every 100 hours of service. Additionally, the mechanical components of the forward baggage door latch mechanism were considered "on condition" items, with no predetermined life-limit. On May 29, 2008, the Federal Aviation Administration issued a safety alert for operators (SAFO 08013), recommending a visual inspection of the baggage door latches and locks, additional training of flight and ground crews, and the removal of unapproved lock devices. In July 2008, Piper Aircraft issued a mandatory service bulletin (SB 1194, later 1194A), requiring the installation of a key lock device, mandatory recurring inspection intervals, life-limits on safety-critical parts of forward baggage door components, and the installation of a placard on the forward baggage door with instructions for closing and locking the door to preclude an in-flight opening. Post accident inspection discovered no mechanical discrepancies with the airplane other than the baggage door latch. The airplane manufacturer's pilot operating handbook did not contain emergency procedures for an in-flight opening of the nose baggage door, nor did the operator's pilot training program include instruction on the proper operation of the nose baggage door or procedures to follow in case of an in-flight opening of the door. Absent findings of any other mechanical issues, it is likely the door locking mechanism was not fully engaged and/or the baggage shifted during takeoff, and contacted the exposed internal latching mechanism, allowing the cargo door to open. With the airplane operating at a low airspeed and altitude, the open baggage door would have incurred additional aerodynamic drag and further reduced the airspeed. The pilot's immediate turn towards the airport, with the now fully open baggage door, likely resulted in a sudden increase in drag, with a substantive decrease in airspeed, and an aerodynamic stall.

While preparing the flight at Tehran-Mehrabad Airport, the copilot proceeded with a walk around check of the airplane. As the OAT was near freezing level and there were some light snow showers, he requested a deicing. Nevertheless, as there were already a few number of aircraft waiting for deicing, the captain decided to takeoff without deicing. At 0731LT, the crew was cleared for takeoff and started the takeoff procedure. After liftoff, the aircraft started to roll to the left then to the right. Losing altitude, the left wing impacted ground and the aircraft crash landed, coming to rest and bursting into flames. All 113 occupants were rescued, among them 11 were seriously injured including four crew members.

Around 1100LT, an airport maintenance team consisting of four people in two cars (Kia minivan) was cleared to enter runway 08R to perform maintenance work on the runway lighting system. Two of the men were working at about 600 meters from the threshold and the two other men were working at about 1500 meters from the threshold. Visibility at the time was poor due to thick fog. At 11:04 the runway was vacated by both vehicles due to landing traffic. At 11:06 they were recleared to enter the runway. At 11:25:13 flight ROT3107, a Boeing 737-300, was cleared to enter runway 08R for takeoff. The flight was cleared for takeoff at 11:26:07. Between 11:26:40 and 11:26:50 the control tower asked the maintenance workers if the runway was clear but got no reply. During the takeoff roll, at a speed of 90 knots, the aircraft collided with one of the van that was 'parked' about 600 metres from the threshold with its left engine and left main gear. The van was totally destroyed upon impact and the aircraft veered off runway to the left and came to rest 137 metres to the left of the centerline and 950 metres from the threshold. All 123 occupants evacuated safely and there were no injuries with ground maintenance personnel.

On December 25, 2007 a crew of JetConnection Businessflight AG airline including the PIC, the co-pilot and a flight attendant was conducting a charter flight JCX826 routed Hannover (Germany), Astana (Republic of Kazakhstan) – Macao (China) on a CL-604 aircraft (registration D-ARWE). Apart from the crew there was one passenger on board. At 12:10 (hereinafter UTC time is used) on December 25, 2007 the crew took off at Hannover Airport. During the flight the crew was informed that there was no fuel available for refueling the aircraft at Astana Airport. Due to this the crew decided to change the flight route and refuel the aircraft at Almaty International Airport (Republic of Kazakhstan). The flight from Hannover to Almaty in accordance with the PIC explanations was normal. No faults in the operation of the aircraft systems or equipment were detected. At 18:46 the crew landed at Almaty Airport. The ground handling service at Almaty Airport was provided by Bercut Air Services KZ based at the airport. The departure from Almaty to Macao according to the schedule was planned for 20:50 on December 25, 2007. The ground handling and servicing was provided by Bercut Air Services KZ Company. In accordance with the work order the Almaty ground services conducted refueling and anti-icing. The Pre-Flight Check was conducted by the PIC. He also monitored the refueling and stabilizer and wing anti-icing. According to the PIC interrogation there were no faults detected in the operation of aircraft systems and equipment. 8460 liters (6827 kg) of TC-1 condition fuel was refueled. According to the estimations, total fuel on board was 7605 kg. The refueled fuel was distributed in the fuel tanks in accordance with the AFM of the CL-604 aircraft. In accordance with the estimations the aircraft weight was 20659 kg, CG 33,1%, which was within the CL-604 AFM limitations. During the pre-flight preparation for the flight to Macao the crew of the CL-604 D-ARWE did not receive the meteorological consultation or documentation at the Almaty Meteorological Center. According to BFU information the crew of the JCX826 flight had received the integrated meteorological consultation for the flight to Macao before the takeoff from Hannover. In Almaty PIC has received updated data through the Internet from the website of the German Meteorological Service (DWD) and also from the PPS provider of the JetConnection Businessflight AG (Billund, Denmark). According to the ATC tape recorder data containing the communication of the СL-604 D-ARWE crew with the ATC offices of Almaty airport, at 20:17:55 the crew informed the Ground Control that they were ready to startup and taxi right after the completion of the anti-icing procedure. At 20:18:24 the Ground Control instructed the crew: “JCX826, expect start up in 5 minutes.” At 20:20:48 in reply to the Controller’s request if they were ready for start-up the crew reported: “We are expecting anti-icing which is about to start now”. While waiting for the anti-icing the crew received the ATC clearance for departure. In accordance with the DE-ICING\ANTI-ICING REQUEST from the 25.12.2007, signed by the PIC and the Bercut Air Servises KZ manager the processing with using Type 1 and Type 2 fluids was conducted in two steps. On the first stage Type 1 deicing fluid (Killfrost DF Plus) was applied to remove the icing with the estimated fluid to water ratio of 70/30%. According to the enquiry of the de-icing operator the temperature of the Type 1 fluid in the tank of the SIMON GLOBAL 2110 machine used for the fluid application was about + 80˚ С, and at the outlet of the sprayer it was not less than +60˚ С. Note: The check of the SIMON GLOBAL 2110 machine conducted by the investigation team after the accident revealed that the temperature of the Type 1 fluid at the outlet of the sprayer is +66˚ С, which complies with the СL-604 OM (Part 1, page 06-12-17). On the second stage of the anti-icing procedure the Type 2 anti-icing fluid was used (Killfrost ABC 2000) with the estimated fluid to water ratio of 100/0%. Note: In the fluid Type 1 and Type 2 delivery receipt No.4002014 by mistake was shown unreal concentration 70/00 for the Type 2 fluid instead of its real concentration 100/00. The OM of the CL-604 does not suggest preliminary heating and heating monitoring of Type 2 fluid. According to the record in the aircraft fuelling receipt the amount of the applied Type 2 fluid was 250 liters. According to the requirements of Annex A, page XXI of the AEA, Training Recommendation and background Information for de-icing/anti-icing of aircraft on the ground, Edition 2, September 2005 the recommended anti-icing fluid minimum for the wing and stabilizer of a CL-604 type aircraft was 100 liters. Thus enough Type 2 fluid was applied for the anti-icing of CL-604 D-ARWE. The inspection of the fluid samples used for the de-icing/anti-icing of the CL-604 D-ARWE aircraft conducted at Almaty airport laboratory revealed that the Type 1 fluid had an actual fluid to water ratio of 67/33% while the Type 2 fluid 99/1%. Provided the OAT at Almaty airport at the time of the fluid application was minus 13˚ С, the mentioned ratios were within the requirements of the CL-604 OM (Part 1, Section VI, Cold Weather Operations). The actual weather at Almaty airport according to the request of the Approach Control for 20:49 was as follows: surface wind 360˚ 2 m/sec, RVR 2900 m, light snow, mist, clouds 8 oktas, nimbostratus, fractonimbus, cloudbase 150 m, QFE 718 mm mercury, OAT minus 12,9˚ С, dewpoint minus 13,7˚, moisture content 93%, QFE 718 mm mercury. In accordance with the de-icing/anti-icing operator the de-/anti-icing procedure was conducted in compliance with the CL-604 OM recommendations in the following order: stabilizer, left wing, right wing. Every surface was applied first with Type 1 and then Type 2 fluid. The time between the completion of the Type 1 application and the beginning of the Type 2 application in accordance with the operator’s explanations did not exceed 1.5-2 minutes which is suggested in Section VI of the CL0604 OM. According to the estimations conducted by the investigation team the application of the Type 2 fluid was started at 20:37. Note: In accordance with the CL-604 OM (Part 1, page 06-12-13), the holdover time of the Type 2 fluid with the fluid to water ration of 100/0 in the OAT range of -3…-20˚ С, with precipitation in the form of snow and snow grain is 15…30 minutes. According to the information recorded by the FDR, during the de-/anti-icing the aircraft flaps were retracted while the stabilizer deflection was minus 4,7˚. By 20:43 the de-/anti-icing procedure was completed. On leaving the aircraft the PIC made a visual and tactile (by touching the wing surface) inspection of the anti-icing quality, admitted that it was satisfactory by signing in the de-/anti-icing receipt. After that the PIC returned to the aircraft and the crew began the engine start-up. In accordance with the FDR information, by 20:46 the crew had started up first the right engine and then the left engine. The N2 of the right and left engine in the idle mode was 61,5 % and 62,0 % respectively. In 10 seconds after the left engine start-up the Cowl Anti-Ice was engaged. In accordance with the CVR information, a check at a stage After Engine Start was performed by the flight crew in a volume which stipulated by the JetConnection Businessflight AG “ABBRIVIATED CHECKLIST”. However a comparison of this checklist with the CL-604 D-ARWE AFM checklist (Chapter 4 “Normal Procedures” Section “Consolidated Checklists” Item L “After Engine Start Check”) shows the absences of WAI and CAI systems checks. Note: For a number of other preflight preparation stages the JetConnection Businessflight AG “ABBRIVIATED CHECKLIST” also doesn’t cover all procedures stipulated by the CL-604 AFM. At 20:47:42 the crew reported the Ground Control that they were ready for taxiing. At 20:48:25 the Ground Control cleared the crew for the holding point following the leader van. Within 20:51:17 – 20:51:45, the crew checked the rudder, the ailerons and elevators and extended the flaps to the takeoff position (Flaps 20). The stabilizer position (-4,7˚) did not change. At 20:51:55 the crew was instructed by the Ground Control to expect further instructions at the holding point and contact the Tower Control. At 20:52:17 after contacting the Tower Control the crew was instructed to wait on the holding point as there was an MD-83 aircraft making Flight UKM 109 on final at a distance of 14 km. At 20:57:15, after the MD-83 landed the Tower Control cleared the CL-604 D-ARWE to line up at RWY 05 and at 21:01:30 they were cleared for takeoff. During the takeoff an increasing right bank started developing. As the aircraft was banking to the right it touched the right runway edge with its right wing tip. Then the aircraft, leaning on the right wing, moved to the graded airfield to the right of the runway and hit its surface with the right main landing gear and nose landing gear. During the further movement the aircraft hit the reinforced fence of the airdrome and shifting on the ground 190 m beyond the airdrome finally stopped. At the final stage of movement a fire occurred which was extinguished by the airport fire brigades. The actual weather at Almaty airport checked after the accident alert at 21:04 was as follows: wind 350° 4 m/sec, visibility 1200 m (RVR 2500 m), snow, mist, clouds 8 oktas, nimbostratus, fractonimbus, cloudbase 120 m, OAT minus 14° С, dewpoint minus 15° С, moisture content 92%, pressure 718 mm mercury. Runway 05 condition – dry snow up to 10 mm, friction factor 0.32. The accident occurred on December 25, 2007 at 21:02 UTC (26.12.2007 at 03:02 local time).

About 0800, the commercial pilot did a preflight inspection of the accident airplane, in preparation for a cargo flight. Dark night, visual meteorological conditions prevailed. He indicated that the weather conditions were clear and cold, and frost was on the airplane. He said the frost was not bonded to the skin of the airplane, and he was able to use a broom to clean off the frost, resulting in a clean wing and tail surface. He reported that no deicing fluid was applied. After takeoff, he retracted the flaps to about 5 degrees at 110 knots of airspeed. The airplane then rolled to the right about three times in a manner he described as a wave, or vortex-like movement. He applied left aileron and lowered the flaps to 20 degrees, but the roll to the right was more severe. The pilot said the engine power was "good." He then noticed that the airplane was descending toward the ground, so he attempted to put the flaps completely down. His next memory was being outside the airplane after it collided with the ground. The airplane's information manual contains several pages of limitations and warnings about departing with even small amounts of frost, ice, snow, or slush on the airplane, as it adversely affects the airplane's flight characteristics. The manufacturer requires a visual or tactile inspection of the wings, and horizontal stabilizer to ensure they are free of ice or frost if the outside air temperature is below 10 degrees C, (50 degrees F), and notes that a heated hangar or approved deicing fluids should be used to remove ice, snow and frost accumulations. The weather conditions included clear skies, and a temperature of -11 degrees F. Post accident examination of the airplane revealed no observed mechanical malfunction. An examination of the engine revealed internal over-temperature damage, and minor external fire damage consistent with a massive spike of fuel flow at the time of ground impact. Damage to the propeller blades was consistent with high power at the time of ground impact. The rolling/vortex motion of the airplane was consistent with airframe contamination due to frost.

The cargo flight was departing on its fourth flight leg of a five-leg flight in night instrument conditions, which included a surface observation of light snow and a broken ceiling at 500 feet above ground level (agl). One pilot who departed just prior to the accident flight indicated that moderate snow was falling and that he entered the clouds about 200 feet agl. The accident airplane's wings and tail were de-iced prior to departure. Radar track data indicated the accident flight was about 45 seconds in duration. An aircraft performance radar study indicated that the airplane reached an altitude of about 1,130 feet mean sea level (msl), or about 400 feet above ground level, about 114 knots with a left bank angle of about 29 degrees. The airplane descended and impacted the terrain at an airspeed of about 155 knots, a pitch angle of -16 degrees, a left roll angle of 22 degrees, and a descent rate of 4,600 feet per minute. The study indicated that the engine power produced by the airplane approximately matched the engine power values represented in the pilot's operating handbook. The study indicated that the required elevator deflections were within the available elevator deflection range, and that the center-of-gravity (CG) position did not adversely affect the controllability of the airplane. The study indicated that the load factor vectors, the forces felt by the pilot, could have produced the illusion of a climb, even when the airplane was in a descent. The inspection of the airframe and engine revealed no anomalies that would have precluded normal operation.