Crash of a Swearingen SA226TC Metro II in Reus

Date & Time: Jan 31, 2004 at 1800 LT
Type of aircraft:
Operator:
Registration:
EC-HCU
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Reus - Barcelona
MSN:
TC-390
YOM:
1981
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3500
Captain / Total hours on type:
2700.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
360
Circumstances:
The crew was completing a positioning flight from Reus to Barcelona for maintenance purposes. During take off roll on runway 07, at a speed of 80 knots, the nose gear collapsed. The aircraft slid on its nose for few dozen metres before coming to rest on the runway. Both pilots escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The nose gear folded because the lever was in the gear up position. The lever was in that position either due to the failure of the crew to carry out the checklists in full, in the event that the aircraft was delivered to them with the gear lever in the gear retracted position, or inadvertent action on the gear lever at some point between the last check by the crew and the moment of the accident.
Final Report:

Crash of an Ilyushin II-18D in Luena

Date & Time: Jan 27, 2004 at 1440 LT
Type of aircraft:
Operator:
Registration:
ER-ICJ
Flight Phase:
Survivors:
Yes
Schedule:
Luena – Luanda
MSN:
186 0091 02
YOM:
1966
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll on runway 29, the aircraft did not accelerate as expected. The captain decided to abort the takeoff procedure but the aircraft could not be stopped within the remaining distance. It overran and collided with trees located 100 meters further. A crew member was injured and the aircraft was damaged beyond repair.

Crash of a Cessna 208B Grand Caravan off Pelée Island: 10 killed

Date & Time: Jan 17, 2004 at 1638 LT
Type of aircraft:
Operator:
Registration:
C-FAGA
Flight Phase:
Survivors:
No
Schedule:
Pelée Island – Windsor
MSN:
208B-0658
YOM:
1998
Flight number:
GGN125
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
3465
Captain / Total hours on type:
957.00
Aircraft flight hours:
7809
Circumstances:
On 17 January 2004, the occurrence pilot started his workday in Toronto, Ontario, reporting for duty at 0445 eastern standard time. In the morning, he completed flights in the Cessna 208B Caravan from Toronto to Windsor, Ontario, Windsor to Pelee Island, Ontario, and then Pelee Island to Windsor where the aircraft landed at 0916. At approximately 1500, the pilot received local weather and passenger information by telephone from the Pelee Island office personnel. The 1430 weather was reported as follows: ceiling 500 feet obscured, visibility two miles. There were eight male passengers for pick up at Pelee Island. One additional passenger was travelling with the pilot. There was no discussion concerning the amount of cargo to be carried or the passenger weights. At 1508, the pilot received a faxed weather package that he had requested from the Flight Information Centre (FIC) in London, Ontario. At 1523, the aircraft was refuelled in preparation for the scheduled 1600 departure to Pelee Island. The passengers were loaded earlier than usual to allow time for aircraft de-icing, as wet snow had accumulated on the fuselage and wings since the previous flight. At 1555, the aircraft was de-iced with Type 1 de-icing fluid, and it departed for Pelee Island at 1605 on an instrument flight rules (IFR) flight plan as Flight GGN125. At 1615, the pilot advised the Cleveland Control Centre, Ohio, United States, that he had Pelee Island in sight, was cancelling IFR, and was descending out of 5000 feet. The pilot also advised Cleveland that he would be departing IFR out of Pelee Island in about 20 minutes as GGN126 and asked if a transponder code could be issued. The Cleveland controller issued a transponder code and requested a call when GGN126 became airborne. The pilot advised that the flight would depart on Runway 27 then turn north. These were the last recorded transmissions from the aircraft. The aircraft landed at 1620. While on the ramp, two individuals voiced concern to the pilot that there was ice on the wing. Freezing precipitation was falling. The pilot was observed to visually check the leading edge of the wing; however, he did not voice any concern and proceeded with loading the passengers and cargo. At approximately 1638, GGN126 departed Pelee Island for Windsor. After using most of the runway length for take-off, the aircraft climbed out at a very shallow angle. No one on the ground observed the aircraft once it turned toward the north; however, witnesses who were not at the airport reported that they heard the sound of a crash, then no engine noise. A normal flight from Pelee Island to Windsor in the Cessna Caravan takes 15 to 20 minutes. Shortly after the aircraft departed, the ticket agent in Windsor received a call from Pelee Island reporting that a crash had been heard. At 1705, when the aircraft had not arrived, the ticket agent called Windsor tower. The pilot had not made contact with any air traffic services (ATS) facility immediately before or after departure, so there was nothing in the ATS system to indicate that the aircraft had taken off. It was, therefore, unaccounted for. There was no signal heard from the emergency locator transmitter (ELT). At 1710, the Windsor tower controller contacted the Rescue Coordination Centre in Trenton, Ontario, and a search was initiated. At 1908, the aircraft empennage and debris were spotted by a United States Coast Guard (USCG) helicopter on the frozen surface of the lake, about 1.6 nautical miles (nm) from the departure end of the runway. There were no survivors. The empennage sank beneath the surface some four hours later. The wreckage recovery was not fully completed until 13 days later.
Probable cause:
Findings as to Causes and Contributing Factors:
1. At take-off, the weight of the aircraft exceeded the maximum allowable gross take-off weight by at least 15 per cent, and the aircraft was contaminated with ice. Therefore, the aircraft was being flown significantly outside the limitations under which it was certified for safe flight.
2. The aircraft stalled, most likely when the flaps were retracted, at an altitude or under flight conditions that precluded recovery before it struck the ice surface of the lake.
3. On this flight, the pilotís lack of appreciation for the known hazards associated with the overweight condition of the aircraft, ice contamination, and the weather conditions was inconsistent with his previous practices. His decision to take off was likely adversely affected by some combination of stress and fatigue.
Findings as to Risk:
1. Despite the abbreviated nature of the September 2001 audit, the next audit of Georgian Express Ltd. was not scheduled until September 2004, at the end of the 36-month window.
2. The internal communications at Transport Canada did not ensure that the principal operations inspector responsible for the air operator was aware of the Pelee Island operation.
3. The standard passenger weights available in the Aeronautical Information Publication at the time of the accident did not reflect the increased average weight of passengers and carry-on baggage resulting from changes in societal-wide lifestyles and in travelling trends.
4. The use of standard passenger weights presents greater risks for aircraft under 12 500 pounds than for larger aircraft due to the smaller sample size (nine passengers or less) and the greater percentage of overall aircraft weight represented by the passengers. The use of standard passenger weights could result in an overweight condition that adversely affects the safety of flight.
5. The Cessna Caravan de-icing boot covers up to a maximum of 5% of the wing chord. Research on this wing has shown that ice accumulation beyond 5% of the chord can result in degradation of aircraft performance.
6. At the Pelee Island Airport, the air operator did not provide the equipment that would allow an adequate inspection of the aircraft for ice during the pre-flight inspection and did not provide adequate equipment for aircraft de-icing.
7. Repetitive charter operators are not considered to be scheduled air operators under current Transport Canada regulations, and, therefore, even though the charter air operator may provide a service with many of the same features as a scheduled service, Transport Canada does not provide the same degree of oversight as it does for a scheduled air operator.
8. A review of the Canadian Aviation Regulations regarding simulator training requirements indicates that there is no requirement to conduct recurrent simulator training if currency and/or pilot proficiency checks do not lapse.
9. Commercial Air Service Standard 723.91(2) does not clearly indicate whether there is a requirement for simulator training following expiration of a pilot proficiency check.
10. Incorrect information on the passenger door placards, an incomplete safety features card, and the fact that the operating mechanisms and operating instructions for the emergency exits were not visible in darkness could have compromised passenger egress in the event of a survivable accident.
11. The dogs being carried on the aircraft were not restrained, creating a hazard for the flight and its occupants.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter in Sturt Island

Date & Time: Jan 5, 2004
Operator:
Registration:
P2-KSG
Flight Phase:
Survivors:
Yes
MSN:
509
YOM:
1976
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from a grassy runway (780 metres long), the pilot noted standing water on the ground. He attempted to take off prematurely to avoid these puddles but the aircraft stalled and crash landed. All three occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Boeing 737-3Q8 off Sharm el-Sheikh: 148 killed

