Crash of a Piper PA-46-310P Malibu in Ellington: 2 killed

Date & Time: Sep 17, 2005 at 2124 LT
Operator:
Registration:
N69146
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ellington – Lago Vista
MSN:
46-8508076
YOM:
1985
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
641
Captain / Total hours on type:
330.00
Aircraft flight hours:
3916
Circumstances:
The 641-hour private pilot and passenger were departing on a 155-nautical mile night cross country flight. Shortly after the airplane took off, the tower controller heard a weak transmission that she could not completely understand, but did hear the words "engine" and "power." The controller asked the pilot to "say again", but there was no response. She again asked, "say again" and the pilot transmitted, " I'm going down." There were no further communications from the pilot. While approximately 400 feet above ground level, the airplane's engine stopped producing power. While in a left turn, the left wingtip impacted the ground and the airplane cartwheeled. The debris field encompassed an area approximately 125 feet long and approximately 50 feet wide. Witness reports of the airplane's flight path along with the wreckage distribution path were consistent with the pilot's attempt to return to the airport. A post-impact fire consumed the fuselage and caused extensive thermal damage to the engine and wings. An examination of the wreckage revealed the landing gear and wing spoilers were in the retracted position. The position of the flaps could not be determined. No mechanical deficiencies were noted with the airframe that could have prevented normal operations. Examination of the engine revealed no preimpact anomalies. The reason for loss of engine power could not be determined.
Probable cause:
The pilot's improper in-flight decision to maneuver back to the departure airport following a loss of engine power on initial climb. Contributing factors were the loss of engine power for undetermined reasons, and the dark night conditions.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Murandi

Date & Time: Sep 8, 2005 at 0815 LT
Operator:
Registration:
9Q-CBO
Flight Phase:
Survivors:
Yes
Schedule:
Goma – Beni
MSN:
735
YOM:
1980
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Two minutes after takeoff from Goma Airport, the crew reported engine problem and decided to make an emergency landing near Murandi, Nyiragongo territory. The aircraft came to rest in a banana plantation, lost its right wing and was damaged beyond repair. Three passengers were injured while 17 other occupants escaped unhurt.

Crash of a Boeing 737-230 in Medan: 149 killed

Date & Time: Sep 5, 2005 at 1015 LT
Type of aircraft:
Operator:
Registration:
PK-RIM
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Medan - Jakarta
MSN:
22136
YOM:
1981
Flight number:
RI091
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
112
Pax fatalities:
Other fatalities:
Total fatalities:
149
Captain / Total flying hours:
7522
Captain / Total hours on type:
7302.00
Copilot / Total flying hours:
2353
Copilot / Total hours on type:
685
Aircraft flight hours:
51599
Aircraft flight cycles:
51335
Circumstances:
On 5 September 2005, at 03:15 UTC, Mandala Airlines registered PK-RIM, operating as flight number MDL 091, a Boeing 737-200 departing for Soekarno-Hatta Airport, Jakarta from Medan. The previous flight was from Jakarta and arrived at Medan uneventfully. The same crew have flight schedule on the same day and returned to Jakarta. The flight was a regular scheduled passenger flight and was attempted to take-off from Polonia Airport, Medan, North Sumatra to Jakarta and it was the second trip of the day for the crew. At 02.40 UTC information from dispatcher, those embarking passengers, cargo process and all flight documents were ready. At 02.52 UTC, Mandala/MDL 091 asked for push back and start up clearance bound for Jakarta from the Air Traffic Controller/ATC, after received the approval from the ATC they began starting the engines. At 02.56 UTC, the controller cleared MDL 091 taxi into position on runway 23 via Alpha. At 03.02 UTC, MDL 091 received clearance for take off with additional clearance from ATC to turn left heading 120º and maintain 1500 ft. The MDL 091 read back the clearance heading 120º and maintains 1000 ft. The ATC corrected the clearance one thousand five hundred feet. The MDL 091 reread back as 1500 ft. Some of the passengers and other witnesses stated that the aircraft has lifted its nose in an up attitude and take off roll was longer than that normally made by similar airplanes. Most of them stated that the aircraft nose began to lift-off about few meters from the end of the runway. The ATC tower controller recalled that after rotation the plane began to “roll” or veer to the left and to the right. Some witnesses on the ground recalled that the airplane left wing struck a building before it struck in the busy road, then heard two big explosions and saw the flames. Persons on board in MDL 091, 5 crew and 95 passengers were killed, 15 passengers seriously injured and 2 passengers (a mother and child) were reported survived without any injuries; and other 49 persons on ground were killed and 26 grounds were serious injured.
Probable cause:
The National Transportation Safety Committee determines that probable causes of this accident are:
• The aircraft took-off with improper take off configuration namely with retracted flaps and slats causing the aircraft failed to lift off.
• Improper checklist procedure execution had lead to failure to identify the flap in retract position.
• The aircraft’s take off warning horn was not heard on the CAM channel of the CVR. It is possible that the take-off configuration warning horn was not sounding.
Final Report:

Crash of a PZL-Mielec AN-2TP in Zielona Góra

Date & Time: Sep 2, 2005
Type of aircraft:
Operator:
Registration:
SP-ANA
Flight Phase:
Survivors:
Yes
Schedule:
Zielona Góra - Zielona Góra
MSN:
1G29-21
YOM:
1963
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft was engaged in a local survey flight (forest fire) in the region of Zielona Góra. Shortly after takeoff, while in initial climb, the engine failed. The aircraft stalled and crashed in a wooded area. All three occupants were injured and the aircraft was damaged beyond repair.
Probable cause:
Engine failure for unknown reasons.

Crash of a Dassault Falcon 20D-5 in Lorain

Date & Time: Sep 1, 2005 at 1950 LT
Type of aircraft:
Operator:
Registration:
N821AA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lorain - Saint Louis
MSN:
203
YOM:
1970
Flight number:
JUS821
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4444
Captain / Total hours on type:
639.00
Copilot / Total flying hours:
2172
Copilot / Total hours on type:
193
Aircraft flight hours:
16970
Circumstances:
The small, twin-engine business jet was about 15 feet above the runway on takeoff, when a flock of birds from both sides of the runway flew up in front of the airplane. The number two engine "surged," and "loud reports" were heard before the copilot noted a complete loss of power on the number two engine instruments. The airplane climbed for about 10 seconds, before the copilot observed the gas producer (N1) gauge on the number one engine decay through 50 percent. The stall warning horn sounded, and the pilot adjusted the flight controls for landing. The airplane contacted the runway with the landing gear retracted, overran the runway, struck a fence, crossed a road, and came to rest in a cornfield about 1,000 feet beyond the initial point of ground contact. Post accident examination of both engines revealed evidence and damage consistent with multiple bird ingestion.
Probable cause:
The ingestion of multiple birds in each engine at takeoff, which resulted in a complete loss of engine power.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Bogotá: 8 killed

Date & Time: Sep 1, 2005 at 1045 LT
Operator:
Registration:
HK-3069P
Flight Phase:
Survivors:
No
Schedule:
Bogotá - Puerto Berrío
MSN:
31-8352036
YOM:
1983
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
753
Captain / Total hours on type:
83.00
Copilot / Total flying hours:
105
Aircraft flight hours:
2090
Circumstances:
Shortly after takeoff from Bogotá-Guaymaral Airport runway 10, while in initial climb, the crew initiated a left turn in accordance with procedures. The copilot contacted ATC and declared an emergency following technical problems. The crew was immediately cleared to land at his discretion when the aircraft entered an uncontrolled descent and crashed in a prairie located 600 metres from the runway 28 threshold. The aircraft was totally destroyed and all eight occupants were killed.
Probable cause:
A possible fuel contamination affected the power on one engine or both. The aircraft was overloaded at takeoff, which, compounded by the considerable loss of power to the engines due to the altitude of the aerodrome, did not allow the pilot to maneuver the aircraft to return to the runway. In addition, the center of gravity, despite being within the permissible limits, was too far behind for an operation in adverse weather conditions.
Final Report:

Crash of a Dornier DO.28D-2 Skyservant off Puerto Ayacucho: 1 killed

Date & Time: Aug 14, 2005 at 1230 LT
Type of aircraft:
Registration:
YV-740C
Flight Phase:
Survivors:
Yes
MSN:
4113
YOM:
1971
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Shortly after takeoff from Puerto Ayacucho Airport, while climbing, one of the engine failed. The aircraft stalled and crashed in the Orinoco River, coming to rest upside down. A passenger was killed while 12 other occupants were injured.
Probable cause:
Engine failure for unknown reasons.

Crash of a Piper PA-61P Aerostar (Ted Smith 601) in Sinton

Date & Time: Aug 4, 2005 at 0800 LT
Registration:
N15BA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Sinton - Sinton
MSN:
61-0382-126
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7200
Captain / Total hours on type:
20.00
Aircraft flight hours:
3943
Circumstances:
After takeoff for a maintenance check flight, both engines on the twin-engine airplane experienced a loss of engine power. The 7,200-hour pilot had recently purchased the airplane, which had not been flown for nearly four years. The pilot, who is also a certificated airframe and powerplant mechanic, completed the inspection of the airplane prior to takeoff. During the engine run-up, the pilot noticed that the RPM and manifold pressure on the left engine did not correspond with those of the right engine. During the takeoff roll, the pilot believed the RPM on both engines began to rise to near acceptable levels, but not entirely. However, he did not abort the takeoff. The airplane became airborne for a short time, and then began to descend into trees before impacting the ground. The reason for the reported loss of engine power could not be determined.
Probable cause:
The pilot's failure to abort the takeoff and the subsequent loss of engine power for undetermined reasons. Contributing factors were the attempted operation of the airplane with known deficiencies in the equipment and the lack of suitable terrain for the forced landing.
Final Report:

Crash of a Cessna 208B Grand Caravan in Globe

Date & Time: Jul 22, 2005 at 0830 LT
Type of aircraft:
Registration:
N717BT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Phoenix – Globe – Safford
MSN:
208B-0863
YOM:
2000
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5545
Captain / Total hours on type:
203.00
Aircraft flight hours:
4461
Circumstances:
The airplane impacted a road and scrub brush during a forced landing, which was preceded by a total loss of engine power. According to the pilot, he heard a loud "thunk" during takeoff climb and noted a loss of engine power. He manipulated the power lever from the full forward position to the full aft position ("stop-to-stop") and noted he had no power. Post-accident examination of the Pratt & Whitney Canada PT6A -114A engine revealed that the compressor turbine (CT) vane's outer rim liberated a section of metal that damaged the turbine blades downstream. The area of liberated material from the CT vane outer rim was examined by the manufacturer's metallurgists. The fracture surface of the outer rim showed evidence of fatigue with signs of oxidation in some areas indicating the crack had been in existence for some time. The liberated material impact damaged the CT blades and resulted in a loss of power. Review of the operator's records revealed that the engine was approved for an extension beyond the normally recommended 3,600-hour overhaul period, to 5,100 hours. The engine had accumulated 4,461.3 hours at the time of the accident. In addition, the turbine section (hot section) had a recommended overhaul period of 1,800 hours; however, the operator instead elected to utilize an engine trend monitoring program in accordance with a manufacturer issued service bulletin. Many errors were noted with the operator's manually recorded data utilized for the trend monitoring. However, it is not likely that the engine trend data, even had it been correctly recorded and monitored, would have depicted the fatigue cracking in the CT vane outer rim. As a result, the manufacturer issued a service information letter (SIL) PT6A116 in January 27, 2003 (following a similar investigation), which reminded operators to conduct borescope inspections of the CT vane during routine fuel nozzle maintenance, as the manufacturer's maintenance manual recommended. Review of the maintenance record entries for the accident engine revealed no evidence that a borescope inspection had been conducted in conjunction with the fuel nozzle checks.
Probable cause:
The fatigue failure of the compressor turbine stator vane, the liberation of vane material into the compressor turbine, and the total loss of engine power. Also causal was the operator's failure to inspect the compressor turbine vane during fuel nozzle checks.
Final Report:

Crash of a Rockwell Grand Commander 680FL in North Las Vegas

Date & Time: Jul 21, 2005 at 1707 LT
Operator:
Registration:
N7UP
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
North Las Vegas - North Las Vegas
MSN:
680-1349-29
YOM:
1963
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5285
Captain / Total hours on type:
75.00
Aircraft flight hours:
8942
Circumstances:
The airplane descended into the ground during takeoff-initial climb on a local fire reconnaissance flight. Witnesses reported that airplane became airborne, but was not climbing, and it continued down the runway in a nose-up attitude in ground effect until impacting terrain about 600 feet southeast from the departure end of the runway. The ambient temperature was about 107 degrees Fahrenheit, and the density altitude was calculated at 5,878 feet mean sea level. On scene examination found the flaps in the 30-degree position, which also corresponded to the flap actuator position. The cockpit indicator for the flaps also showed a 30-degree extension. A subsequent bench test of the combined flap/gear selector valve was conducted. During the initial inspection, both the gear selector and the flap selector valves were bent, but otherwise operational. The "stop-pin" on the flap selector lever was missing. There was no leakage of fluid during this test. Examination of both engines revealed no abnormalities, which would prevent normal operations. The aircraft flight manual specifies that the flaps should be set at 1/4 down (10 degrees) for normal takeoff.
Probable cause:
The pilot's excessive selection of flaps prior to takeoff, which resulted in a failure to obtain/maintain an appropriate climb airspeed, and an inadvertent stall/mush during takeoff-initial climb. A factor contributing to the accident was a high density altitude.
Final Report: