Takeoff (climb)

The crew took delivery of the aircraft in Farnborough and was supposed to transfer it in Abuja following fuel stop in Paris-Le Bourget, Oued Isara and Kaduna. Shortly after takeoff from Kaduna Airport runway 05, while in initial climb, one of the engine caught fire. The pilot-in-command lost control of the airplane that stalled and crashed, bursting into flames. Both occupants were killed.

The twin-engine airplane was destroyed by impact with terrain about 2.5 miles northeast of the airport while returning to the airport with an engine problem. A witness reported that the FAR Part 135 on-demand passenger flight had been scheduled for a 0900 departure, but because the flight had not been confirmed, a pilot was not scheduled to fly the flight. The accident pilot arrived at the airport about 1005. A witness reported that the pilot was not in the office for more than two minutes when he "grabbed the status book," walked straight to the airplane, and boarded. A lineman serviced both engines at 0930 with oil, but failed to put the dipstick back in the right engine oil filler tube. Witnesses reported that they did not see the pilot perform a preflight. The pilot was unaware that the dipstick was left on the right wing of the airplane. The pilot taxied the airplane forward about 5 feet and abruptly stopped and shut down both engines. The pilot got out of the airplane. The lineman reported that he approached the pilot and asked what was wrong. The lineman reported that the pilot closed the oil flap door on the right engine, and said that the oil flap door had been left open. The pilot restarted the engines and departed about 1008. About three minutes after takeoff, the pilot informed departure control that he needed to return to the airport due to an oil leak. The pilot reported over the Unicom radio frequency that he was returning because he was having trouble with the right engine. Radar track data indicated that about 1013, the airplane's position was about 1.5 miles directly north of the airport about 1,800 feet msl, heading south at 126 knots calibrated airspeed (CAS). The airplane continued to fly south directly to the airport. The radar track data indicated that instead of landing on runway 18, the airplane flew over the airport, paralleling runway 18. About 1014, the airplane's position was over the airport at an altitude of about 1,460 feet msl (550 feet above ground level), heading south at about 97 knots CAS. The airplane continued to fly south past the airport, entered a left turn, and turned back to the north. The last radar return was recorded about 1016. The airplane's position was approximately 1.5 miles east of the approach end of runway 18 at an altitude of about 1,116 feet msl (344 feet agl), heading north at about 99 knots CAS. The impact site was located about 2.5 miles north of the last radar return. A witness, located about 1/4 mile from the accident site, observed the airplane flying "really low." He reported, "The motor on the plane wasn't cutting out or sputtering." Another witness reported, "The plane lifted up over power lines then went across a field about 50 to 80 ft off ground." The airplane impacted a harvested cornfield in a Page 2 of 11 CHI06FA026 steep nose-down attitude, and traveled 45 feet before stopping. The inspection of the airplane revealed that the landing gear was down, flaps were found in a 20-degree down position, and neither propeller was feathered. The post accident inspection of the airplane's engines and airframe revealed no preexisting anomalies that could be associated with a pre-impact condition.

According to the pilot, the airplane took off with a flaps setting of 25 percent, per the operator’s procedures at the time. He stated that, immediately after raising the landing gear after takeoff, he heard an explosion and saw that all gauges for the left engine, a Pratt & Whitney Canada (P&WC) PT6A-34, pointed to zero, indicating a loss of power to the left engine. He also noted that the left propeller had completely stopped so he added full power to the right engine, left the flaps at 25 percent, and left the landing gear up. He further stated that, although he “stood on the right rudder,” he could not stop the airplane’s left turning descent. The pilot later noted that, after the left engine lost power, he “couldn’t hold V speeds” and “the stall warning horn was going off the whole time.” Post accident examination of the accident airplane’s left engine revealed that that it had failed and that the propeller had been feathered. Examination of the trim positions revealed that the rudder was at neutral trim and the aileron was at full left trim. Although these trim positions could have been altered when the wings separated from the fuselage during ground impact, the pilot’s comment that he “stood on the rudder” suggests that he either had not trimmed the airplane after the engine failure or had applied trim opposite the desired direction. The activation of the stall warning horn and the pilot’s statement that he “couldn’t hold V speeds” indicate that he also did not lower the nose sufficiently to maintain best single-engine rate of climb or best single-engine angle of climb airspeed. In addition, a performance calculation conducted during the National Transportation Safety Board’s investigation revealed that the airplane, with flaps set at 25 degrees, would have been able to climb at more than 400 feet per minute if the pilot had maintained best single-engine rate of climb airspeed and if the airplane had been properly trimmed. Post accident examination of the accident airplane’s left engine revealed fatigue fracturing of the first-stage sun gear.[1] According to the airplane’s maintenance records, during an October 1998 engine overhaul, the first-stage planet gear assembly was replaced due to “frosted and pitted gear teeth.” The planet gear assembly’s mating sun gear was also examined during overhaul but was found to be serviceable and was reinstalled with the new planet gear assembly, which was an accepted practice at the time. However, since then, the engine manufacturer determined that if either the sun gear or planet gear assembly needed to be replaced with a zero-time component, the corresponding mating gear/assembly must also be replaced with a zero-time component; otherwise, the different wear patterns on the gears could potentially cause “distress” to one or both of the components. Review of maintenance records showed that the engines were maintained, in part, under a Federal Aviation Administration (FAA)-approved “on-condition” maintenance program;[2] Business Air’s maintenance program was approved in May 1995. In April 2002, P&WC, the engine manufacturer, issued Service Bulletin (SB) 1403 Revision 7, which no longer mentioned on-condition maintenance programs and required, for the first time for other time between overhaul extension options, the replacement of a number of PT6A-34, -35, and -36 life-limited engine components, including the first-stage sun gear at 12,000 hours total time since new. The first-stage sun gear on the accident airplane failed at 22,064.8 hours. In November 2005 (when the Manchester accident occurred), Business Air was operating under an engine on-condition maintenance program that did not incorporate the up-to-date PT6A 34, -35, and -36 reliability standards for the life-limited parts listed in SB 1403R7 because the SB did not address previously approved on-condition maintenance programs. Three months later, in an e-mail message to Business Air, P&WC stated that it would continue to “endorse” Business Air’s engine on-condition maintenance program. Although SB 1403R7 improves PT6A-34, -35, and -36 engine reliability standards, allowing grandfathered on condition maintenance programs for these engines is less restrictive and does not offer the same level of reliability. The National Transportation Safety Board’s review of maintenance records further revealed numerous deficiencies in Business Air’s on-condition engine maintenance program that appear to have gone undetected by the Portland, Maine, Flight Standards District Office (FSDO), which is in charge of monitoring Business Air’s operations. For example, one infraction was that Business Air did not specify which parts were included in its on-condition maintenance program and which would have been removed by other means, such as hard-time scheduling.[3] Also, the operator used engine condition trend monitoring as part of determining engine health; however, review of records revealed missing data, inaccurate data input, a lack of regular trend analyses, and a failure to update trends or reestablish baselines when certain maintenance was performed. Another example showed that, although Business Air had an engine-oil analysis program in place, the time it took to send samples for testing and receive results was lengthy. According to maintenance records, the operator took an oil sample from the accident engine more than 2 weeks before the accident and sent it for testing. The oil sample, which revealed increased iron levels, would have provided valuable information about the engine’s health. However, the results, which indicated a decline in engine health, were not received until days after the accident. If the FAA had been properly monitoring Business Air’s maintenance program, it may have been aware of the operator’s inadequate maintenance practices that allowed, among other things, an engine with a sun gear well beyond what the manufacturer considered to be a reliable operating timeframe to continue operation. It also took more than 2 1/2 years after the accident for the FAA to finally present a consent order[4] to the operator, in which both parties not only acknowledged the operator’s ongoing maintenance inadequacies but also the required corrective actions. [1] A sun gear is the center gear around which an engine’s planet gear assembly revolves; together, the sun gear and planet gear assembly provide a means of reducing the engine’s rpm to the propeller’s rpm. [2] According to FAA Advisory Circular (AC) 120-17A, “Maintenance Control by Reliability Methods,” under on-condition maintenance programs, components are required to be periodically inspected or checked against some appropriate physical standard to determine whether they can continue in service. [3] According to FAA AC 120-17A, “Maintenance Control by Reliability Methods,” under hard time maintenance programs, components are required to be periodically overhauled or be removed from service. [4] A consent order is a voluntary agreement worked out between two or more parties to a dispute. It generally has the same effect as a court order and can be enforced by the court if anyone does not comply with the orders. [4] A consent order is a voluntary agreement worked out between two or more parties to a dispute. It generally has the same effect as a court order and can be enforced by the court if anyone does not comply with the orders.

The 4,100-hour commercial pilot lost directional control of the single-pilot twin-engine turbojet while taking off from runway 22 (7,602-feet long by 150-feet wide), and impacted the ground about 3,750 feet from the point of departure. Several witnesses reported that the airplane climbed to approximately 150 feet, rolled to the right, descended, and then struck the ground inverted. The weather was day VFR and the wind was reported from 170 degrees at 10 knots. Examination of the wreckage revealed that none of the main-entry door latching pins were in their fully locked position. The airplane's flight controls and engines did not disclose any mechanical discrepancies. The flaps were in the takeoff position and the control lock was unlocked. The pilot had not flown the airplane for over nine months because of extensive maintenance; the accident occurred on its first test flight out of maintenance. Since the pilots flight records were not found, it is unknown how much flight time the pilot had flown in the last nine months. The other airplane that the pilot owned was a Cessna 650, but witnesses stated that the pilot was only qualified as a co-pilot. Most of the maintenance records that were located were not completed; an approval for return-to-service was not found. Another airplane that had declared an emergency was on a 10-mile final when the tower cleared the accident airplane for takeoff, with no delay on the takeoff roll. No additional communication or distress calls were reported from the accident airplane. The airplane was not equipped with either a flight data recorder or a cockpit voice recorder. No anomalies were found on either engine that could have prevented normal engine operation.

The twin engine aircraft departed Bergamo-Orio al Serio Airport on a night cargo service to Zagreb, carrying one passenger (the captain's wife), two pilots and a load of 1,600 kilos of small packages. After takeoff from runway 28, while climbing in foggy conditions, the aircraft entered a left turn then descended, collided with a powerline and crashed in an open field located one km north of the airfield. The aircraft disintegrated on impact and all three occupants were killed.

The accident was reported to erstwhile Accident Investigation and Prevention Bureau (AIPB) now Accident Investigation Bureau (AIB) on Saturday 22nd of October, 2005. The site of the wreckage was located on the 23rd of October, 2005 and investigation began the same day. On October 22, 2005, at 2040 hrs, Bellview Airlines (BLV) Flight 210, a Boeing B737-200, 5N-BFN, crashed while climbing to cruise altitude shortly after take-off from Murtala Muhammed Airport, Lagos (LOS). The flight was operating under the provisions of the Nigerian Civil Aviation Authority (NCAA) Air Navigation Regulations (ANRs) as a scheduled domestic passenger flight from LOS to Abuja International Airport (ABV). The flight departed LOS for ABV at 2035 hrs, with 2 pilots, 1 licensed engineer, 3 flight attendants, and 111 passengers on board. The airplane entered a descent and impacted open terrain at Lisa Village, Ogun State. All 117 persons were killed and the airplane was destroyed by impact forces and fire. Instrument meteorological conditions prevailed. The airplane was operated on an Instrument Flight Rule (IFR) plan. The accident occurred on the final leg of a one-day round trip from Abuja to Abidjan with intermediate stops at Lagos and Accra for both the outbound and inbound segments. The trip through the second stop at Accra (the fourth leg) was reported without incident. On the fifth leg, during the taxi for takeoff at Accra, the pilot and the engineer discussed the low pressure reading of 650 psi in the brake accumulator system according to the pilot that flew the aircraft from Accra to Lagos. Normal accumulator brake pressure is 1000 psi. The captain continued the flight to the destination, LOS, without incident, where the discrepancy was logged. The engineer briefed the maintenance crew about the low pressure reading. The crew consisted of two Licensed Aircraft Engineers (LAEs) and the outbound engineer for Flight 210. LAEs and engineer on riding coverage worked together to troubleshoot the brake system, which included verifying the pressure reading with the pressure gauge from another Boeing 737 (5N-BFM) in the fleet. It was determined that the source of the low pressure was due to a faulty brake accumulator. On checking the Minimum Equipment List (MEL), the maintenance engineers decided that the aircraft could be released for operation with the fault. Before Flight 210 departed, the captain discussed en-route weather with another pilot who had just completed a flight from Port Harcourt to Lagos. The other pilot informed the accident captain of a squall line in the vicinity of Benin. The accident captain indicated that he experienced the same weather condition on his previous flight from Abuja to Lagos. The chronology of the flight was determined from the transcript of the recorded radio communications between Air Traffic Control and Flight 210 and post accident interviews of air traffic personnel. According to the transcript, the pilot of Flight 210 contacted the tower at 1917:02 UTC and requested for startup and clearance was given. The controller gave him the temperature and QNH, which were 27 degrees Centigrade and 1010 millibars respectively. At 1924:08 UTC, the Pilot requested and got approval for taxi to Runway 18L. At 1927 UTC, the tower requested for Persons on Board (POB), endurance and registration. In response, the pilot indicated the number of persons on board as 114 minus 6 crew, fuel endurance as 3 hours and 50 minutes and registration 5N-BFN. The tower acknowledged the information and issued the route clearance via Airway UR778, Flight Level 250, with a right turn-out on course. The pilot read back the clearance and the controller acknowledged and instructed the pilot to report when ready for takeoff. At 1927:55 UTC, the pilot requested “can we have a left turn out please?” and soon afterwards his request was granted by the controller. At 1928:08 UTC, the tower cleared BLV 210 as follows: "BLV 210 RUNWAY HEADING 3500FT LEFT TURN ON COURSE" At 1928;12 UTC, BLV 210 replied "3500FT LEFT TURN ON COURSE 210". 1928:47 UTC, the pilot reported ready for takeoff, and after given the wind condition as 270 degrees at 7 knots the controller cleared Flight 210 for departure at 1928:50 UTC. The pilot acknowledged the clearance, and at 1929:14 UTC requested “And correction, Bellview 210, please we will take a right turn out. We just had a sweep around the weather and right turn out will be okay for us.” The controller responded “right turn after departure, right turn on course” and the pilot acknowledged. According to the transcript, at 1931:52 UTC, the controller reported Flight 210 as airborne and instructed the pilot to contact LOS Approach Control. During the post-crash interview, the controller indicated he saw the airplane turn right, but was unable to determine its attitude due to darkness. He indicated the airplane sounded and appeared normal. At 1932:22 UTC, the pilot made initial contact with Approach Control and reported “Approach, Bellview 210 is with you on a right turn coming out of 1600 (feet)”. The Approach Control replied “report again passing one three zero.” The pilot acknowledged at 1932:35 UTC, and that was the last known transmission from the flight. According to the transcript, the controller attempted to regain contact with the flight at 19:43:46 UTC. Repeated attempts were unsuccessful. Emergency alert was then sent out to relevant agencies including the National Emergency Management Agency (NEMA) for search and rescue operations to commence. The airplane struck the ground on flat terrain in a relatively open and wooded area, 14NM north of the airport (6˚ 48’ 43” N and 3˚ 18’ 19” E).

On the day before the occurrence, the accident aircraft arrived in Winnipeg, Manitoba, on a flight from Thunder Bay, Ontario. The aircraft was parked in a heated hangar overnight and was pulled outside at about 0410 central daylight time. The pilot reviewed the weather information and completed planning for the flight, which was estimated to take two hours and six minutes. The aircraft was refuelled and taxied to Apron V at the Winnipeg International Airport, where it was loaded with cargo. After loading was complete, the pilot obtained an instrument flight rules (IFR) clearance for the flight to Thunder Bay, taxied to Runway 36, received take-off clearance, and departed. The aircraft climbed on runway heading for about one minute to an altitude of 1300 feet above sea level (asl), 500 feet above ground level (agl). The flight was cleared to 9000 feet asl direct to Thunder Bay, and the pilot turned on course. The aircraft continued to climb, reaching a maximum altitude of 2400 feet asl about 2.5 minutes after take-off. The aircraft then started a gradual descent averaging about 400 feet per minute (fpm) until it descended below radar coverage. The accident occurred during hours of darkness at 0543. The Winnipeg Fire Paramedic Service were notified and responded from a nearby station.

The airline transport certificated pilot with 10 skydiving passengers began a takeoff in a tailwheel-equipped and turboprop powered airplane on a CFR Part 91 skydiving flight. As the airplane started its climb, the pitch angle of the nose of the airplane increased until the airplane appeared to stall about 50 to 100 feet agl. It descended and impacted the runway in a left wing, nose low attitude. Several FAA inspectors responded to the accident site and documented the accident scene and the airplane systems. The inspectors reported that flight control continuity was established, and they noted that the stabilizer appeared to be in a nose up trim position. Measurement of the stabilizer trim position equated to a 56.5 percent nose up trim condition. The airplane's horizontal stabilizer trim system is electrical. An electric trim indicator, and a trim warning light were installed in the upper left portion of the instrument panel. The light will illuminate if "full-up" trim is set, and the engine is producing over 80 percent power. A placard stating, "Set Correct Trim for Takeoff," was installed on the lower instrument panel in front of the pilot position. The airplane's flight manual contains a "Before Takeoff" warning, which states, in part: "Warning - An extreme out-of-trim stabilizer can, in combination with loading, flaps position and power influence, result in an uncontrollable aircraft after the aircraft leaves the ground." In addition, a caution states, in part: "Caution - Failure to set correct trim settings will result in large control forces and/or unrequested pitching/yawing." Pilot actions listed in the "Before Takeoff" checklist include stabilizer trim settings. The airplane contained seat belts for all passengers, but the pilot's shoulder harness was not used, as it was folded and tie-wrapped near its upper attach point.

The 700-hour private pilot flying the twin-engine airplane with four passengers aboard used approximately three-quarters of runway 18 before becoming airborne. After establishing a positive rate of climb, the pilot retracted the landing gear and pitched the airplane for a 92 knot climb. Shortly thereafter the rate of climb decreased and the airplane's control authority began to decay. The pilot responded by applying full throttle to both engines and reduced the angle of attack in an attempt to regain airspeed. The pilot was able to arrest the airplane's decaying airspeed and descent; however, the airplane collided with a barn and then a grassy field before coming to rest in an upright position. The pilot and passengers were able to egress the airplane unassisted and the airplane was engulfed in flames a few minutes later. About 23 minutes after the mishap the weather reporting station 24 miles north of the accident site reported, the wind from 230 degrees at 6 knots, the temperature 84 degrees Fahrenheit, and dew point of 60 degrees Fahrenheit. Runway 18 was reported as a 4,002-foot long by 60-foot wide asphalt runway with trees near the departure end. The field elevation at the airport was reported at 544 feet and the density altitude was calculated at 1,860 feet. The estimated weight of the airplane at the time of departure was near its maximum gross weight of 6,000 pounds. The pilot reported that he had not performed a weight and balance check, calculated density altitude, and was not sure of how much fuel was onboard the airplane prior to departure. The pilot further reported that there were no apparent anomalies with the airplane.

On 19 September 2005, the type F-Swearingen SA227-AC aircraft with registration PH-DYM was scheduled to make a charter flight from Rotterdam Airport to Birmingham Airport. Seventeen passengers and two cockpit crew members were on board. The planned departure time was 07.30 hours. The aircraft taxied to the beginning of runway 24 and lined up for take-off. During line-up, the speed levers for the engines were moved from taxi position to flight position. The nose wheel steering fault indicator lit up and the first officer, who was steering the aircraft, responded by saying that he had no nose wheel steering. The captain informed the first officer that he had forgotten to press the switch on the throttles, which activates the nose wheel steering system. The first officer then confirmed that he had nose wheel steering. With the engines in the low RPM range (taxi position, up to 70% of maximum RPM), the pilot can steer the aircraft using the rudder pedals while taxing. When the engines are operated in the high RPM selection (flight position, between 70% and 100% of the maximum RPM), the switch on the throttles, which activates the nose wheel steering system, must be pressed in during the first part of the take-off roll in order to be able to operate the nose wheel with the rudder pedal. At a speed around 50 knots, the switch which activates the nose wheel steering system is released. The aerodynamic forces of on the rudder are then sufficient to take over the steering from the nose wheel. Once take-off clearance was given by air traffic control, the first officer engaged power and started the take-off roll. He stated that once the nose wheel operating switch had been released, the aircraft almost immediately began moving towards the left hand side of the runway. He tried to use the brakes and the directional rudder, to return the aircraft to the centre of the runway. The aircraft had a speed of between 50 and 60 knots at that point. The crew rejected the take-off but could not prevent the aircraft ending up alongside the runway, on the left hand side. The captain stated that various forces influence the directional control of an aircraft during the take-off, such as wind, propeller wash, increasing air speed, etc. These forces necessitate steering corrections during the take-off. Only when the nose wheel steering system was disengaged the captain realized something was wrong. The grass area alongside the runway is lower than the runway and the ground was soft. The left landing gear sank in the soft ground first and, as a result, the aircraft decelerated heavily and the left landing gear broke off almost immediately. The tip of the left wing struck the ground. This caused a ground loop effect and turned the aircraft further left. As a consequence the right landing gear and the nose gear also broke off. Once the aircraft had come to a standstill, the captain switched off all onboard systems and cut off the fuel supply to the engines. Simultaneously, the first officer was given the task of evacuating the passengers. The passengers were calm and left the aircraft without problems via the left hand door at the front of the aircraft. A moment later, the airport fire service arrived at the location of the accident. One of the passengers was taken to hospital for a check-up; he was able to leave hospital the same morning. There was severe damage despite the relatively slow speed at which the aircraft left the runway.