Date & Time: Jan 3, 2004 at 0445 LT
Type of aircraft:
Operator:
Registration:
SU-ZCF
Flight Phase:
Survivors:
No
Schedule:
Sharm el-Sheikh - Cairo - Paris
MSN:
26283
YOM:
1992
Flight number:
FSH604
Country:
Region:
Crew on board:
13
Crew fatalities:
Pax on board:
135
Pax fatalities:
Other fatalities:
Total fatalities:
148
Captain / Total flying hours:
7443
Captain / Total hours on type:
474.00
Copilot / Total flying hours:
788
Copilot / Total hours on type:
242
Aircraft flight hours:
25603
Aircraft flight cycles:
17976
Circumstances:
Following a night takeoff from runway 22R at Sharm el Sheikh-Ophira Airport, the plane climbed and maneuvered for a procedural left turn to intercept the 306 radial from the Sharm el Sheikh VOR station. When the autopilot was engaged the captain made an exclamation and the autopilot was immediately switched off again. The captain then requested Heading Select to be engaged. The plane then began to bank to the right. The copilot then warned the captain a few times about the fact that the bank angle was increasing. At a bank angle of 40° to the right the captain stated "OK come out". The ailerons returned briefly to neutral before additional aileron movements commanded an increase in the right bank. The aircraft had reached a maximum altitude of 5,460 feet with a 50° bank when the copilot stated 'overbank'. Repeating himself as the bank angle kept increasing. The maximum bank angle recorded was 111° right. Pitch attitude at that time was 43° nose down and altitude was 3,470 feet. The observer on the flight deck, a trainee copilot, called 'retard power, retard power, retard power'. Both throttles were moved to idle and the airplane gently seemed to recover from the nose-down, right bank attitude. Speed however increased, causing an overspeed warning. At 04:45 the airplane struck the surface of the water in a 24° right bank, 24° nose-down, at a speed of 416 kts and with a 3,9 G load. The aircraft disintegrated on impact and debris sank by a depth of 900 metres. All 148 occupants were killed, among them 133 French citizens, one Moroccan, one Japanese and 13 Egyptian (all crew members, among them six who should disembark at Cairo). Weather at the time of accident was good with excellent visibility, outside temperature of 17° C and light wind. On January 17, the FDR was found at a depth of 1,020 metres and the CVR was found a day later at a depth of 1,050 metres.
Probable cause:
No conclusive evidence could be found from the findings gathered through this investigation to determine the probable cause. However, based on the work done, it could be concluded that any combination of these findings could have caused or contributed to the accident. Although the crew at the last stage of this accident attempted to correctly recover, the gravity upset condition with regards to attitude, altitude and speed made this attempt insufficient to achieve a successful recovery.
Possible causes:
- Trim/Feel Unit Fault (Aileron Trim Runaway),
- Temporarily, Spoiler wing cable jam (Spoiler offset of the neutral position),
- Temporarily, F/O wheel jam (Spoilers offset of the neutral position),
- Autopilot Actuator Hardover Fault.
Possible contributing factors:
- A distraction developing to Spatial Disorientation (SD) until the time the F/O announced 'A/C turning right' with acknowledgment of the captain,
- Technical log copies were kept on board with no copy left at departure station,
- Operator write up of defects was not accurately performed and resulting in unclear knowledge of actual technical status,
- There are conflicting signals which make unclear whether the captain remained in SD or was the crew unable to perceive the cause that was creating an upset condition until the time when the F/O announced that there was no A/P in action,
- After the time then the F/O announced 'no A/P commander' the crew behavior suggests the recovery attempt was consistent with expected crew reaction, evidences show that the corrective action was initiated in full, however the gravity of the upset condition with regards to attitude, altitude and speed made this attempt insufficient to achieve a successful recovery.
Additional findings:
- The ECAA authorization for RAM B737 simulator was issued at a date later than the date of training for the accident crew although the inspection and acceptance test were carried out at an earlier date.
- Several recorded FDR parameters were unreliable and could not be used for the investigation.
Final Report:

Crash of a Beechcraft A100 King Air in Terrace Bay

Date & Time: Jan 1, 2004
Type of aircraft:
Operator:
Registration:
C-GFKS
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Terrace Bay – Thunder Bay
MSN:
B-247
YOM:
1979
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On take off roll on runway 25 at dusk, left wing struck a snowbank on left side of the runway. Aircraft veered off runway and came to rest in snow with its nose gear sheared off and several damages to the fuselage. Both pilots were uninjured.
Probable cause:
A NOTAM stated that there were windrows four feet high, 10 feet inside the runway lights on both sides of the runway. This NOTAM also stated that the cleared portion of the runway was covered with ¼ inch of loose snow over 60 percent compacted snow and 40 percent ice patches and that braking action was fair to poor. The take-off was being conducted at dusk in conditions of poor lighting and contrast. Crosswind was not a factor.

Crash of a Boeing 727-223 in Cotonou: 141 killed

Date & Time: Dec 25, 2003 at 1459 LT
Type of aircraft:
Operator:
Registration:
3X-GDO
Flight Phase:
Survivors:
Yes
Schedule:
Conakry - Cotonou - Kufra - Beirut - Dubai
MSN:
21370
YOM:
1977
Flight number:
GIH141
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
153
Pax fatalities:
Other fatalities:
Total fatalities:
141
Captain / Total flying hours:
11000
Captain / Total hours on type:
8000.00
Aircraft flight hours:
67186
Aircraft flight cycles:
40452
Circumstances:
Flight GIH 141 was a weekly scheduled flight, performed by the Union des Transports Africains (UTA), between Conakry (Guinea), Cotonou (Benin), Beirut (Lebanon) and Dubai (United Arab Emirates). A stopover at Kufra (Libya) was planned between Cotonou and Beirut. Having departed from Conakry at 10 h 07 with eighty-six passengers, including three babies, and ten crew members, the Boeing 727-223 registered 3X-GDO landed at Cotonou Cadjèhoun on 25 December 2003 at 12 h 25. Nine passengers disembarked. Sixty-three persons, including two babies, checked in at the airport check-in desk. Ten others, including one baby, boarded from an aircraft that had arrived from Lomé (Togo). Passenger boarding and baggage loading took place in a climate of great confusion. The airplane was full. In the cockpit, two UTA executives were occupying the jump seats. Faced with the particularly large number and size of the hand baggage, the chief flight attendant informed the Captain of the situation. The ground handling company’s agents began loading the baggage in the aft hold when one of the operator’s agents, who remains unidentified, asked them to continue loading in the forward hold, which already contained baggage. When the operation was finished, the hold was full. During this time, the crew prepared the airplane for the second flight segment. The co-pilot was discussing his concerns with the UTA executives, reminding them of the importance of determining the precise weight of the loading of the airplane. The flight plan for Kufra, signed by the Captain, was filed with the ATC office but the meteorological dossier that had been prepared was not collected. Fuel was added to fill up the airplane’s tanks (14,244 liters, or 11.4 metric tons). The accompanying mechanics added some oil. The Captain determined the limitations for the flight and selected the following configuration: flaps 25°, air conditioning units shut down. At 13 h 47 min 55, the crew began the pre-flight checklist. Calm was restored in the cockpit. At 13 h 52 min 12, flight GIH 141 was cleared to roll. The co-pilot was pilot flying (PF). The elevator was set at 6 ¾, it was stated that the takeoff would be performed with full power applied with brakes on, followed by a climb at three degrees maximum to gain speed, with no turn after landing gear retraction. As the roll was beginning, a flight attendant informed the cockpit that passengers who wanted to sit near their friends were still standing and did not want to sit down. The airline’s Director General called the people in the cabin to order. Take-off thrust was requested at 13 h 58 min 01, brake release was performed at 13 h 58 min 15. The airplane accelerated. In the tower, the assistant controller noted that the take-off roll was long, though he did not pay any particular attention to it. At 13 h 59, a speed of a hundred and thirty-seven knots was reached. The Captain called out V1 and Vr. The co-pilot pulled back on the control column. This action initially had no effect on the airplane’s angle of attack. The Captain called « Rotate, rotate »; the co-pilot pulled back harder. The angle of attack only increased slowly. When the airplane had hardly left the ground, it struck the building containing the localizer on the extended runway centerline, at 13 h 59 min 11. The right main landing gear broke off and ripped off a part of the underwing flaps on the right wing. The airplane banked slightly to the right and crashed onto the beach. It broke into several pieces and ended up in the ocean. The two controllers present in the tower heard the noise and, looking in the direction of the takeoff, saw the airplane plunge towards the ground. Immediately afterwards, a cloud of dust and sand prevented anything else being seen. The fire brigade duty chief stated that the airplane seemed to have struck the localizer building. The firefighters went to the site and noticed the damage to the building and the presence of a casualty, a technician who was working there during the takeoff. Noticing some aircraft parts on the beach, they went there through a service gate beyond the installations. Some survivors were still in the wreckage, others were in the water or on the beach. Some inhabitants from the immediate vicinity crowded around, complicating the rescuers’ task. The town fire brigade, the Red Cross and the Cotonou SAMU, along with some members of the police, arrived some minutes later.
Probable cause:
The accident resulted from a direct cause:
• The difficulty that the flight crew encountered in performing the rotation with an overloaded airplane whose forward center of gravity was unknown to them; and two structural causes:
• The operator’s serious lack of competence, organization and regulatory documentation, which made it impossible for it both to organize the operation of the route correctly and to check the loading of the airplane;
• The inadequacy of the supervision exercised by the Guinean civil aviation authorities and, previously, by the authorities in Swaziland, in the context of safety oversight.
The following factors could have contributed to the accident:
• The need for air links with Beirut for the large communities of Lebanese origin in West Africa;
• The dispersal of effective responsibility between the various actors, in particular the role played by the owner of the airplane, which made supervision complicated;
• The failure by the operator, at Conakry and Cotonou, to call on service companies to supply information on the airplane’s loading;
• The Captain’s agreement to undertake the take-off with an airplane for which he had not been able to establish the weight;
• The short length of the runway at Cotonou;
• The time of day chosen for the departure of the flight, when it was particularly hot;
• The very wide margins, in particular in relation to the airplane’s weight, which appeared to exist, due to the use of an inappropriate document to establish the airplane’s weight and balance sheet;
• The existence of a non-frangible building one hundred and eighteen meters after the runway threshold.
Final Report:

Crash of a Piper PA-46-500TP Malibu Meridian in Port Orange: 2 killed

Date & Time: Dec 17, 2003 at 0933 LT
Operator:
Registration:
N155BM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Port Orange – Lufkin
MSN:
46-97053
YOM:
2001
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1914
Captain / Total hours on type:
36.00
Aircraft flight hours:
30
Circumstances:
The airplane was destroyed when it impacted trees and terrain following an in-flight loss of control during climb after takeoff. Meteorological information indicates that the cloud ceilings were between 1,200 and 1,700 feet above ground level at the time of the accident. While airborne, the accident pilot reported to another pilot that the cloud ceiling was 1,500 feet. Radar data shows that the airplane flight profile became erratic once it had climbed above about 1,700 feet pressure altitude. The final flight path sequence depicted by the radar data shows a right-hand turn of decreasing radius with an associated rapid rate of descent. The last radar return coincided with the accident location. The non-instrument rated pilot had logged 7.0 hours of simulated instrument experience. The pilot had logged 35.8 hours in the same make and model as the accident airplane, of which, all but 0.3 hours was listed as crosscountry time. No records of training in the same make and model airplane were discovered. No pre-impact mechanical deficiencies were found during the post-accident examination of the wreckage.
Probable cause:
The unqualified pilot's continued flight into known instrument meteorological conditions which resulted in spatial disorientation and subsequent loss of aircraft control. Factors were the pilot's lack of instrument flight experience and the low ceiling.
Final Report:

Crash of a De Havilland DHC-3 Otter in Jellicoe: 2 killed

Date & Time: Dec 16, 2003 at 1200 LT
Type of aircraft:
Operator:
Registration:
C-GOFF
Flight Phase:
Survivors:
Yes
MSN:
65
YOM:
1954
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5016
Captain / Total hours on type:
540.00
Circumstances:
At approximately 0900 eastern standard time (EST), the pilot arrived at the airstrip and prepared the ski-equipped de Havilland DHC–3 (Otter) aircraft (registration C–GOFF, serial number 65) for the morning flight. This Otter was equipped with a turbine engine. Two passengers, with enough supplies for an extended period of time, including a snowmobile and camping gear, were to be flown to a remote location. The pilot loaded the aircraft and waited for the weather to improve. At approximately 1200 EST, the pilot and passengers boarded the aircraft and took off in an easterly direction. The aircraft got airborne near the departure end of the airstrip, and, shortly after take-off, the right wing struck a number of small bushes and the top of a birch tree. The aircraft descended and struck the frozen lake surface, approximately 70 feet below the airfield elevation in a steep, nose-down, right-wing-low attitude. When it came to rest, the aircraft was inverted and partially submerged, with only the aft section of the fuselage remaining above the ice. All of the occupants were wearing lap belts. The pilot and front seat passenger received fatal injuries. The rear seat passenger survived the impact and evacuated the aircraft with some difficulty due to leg injuries. The following morning, about 22 hours after the accident, a local air operator searching for the missing aircraft located and rescued the surviving passenger.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot attempted to take off from an airstrip that was covered with approximately 18 inches of snow, and the aircraft did not accelerate to take-off speed because of the drag; the aircraft was forced into the air and was unable to climb out of ground effect and clear the obstacles.
2. The pilot did not abort the take-off when it became apparent that the aircraft was not accelerating normally and before the aircraft became airborne.
Findings as to Risk:
1. Unidirectional G switches, which are found on many types of ELTs, do not always activate the unit when impact forces are not aligned with the usual direction of flight.
Other Findings:
1. The validity of the aircraft’s certificate of airworthiness was affected while it flew more flights than allowed by the ferry permit issued by Transport Canada.
2. The rear passenger seat was found to be installed incorrectly, contrary to de Havilland Alert Service Bulletin A3/49, dated 19 July 1991.
Final Report:

Crash of a Cessna 441 Conquest II near Birmingham: 2 killed

Date & Time: Dec 10, 2003 at 1420 LT
Type of aircraft:
Registration:
N441W
Flight Phase:
Survivors:
No
Schedule:
Birmingham – Venice
MSN:
441-0181
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8378
Captain / Total hours on type:
424.00
Aircraft flight hours:
5933
Circumstances:
The flight was climbing from 5,000 to 10,000 feet and the pilot obtained a maximum altitude of 6,300 feet. The airplane then began to lose altitude and deviate off course. The pilot declared a mayday and reported the airplane was in a spin. Several witnesses near the accident site reported hearing airplane engine noises and seeing the airplane descend from the clouds in a nose-down spiral to the ground. Two AIRMETs were valid at the time of the accident and included the accident location: "AIRMET TANGO update 3 for turbulence ... . Occasional moderate turbulence below a flight level of 18,000 feet due to wind shear ... ." "AIRMET ZULU update 2 for ice and freezing level ... . Occasional moderate rime and/or mixed icing in clouds and precipitation below 8,000 feet." Two pilots who departed in separate Beech 200 airplanes about the time of the accident airplane stated they encountered "moderate rime" icing between 5,000 and 6,000 feet, and one pilot reported instrument meteorological conditions and light turbulence between 1,800 to 6,000 feet. Examination of the airplane revealed no evidence of airframe or engine malfunction. The de-ice ejector flow control valves for the left wing, right wing, and empennage pneumatic boots were removed for examination, and all valves functioned when power was supplied.
Probable cause:
The pilot's failure to maintain adequate airspeed during climb in icing conditions, which resulted in an inadvertent stall / spin of the airplane and subsequent uncontrolled descent and collision with terrain. A factor was the accumulation of airframe ice.
Final Report: