Crash of a Bushmaster 2000 in Fullerton

Date & Time: Sep 25, 2004 at 1523 LT
Type of aircraft:
Operator:
Registration:
N750RW
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Fullerton - Fullerton
MSN:
2
YOM:
1985
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3700
Captain / Total hours on type:
54.00
Aircraft flight hours:
1420
Circumstances:
The airplane crashed onto a street adjacent to the airport shortly after takeoff. As the airplane started its takeoff roll, it began to veer to the left off of the runway. About midway down the runway the airplane lifted off the ground and flew over a crowd of people assembled at the airport for an airport appreciation day. The airplane climbed to about 50 feet, made a steep roll to the left, flying in-between the control tower and a light pole, and crossed over the boundary fence where the left wing struck a moving vehicle before coming to rest against several parked cars. Numerous photographs (including video footage) were taken by witnesses on the airport of the airplane on the takeoff ground roll and throughout the accident sequence. The photographs clearly show a nylon strap connecting the left elevator and rudder. It was surmised that the use of the nylon strap was as a flight control/gust lock for the airplane. During the investigation, a nylon strap was observed hanging from an S-hook that was attached to the vertical stabilizer/rudder hinge attach point. The loop at the other end of the strap had come apart, and when investigators looked under the left stabilizer/elevator hinge attach area they noted a similar S-hook attached to the hinge attach area.
Probable cause:
The inadequate preflight inspection by the pilot-in-command, where the pilot failed to remove the makeshift gust lock attached to the rudder and left elevator of the airplane. As a result, the airplane veered off the runway surface during the takeoff roll, became airborne, and immediately began an uncontrolled descending left roll until impacting vehicles and the ground.
Final Report:

Crash of a Britten-Norman BN-2A-8 Islander in Hallo Bay

Date & Time: Sep 23, 2004 at 1100 LT
Type of aircraft:
Operator:
Registration:
N6522T
Flight Phase:
Survivors:
Yes
Schedule:
Hallo Bay - Homer
MSN:
136
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4500
Captain / Total hours on type:
300.00
Aircraft flight hours:
16473
Circumstances:
The commercial certificated pilot, with six passengers, was departing from a remote beach in a twin-engine airplane on an on-demand air taxi flight. The beach was oriented north/south, and was utilized by airplanes transporting guests to and from a remote wilderness lodge. Weather conditions at the beach were reported to air taxi operators via satellite phone. The pilot reported that as he was departing toward the north, the wind was from the west about 30 knots, with gusts to 50 knots. About 20 feet agl, a strong gust of wind, or a downdraft, hit the airplane. The airplane descended and the left wing collided with the beach, which spun the airplane 180 degrees. The airplane came to rest in about 2 1/2 feet of water.
Probable cause:
The pilot's inadequate compensation for wind conditions, and his intentional flight into adverse weather conditions, which resulted in a loss of control and collision with terrain during takeoff-initial climb. Factors contributing to the accident were high and gusty wind conditions, and the pilot's inadequate preflight planning.
Final Report:

Crash of a Piper PA-31P-425 Pressurized Navajo in Seville: 3 killed

Date & Time: Sep 1, 2004 at 1602 LT
Type of aircraft:
Operator:
Registration:
EC-GYD
Flight Phase:
Survivors:
No
Schedule:
Seville - Tangier
MSN:
31-7300123
YOM:
1973
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1500
Aircraft flight hours:
4920
Circumstances:
Shortly after takeoff from Sevilla-San Pablo Airport runway 27, while in initial climb, the twin engine aircraft suffered a right engine failure. It rolled to the right then lost height and crashed 1,500 metres from the runway end, bursting into flames. The aircraft was destroyed by impact forces and a post crash fire and all three occupants were killed.
Probable cause:
Failure of the right engine shortly after rotation. Due to the degree of destruction, it was not possible to determine the exact cause of the failure that occurred at a critical stage of flight.
Final Report:

Crash of a Cessna 421C Golden Eagle III in El Questro: 2 killed

Date & Time: Aug 30, 2004 at 1200 LT
Operator:
Registration:
HB-LRW
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
El Questro – Broome
MSN:
421C-0633
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2128
Captain / Total hours on type:
975.00
Aircraft flight hours:
3254
Circumstances:
On 30 August 2004, shortly before 1200 Western Standard Time, the owner-pilot of a twin-engine Cessna Aircraft Company 421C Golden Eagle (C421) aircraft, registered HB-LRW, commenced his takeoff from runway 32 at El Questro Aircraft Landing Area (ALA). The private flight was to Broome, where the pilot intended resuming the aircraft delivery flight from Switzerland to Perth. The available documentation indicated that the flight segments en route to Australia had all been to international or major aerodromes. The pilot of a Cessna Aircraft Company 210 (C210) and his two passengers in the runway 32 parking area witnessed the takeoff. Those witnesses reported that the C421 pilot carried out a pre-flight inspection of the aircraft prior to boarding for the takeoff. During that inspection, he was observed preparing for, and conducting a fuel drain check under the left wing, and to have removed some weed-like material from the right main wheel. He then loaded a small amount of personal luggage into the aircraft cabin, before he and the sole passenger boarded. The C210 pilot witness, who reported having observed a number of twin-engine aircraft operations at another aerodrome, did not comment on the nature of the pilot's start and engines run-up checks. The passenger witnesses reported that the pilot of the C421 made a number of unsuccessful attempts to start the left engine, before reverting to starting the right engine. He then started the left engine and moved the aircraft clear of the C210 in order to conduct his engine run-up checks. The passenger witnesses reported that during those checks they heard a 'frequency vibration' as the C421 pilot manipulated the engines' controls. The witnesses at the parking area reported that the C421 pilot taxied the aircraft onto the runway and applied power to commence a rolling takeoff. They, together with a hearing witness located to the north of the ALA indicated that the engines sounded 'normal' throughout the takeoff. Witnesses who observed the takeoff reported that the aircraft accelerated away 'briskly'. The pilot witness stated that the take-off roll and lift-off from the runway appeared similar to other twin-engine aircraft takeoffs that he had observed. The witnesses at the parking area also stated that, shortly after lift-off from the runway, the aircraft banked slightly to the left at an estimated 10 to 15 degrees angle of bank and drifted left before striking the trees along the side of the runway and impacting the ground. There was no report of any objects falling from the aircraft, or of any smoke or vapour emanating from the aircraft during the takeoff. The aircraft was destroyed by the impact forces and post-impact fire. The pilot and passenger were fatally injured.
Probable cause:
For reasons that could not be determined, the aircraft commenced a slight left angle of bank and drifted left after lift-off at a height from which the pilot was unable to recover prior to striking trees to the left of the runway.
Final Report:

Crash of a Beechcraft A90 King Air in Pensacola

Date & Time: Aug 17, 2004 at 1515 LT
Type of aircraft:
Registration:
N45TT
Flight Phase:
Survivors:
Yes
Schedule:
Pensacola – Gulf Shores
MSN:
LJ-312
YOM:
1967
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1254
Captain / Total hours on type:
18.00
Aircraft flight hours:
10701
Circumstances:
The pilot stated that he was proceeding to a nearby airport to refuel, and during the takeoff from his departure airport, about 3 to 4 seconds after rotating, the right engine ceased operating due to fuel exhaustion. He said that the airplane drifted to the right, and he feathered the right propeller and turned to the right in order to return to the runway. After leveling, he said the airplane started to climb so he reduced power, and as he did so the airspeed dropped to 80 knots, and the stall warning light was activated. He said he added full power to recover, and the aircraft veered radically to the right in the direction of the hangars. Keeping the landing gear in the up position, he said he performed a belly landing and the airplane incurred damage.
Probable cause:
The pilot's inadequate planning/decision and his failure to maintain airspeed which resulted in fuel exhaustion and an inadvertent stall.
Final Report:

Crash of a Cessna 208B Grand Caravan in Panama City

Date & Time: Aug 16, 2004 at 0835 LT
Type of aircraft:
Operator:
Registration:
HP-1397APP
Flight Phase:
Survivors:
Yes
Schedule:
Panama City – Chitré
MSN:
208B-0613
YOM:
1997
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Panama City-Marcos A. Gelabert Airport, while climbing, the crew encountered technical problem with the engine and declared an emergency. He realized he could not return to his departure point so he attempted an emergency landing on a road when the aircraft struck a tree and crashed 9 km weat of the airport. All seven occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Douglas A-26C-45-DT Invader in Rainbow Lake

Date & Time: Aug 12, 2004
Type of aircraft:
Operator:
Registration:
C-FCBK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Rainbow Lake - High Level
MSN:
28940
YOM:
1944
Flight number:
Tanker 11
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot, sole on board, was engaged in a fire fighting mission and was supposed to leave Rainbow Lake for High Level. During the takeoff roll, at a speed of 90 knots, one of the engine lost power. The pilot rejected takeoff and released the load of fire retardant. Unable to stop within the remaining distance, the aircraft overran, rolled for about 1,200 feet then struck a drainage ditch and came to rest. The pilot was seriously injured and the aircraft was damaged beyond repair.

Crash of a Boeing 737-205 in Freetown

Date & Time: Aug 11, 2004 at 1423 LT
Type of aircraft:
Operator:
Registration:
3X-GCM
Flight Phase:
Survivors:
Yes
Schedule:
Freetown - Conakry - Banjul
MSN:
23469
YOM:
1986
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
119
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Due to poor weather conditions in Freetown, the flight was delayed for hours. Finally, the crew was cleared for takeoff from runway 12/30 which is 3,200 metres long. During the takeoff roll, the captain decided to abort for unknown reasons. Unable to stop within the remaining distance, the aircraft overran, lost its right main gear and right engine before coming to rest in a grassy area located 100 metres past the runway end. All 127 occupants were rescued, among them 50 passengers were injured. The aircraft was damaged beyond repair.
Probable cause:
The accident was the consequence of the non-application by the crew of the checklist prior to takeoff and the lack of coordination between the copilot, who was the pilot flying, and the captain.

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Lakeway: 6 killed

Date & Time: Aug 3, 2004 at 1159 LT
Registration:
N601BV
Flight Phase:
Survivors:
No
Schedule:
Lakeway – Oklahoma City
MSN:
61-0272-058
YOM:
1976
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
3500
Aircraft flight hours:
4483
Circumstances:
The commercial pilot, who managed the airplane and jointly owned it with one of the passengers, departed from a 3,930-foot-long, asphalt runway on a warm day. Weight and balance calculations, which investigators derived from estimated weights for total fuel, passengers, and cargo loads, determined that the airplane was likely within center of gravity limitations and about 208 pounds below its maximum gross weight. One witness stated that the airplane became airborne near the end of the runway before it began a shallow climb and clipped small branches on the tops of trees that were about 30 feet tall. That witness and others observed that the airplane continued past the trees, made a steep bank to the left, rolled inverted, and nose-dived to the ground. The witnesses' descriptions of the airplane's flightpath and the examination of the debris path and wreckage at the accident site are consistent with an impact following an aerodynamic stall. According to calculations performed using the airplane's published performance data chart, for the airplane's configuration and estimated weight and the density altitude conditions at the time of the accident, the airplane would have required about 3,800 feet on a paved, level runway to clear a 50-foot obstacle with the pilot using the short-field takeoff technique. Although the chart does not make any allowances for an upsloping runway or provide data for a 30-foot obstacle, the runway slope is slight (a 27-foot rise over the entire length) and likely did not significantly increase the airplane's takeoff roll, and interpolation of the data revealed no significant distance differences for the shorter obstacle. However, according to the chart, the 3,800-foot distance is contingent upon the pilot holding the airplane's brakes, applying full engine power with the brakes set, and then releasing the brakes to initiate the takeoff roll. In addition, the airplane's ability to achieve its published performance parameters (which are derived from test flights in new airplanes) can be degraded by a number of factors, such as pilot deviations from the published procedures, reduced engine performance, or increased aerodynamic drag associated with minor damage and wear of the airframe. It could not be determined where on the runway the pilot initiated the takeoff roll or at what point full engine power was applied. However, because the runway was only 130 feet longer than the airplane required (according to its published performance data), there was little margin for any deviations from the published takeoff procedure. Although examination of the engines, propellers, and related systems revealed no evidence of precrash anomalies, postaccident damage precluded engine performance testing to determine whether the engines were capable of producing their full-rated power. Therefore, the significance of maintenance issues with the airplane (in particular, a mechanic's assessment that the turbochargers needed to be replaced and that the airplane's required annual inspection was not completed) could not be determined with respect to any possible effect on the airplane's ability to perform as published. A review of Federal Aviation Administration (FAA) and insurance records revealed evidence that the pilot may have been deficient with regard to his ability to safely operate a PA 60-601P. For example, according to FAA records, as a result of an April 2004 incident in which the pilot landed the accident airplane on a wet grassy runway with a tailwind, resulting in the airplane going off the runway and striking a fence, the FAA issued the pilot a letter of reexamination to reexamine his airman competency. However, the pilot initially refused delivery of the letter; he subsequently accepted delivery of a second letter (which gave the pilot 10 days to respond before the FAA would suspend his certificate pending compliance) and contacted the FAA regarding the matter on Monday, August 2, 2004 (the day before the accident), telling an FAA inspector to "talk to his lawyer." In addition, as a result of the same April 2004 incident, the pilot's insurance company placed a limitation on his policy that required him to either attend a certified PA-60-601P flight-training program before he could act as pilot-in-command of the accident airplane or have a current and properly certificated pilot in the airplane with him during all flights until he completed such training. There was no evidence that the pilot adhered to either of the insurance policy requirements. In addition, the FAA had a previous open enforcement action (a proposed 240-day suspension of the pilot's commercial certificate) pending against the pilot for allegedly operating an airplane in an unsafe manner in September 2003; that case was pending a hearing with an NTSB aviation law judge at the time of the accident. Although the FAA's final rule for Part 91, Subpart K, "Fractional Ownership Operations," became effective on November 17, 2003, the regulations apply to fractional ownership programs that include two or more airworthy aircraft. There was no evidence that the pilot had a management agreement involving any other airplane; therefore, the rules of Part 91, Subpart K, which provide a level of safety for fractional ownership programs that are equivalent to certain regulations that apply to on-demand operators, did not apply to the accident flight. In the year before the accident, the FAA had conducted a ramp check of the pilot and the accident airplane and also conducted an investigation that determined there was not sufficient evidence that the pilot was conducting any illegal for-hire operations.
Probable cause:
The pilot's failure to successfully perform a short-field takeoff and his subsequent failure to maintain adequate airspeed during climbout, which resulted in an aerodynamic stall.
Final Report:

Crash of a Douglas DC-9-14 in Mexico City

Date & Time: Jul 21, 2004 at 1933 LT
Type of aircraft:
Operator:
Registration:
XA-BCS
Flight Phase:
Survivors:
Yes
Schedule:
Mexico City – Durango – Torreón
MSN:
47043
YOM:
1967
Flight number:
JR706
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
52
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
96300
Aircraft flight cycles:
102000
Circumstances:
Shortly after takeoff from runway 05L at Mexico City-Benito Juarez Airport, while in initial climb, the aircraft encountered windshear. It lost height and crash landed on the runway. Upon impact, the landing gear were torn off. Out of control, the aircraft veered off runway, lost its right wing and came to rest. All 56 occupants evacuated safely and the aircraft was destroyed.
Probable cause:
Loss of control upon takeoff due to windshear.