Crash of a De Havilland DHC-2 Beaver near Penticton: 3 killed

Date & Time: Aug 29, 2003 at 1427 LT
Type of aircraft:
Registration:
C-GHAF
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Nanaimo - Penticton - Calgary
MSN:
1408
YOM:
1959
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
915
Captain / Total hours on type:
615.00
Aircraft flight hours:
9029
Circumstances:
The aircraft left Nanaimo, British Columbia, and landed at Penticton Airport at 1232 Pacific daylight time (PDT). The aircraft was fueled with 184 litres of fuel, filling all three belly tanks. At this time, the rear portion of the aircraft cabin was observed to be loaded with luggage and cargo. The pilot/aircraft owner was planning his flight to Calgary (Springbank), Alberta, and spent at least an hour flight planning and talking with the Kamloops Flight Information Centre by telephone. He had some difficulty determining a route to fly to Springbank, because of airspace restrictions due to forest fires, but decided on a routing of Penticton, Kelowna, Vernon, Revelstoke, and Springbank. The aircraft took off from Penticton Airport at 1420 PDT, with the pilot and two passengers on board and crashed approximately seven minutes later in a ravine of Penticton Creek, 11 nautical miles northeast of Penticton Airport. A post-impact fire broke out and consumed most of the fuselage area. The fire caused a small forest fire, seen by a firefighting aircraft crew. There were no radio calls from the occurrence aircraft, and the three occupants were fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. As the aircraft approached high terrain in a climb, the pilot, for undetermined reasons, did not turn away from the terrain; the aircraft struck tree tops and crashed.
2. The aircraft’s climb performance was adversely affected by density altitude and the relatively high aircraft weight, so that the aircraft was unable to clear the high terrain ahead.
Findings as to Risk:
1. The licensed passenger had not informed the TC medical examiner who conducted her last medical that she had been diagnosed with coronary artery disease, posing the risk that she could pilot an aircraft while not medically fit to do so.
2. The aircraft was being operated at a higher weight than was justified by the STC, under which it was converted to an amphibian. Some of the structural modifications called for by the STC for the higher weight had not been carried out.
Other Findings:
1. It could not be determined who was piloting the aircraft on the occurrence flight.
Final Report:

Crash of a Beechcraft 1900D off Hyannis: 2 killed

Date & Time: Aug 26, 2003 at 1540 LT
Type of aircraft:
Operator:
Registration:
N240CJ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hyannis - Albany
MSN:
UE-40
YOM:
1993
Flight number:
US9446
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2891
Captain / Total hours on type:
1364.00
Copilot / Total flying hours:
2489
Copilot / Total hours on type:
689
Aircraft flight hours:
16503
Aircraft flight cycles:
24637
Circumstances:
The accident flight was the first flight after maintenance personnel replaced the forward elevator trim cable. When the flightcrew received the airplane, the captain did not address the recent cable change noted on his maintenance release. The captain also did not perform a first flight of the day checklist, which included an elevator trim check. Shortly after takeoff, the flightcrew reported a runway trim, and manually selected nose-up trim. However, the elevator trim then traveled to the full nose-down position. The control column forces subsequently increased to 250 pounds, and the flightcrew was unable to maintain control of the airplane. During the replacement of the cable, the maintenance personnel skipped a step in the manufacturer's airliner maintenance manual (AMM). They did not use a lead wire to assist with cable orientation. In addition, the AMM incorrectly depicted the elevator trim drum, and the depiction of the orientation of the cable around the drum was ambiguous. The maintenance personnel stated that they had completed an operational check of the airplane after maintenance. The Safety Board performed a mis-rigging demonstration on an exemplar airplane, which reversed the elevator trim system. An operational check on that airplane revealed that when the electric trim motor was activated in one direction, the elevator trim tabs moved in the correct direction, but the trim wheel moved opposite of the corresponding correct direction. When the manual trim wheel was moved in one direction, the elevator trim tabs moved opposite of the corresponding correct direction.
Probable cause:
The improper replacement of the forward elevator trim cable, and subsequent inadequate functional check of the maintenance performed, which resulted in a reversal of the elevator trim system and a loss of control in-flight. Factors were the flightcrew's failure to follow the checklist procedures, and the aircraft manufacturer's erroneous depiction of the elevator trim drum in the maintenance manual.
Final Report:

Crash of a Let L-410UVP-E3 in Cap Haïtien: 21 killed

Date & Time: Aug 24, 2003 at 0457 LT
Type of aircraft:
Operator:
Registration:
HH-PRV
Flight Phase:
Survivors:
No
Schedule:
Cap Haïtien - Port-de-Paix
MSN:
87 20 01
YOM:
1987
Flight number:
TBG1301
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
21
Captain / Total flying hours:
8863
Captain / Total hours on type:
701.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
275
Aircraft flight hours:
2982
Aircraft flight cycles:
4154
Circumstances:
Shortly after a night takeoff from runway 05 at Cap Haïtien Airport, while in initial climb, the crew reported technical problems, declared an emergency and was cleared to return. While on base leg, the aircraft lost height and crashed in a sugar cane field located 2 km from the airport, bursting into flames. All 21 occupants were killed. It was later reported that the door of the forward baggage hold opened during takeoff.
Probable cause:
The accident was the consequence of a stall during approach while on the downwind leg base due to a loss of VMC at low altitude.
The following contributing factors were identified:
- Failure of the crew to manage the approach procedure (poor CRM),
- Use of maximum flaps (42°),
- Insufficient altitude,
- Lack of coordination between crew members,
- A possible state of fatigue of the captain,
- A possible overweight aircraft,
- The opening of the forward baggage hold door during takeoff.
Final Report:

Crash of a Cessna 208B Grand Caravan in Old Fangak

Date & Time: Aug 19, 2003
Type of aircraft:
Operator:
Registration:
5Y-TWI
Flight Phase:
Survivors:
Yes
MSN:
208B-0606
YOM:
1997
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While taking off from Old Fangak Airstrip, the single engine aircraft hit trees located past the runway end, nosed down and crashed in a marsh. All six occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Cessna 404 Titan II in Jandakot: 2 killed

Date & Time: Aug 11, 2003 at 1537 LT
Type of aircraft:
Operator:
Registration:
VH-ANV
Flight Phase:
Survivors:
Yes
Schedule:
Jandakot - Jandakot
MSN:
404-0820
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
16722
Captain / Total hours on type:
12345.00
Aircraft flight hours:
16819
Circumstances:
The aircraft took off from runway 24 right (24R) at Jandakot Airport, WA. One pilot and five passengers were on board the aircraft. The flight was being conducted in the aerial work category, under the instrument flight rules. Shortly after the aircraft became airborne, while still over the runway, the pilot recognized symptoms that he associated with a failure of the right engine and elected to continue the takeoff. The pilot retracted the landing gear, selected the wing flaps to the up position and feathered the propeller of the right engine. The pilot later reported that he was concerned about clearing a residential area and obstructions along the flight path ahead, including high-voltage powerlines crossing the aircraft’s flight path 2,400 m beyond the runway. The aircraft was approximately 450 m beyond the upwind threshold of runway 24R when the pilot initiated a series of left turns. Analysis of radar records indicated that during the turns, the airspeed of the aircraft reduced significantly below the airspeed required for optimum single-engine performance. The pilot transmitted to the aerodrome controller that he was returning for a landing and indicated an intention to land on runway 30. However, the airspeed decayed during the subsequent manoeuvring such that he was unable to safely complete the approach to that runway. The pilot was unable to maintain altitude and the aircraft descended into an area of scrub-type terrain, moderately populated with trees. During the impact sequence at about 1537, the outboard portion of the left wing collided with a tree trunk and was sheared off. A significant quantity of fuel was spilled from the wing’s fuel tank and ignited. An intense postimpact fire broke out in the vicinity of the wreckage and destroyed the aircraft. Four passengers and the pilot vacated the aircraft, but sustained serious burns in the process. One of those passengers died from those injuries 85 days after the accident. A fifth passenger did not survive the post-impact fire.
Probable cause:
Significant factors:
1. The material specification contained in the engineering order for replacing the pump bushing of the engine driven fuel pump (EDFP) fitted to the right engine was not appropriate.
2. High torsional loads between the EDFP’s spindle shaft and the sleeve bearing sheared the pump’s drive shaft during a critical phase of flight.
3. The reduction in fuel pressure was insufficient to sustain operation of the engine at the take-off power setting.
4. The loss of engine power occurred close to the decision speed with the landing gear extended while the aircraft was over the runway.
5. The pilot elected to continue the takeoff.
6. The aircraft was manoeuvred, including turns and banks, at low altitude resulting in a decrease in airspeed below that required to maximise one-engine inoperative performance.
7. The pilot was unable to maintain the aircraft’s altitude over terrain that was unsuitable for an emergency landing.
Final Report:

Crash of a Cessna 340A in Bishop: 1 killed

Date & Time: Aug 8, 2003 at 2132 LT
Type of aircraft:
Operator:
Registration:
N340DC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bishop - Upland
MSN:
340A-0968
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1302
Captain / Total hours on type:
1.00
Aircraft flight hours:
1123
Circumstances:
During a nighttime takeoff initial climb, the airplane collided with terrain near the airport. Witnesses reported watching the airplane accelerate on runway 12, rotate, and climb to 200 to 300 feet above ground level. The climb rate decreased and the airplane appeared to initiate a left turn, with the roll continuing to a wings vertical attitude. At this point the airplane descended into the terrain. One witness north of the accident site described the landing lights going from horizontal to vertical followed by a decrease in engine sound just before impact. According to the airplane owner, the pilot had never flown the accident airplane before the first leg to the accident location to drop off the owner and another passenger. Examination of the pilot records failed to locate any previous flight time in Cessna 300 or 400 series airplanes. In the last 30 days he had given instruction in a smaller light twin engine airplane. Post accident examination of the wreckage revealed the landing gear to be in the down position at the time of impact. The retractable landing lights were extended and the nose gear taxi light was destroyed. Both propellers exhibited symmetrical power signatures. No preimpact mechanical malfunctions or failures were identified. The impact site was east of the airport about 0.68 nautical miles. The departure direction is towards a mountain range with sparse population and few ground reference lights. The moon's disk was 25 degrees above the southeastern horizon and was 89 percent illuminated. The FAA AC61-23C Pilot's Handbook of Aeronautical Knowledge addresses the environmental factors and potential in-flight visual illusions, which could affect pilot performance. The reference material describes Somatogravic Illusion as, "a rapid acceleration during takeoff can create the illusion of being in a nose up attitude. The disoriented pilot will push the airplane into a nose low, or dive attitude. A rapid deceleration by a quick reduction of the throttles can have the opposite effect, with the disoriented pilot pulling the airplane into a nose up, or stall attitude."
Probable cause:
The pilot's in-flight loss of control due to a Somatogravic illusion and/or spatial disorientation. Factors in the accident were the dark lighting conditions and the pilot's lack of familiarity with the airplane.
Final Report:

Crash of a Boeing 707-3J6C in Dhaka

Date & Time: Jul 11, 2003 at 0638 LT
Type of aircraft:
Operator:
Registration:
5X-AMW
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Dhaka - Amman
MSN:
20723
YOM:
1974
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from runway 14 at Dhaka-Zia Ul-Haq Airport, the crew encountered an unexpected situation and the captain decided to abandon the takeoff procedure. Unable to stop within the remaining distance (runway 14 is 3,200 metres long), the aircraft overran, lost its undercarriage and came to rest 450 metres further. All five crew members escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Lockheed C-130H Hercules at Boufarik AFB: 15 killed

Date & Time: Jun 30, 2003 at 1100 LT
Type of aircraft:
Operator:
Registration:
7T-WHQ
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Boufarik AFB - Boufarik AFB
MSN:
4926
YOM:
1982
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
15
Circumstances:
The crew departed Boufarik AFB on a local training flight. Shortly after takeoff, while in initial climb, the crew informed ATC about an engine fire and elected to return for an emergency landing. Few seconds later, control was lost and the aircraft crashed in the district of Beni Mered, less than 2 km from the end of runway 22. The aircraft was totally destroyed by impact forces and a post crash fire as well as eight houses. All four crew members were killed as well as 11 people on the ground. Six other people on the ground were seriously injured.
Probable cause:
Engine fire for unknown reasons.

Crash of a Tupolev TU-134SKh in Nyagan

Date & Time: Jun 24, 2003
Type of aircraft:
Operator:
Registration:
RA-65929
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nyagan – Salekhard
MSN:
66495
YOM:
1987
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was subject to major maintenance during the last two months, especially with the rudder actuators that were replaced. As there were still problems with the actuators during the last flight, decision was taken to make the appropriate adjustments followed by a flight to Salekhard. During the takeoff roll on runway 16/34, at a speed of 150 km/h, the aircraft deviated to the left and the captain decided to counter this deviation by using the nosewheel steering system. This caused the right front tyre to burst. At a speed of 250 km/h, the takeoff procedure was abandoned but this decision was taken too late. Unable to stop within the remaining distance (the runway 16/34 is 2,530 metres long), the aircraft overran, lost its nose gear and rolled for 577 metres before coming to rest. All 11 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The following findings were identified:
- Poor quality of work from the engineering personnel of Voronezh Avia during the replacement and adjustment of the hydraulic amplifier GU-108D,
- Unsatisfactory flying and technical operation of the aircraft after the completion of the replacement of the hydraulic amplifier, during which the incorrectly installed rudder actuator was not discovered,
- The decision taken by the crew to continue the takeoff procedure despite significant efforts needed for the deflection of the right rudder pedal already noted during the preflight checks,
- The late rejection of the takeoff procedure.

Crash of a Piper PA-31P Pressurized Navajo in Augusta: 2 killed

Date & Time: Jun 16, 2003 at 1302 LT
Type of aircraft:
Registration:
N577FS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Augusta – Belmont
MSN:
31-7730008
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8000
Aircraft flight hours:
4412
Circumstances:
A witness at the airport stated the airplane appeared to use half of the 8,000-foot runway on takeoff roll, and the climb out appeared "very flat." During climbout, the pilot reported to the tower controller the airplane "lost an engine," and he announced intentions to return to the runway. The controller stated he noticed the airplane continued straight out and appeared to be losing altitude. Witnesses north of the airport observed the airplane flying low and described its engine noises as "erratic," "skipping," "sputtering," and "some sort of backfire." One witness stated the airplane was moving slowly to the north with a high nose-up angle, and the airplane "appeared to stall" then dove vertically into the trees. Examination of the accident site revealed wreckage debris and broken trees were scattered approximately 120 feet. The airframe, engines, and the right propeller sustained fire damage. The left propeller, top forward portion of the left engine case, and the left propeller gear shaft and bearings were not located. Examination of recovered components revealed no evidence of mechanical malfunction could be determined. According to the Pilot's Operating Handbook for the Piper PA-31P, the stall speed for the airplane with the gear and flaps up is: "(7800 lbs) 80 KCAS, 81 KIAS."
Probable cause:
The pilot's failure to maintain airspeed while maneuvering on initial take off climb resulting in an inadvertent stall, loss of control, and subsequent in-flight collision with trees and a swamp. A factor in the accident was a reported loss of engine power for undetermined reasons.
Final Report: