Crash of a Learjet 45 in Milan: 2 killed

Date & Time: Jun 1, 2003 at 1526 LT
Type of aircraft:
Operator:
Registration:
I-ERJC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Milan - Genoa - Amsterdam
MSN:
45-093
YOM:
2000
Flight number:
ERJ1570
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1031
Captain / Total hours on type:
544.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
14
Aircraft flight hours:
931
Aircraft flight cycles:
890
Circumstances:
The aircraft departed Milan-Linate Airport on a positioning flight to Genoa to pick up passengers for Amsterdam. Shortly after takeoff from runway 36R, while in initial climb, the aircraft collided with a flock of pigeons that struck both engines. The crew declared an emergency and reported technical problems without giving any other details. He was cleared for an immediate return and initiated a turn to the east. One minute and 25 seconds after takeoff, the aircraft entered an uncontrolled descent and crashed on a factory located 750 metres southeast from the runway 36R threshold. The aircraft was totally destroyed by impact forces and a post crash fire and both pilots were killed.
Probable cause:
The event, triggered by a multiple impact with birds during take-off, was caused by the loss of control in flight of the aircraft, due to an aerodynamic stall during the return to the departure airport, which could not be recovered due to the reduced altitude available.
The following factors contributed to the event:
- The non-implementation of the procedure provided for in the Flight Manual for engine failure after V1, with particular reference to configuration control (undercarriage and flaps), thrust lever management, definition and achievement of safety altitude, maintenance of expected speeds,
- The lack of CRM, already detectable in the ground procedures phase, but significantly worsened as a result of the emergency,
- The lack of experience of FO, on its first flight of line training on the type of aircraft,
- The inadequacy of the measures and of the bird control activity in the manoeuvring area.
Final Report:

Crash of a Rockwell Aero Commander 500B in Grand Canyon

Date & Time: May 28, 2003 at 1720 LT
Registration:
N64TS
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Grand Canyon - Rialto
MSN:
500-1442-156
YOM:
1964
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
26110
Captain / Total hours on type:
850.00
Aircraft flight hours:
4587
Circumstances:
The airplane did not gain altitude after takeoff and collided with trees and terrain off the departure end of the runway. Prior to takeoff the pilot received a computerized weather briefing that showed generally good conditions. The tower controller cleared the pilot to taxi to the active runway (runway 21) and issued winds, which were 300 degrees at 10 knots, a direct crosswind. During the initial climb after liftoff, the pilot saw that the airplane had stopped climbing and he asked for and received the wind information again. With the airplane not climbing and headed directly for some trees, the pilot maneuvered the airplane towards a clearing but the left wing hit a tree and the airplane descended into the ground. The pilot reported no mechanical problems with the airframe and engines. The density altitude was calculated to be 9,481 feet. The aircraft's gross weight at the time of takeoff was 6,000 pounds. Review of the Airplane Flight Manual climb performance charts for that aircraft weight at the pressure altitude and reported outside air temperature discloses that the airplane should have had a positive rate of climb of about 1,100 feet per minute. The airport was equipped with a wind information recording system, which had four sensors. Three sensors recorded wind information at ground level only. They were placed, one each, at the approach, middle, and departure ends of the runway. Wind data was recorded every 10 seconds. The system does not have the capability to predict or warn of wind shear events. During the aircraft's departure, the approach end sensor recorded winds at 068 degrees at 1 knot; the middle sensor recorded winds at 293 degrees at 5 knots; and the departure sensor recorded winds at 302 degrees at 2 knots. At the next data sampling (10 seconds later), the departure end sensor recorded a wind increase of 10 knots, and the approach end recorded a wind shift from a headwind to a tailwind at 10 knots. A full analysis of the weather conditions indicated that due to developing convection over the runway the airplane likely encountered a wind shear (increasing tailwind) event that seriously degraded the takeoff and climb performance.
Probable cause:
The pilot's encounter with a wind shear just after liftoff.
Final Report:

Crash of a Piper PA-31P Pressurized Navajo Woodruff: 4 killed

Date & Time: May 25, 2003 at 1754 LT
Type of aircraft:
Operator:
Registration:
N36DR
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Woodruff - DuPage
MSN:
31-7530025
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
11850
Aircraft flight hours:
5384
Circumstances:
The twin-engine airplane was destroyed when it impacted trees and terrain shortly after takeoff. The airplane was consumed in a post-impact fire. Witnesses reported seeing the airplane climbing at a lower than normal rate just after takeoff. One witness did not hear the airplane. Another witness reported that the airplane sounded labored and this is what drew his attention to the airplane. The airplane came to rest in a wooded area about 3,500 feet from the departure end of the runway, and 700 feet left of the extended runway centerline. The wreckage path through the trees was about 65 degrees left of the runway heading. The first piece of wreckage along the wreckage trail was the left wingtip. Examination of the right propeller revealed chordwise scratching, leading edge damage, and bending and twisting opposite to the direction of rotation. In addition, several tree cuts were observed that were predominately on the right side of the wreckage path. No evidence of rotation was noted with respect to the left propeller, propeller blades, or propeller spinner. On-scene examination revealed no pre-impact anomalies with respect to the airframe, right engine, or right propeller. Follow-on examination of the left engine and propeller revealed no pre-impact anomalies. Calculations based on the power setting table, airspeed chart and en-route distance showed that the airplane would have burned a total of 56 to 71 gallons (28 to 35.5 gallons per side) of fuel for the previous leg of the round-trip flight. The main fuel tanks held a total of 112 gallons of fuel (56 gallons per side). Based on the fuel burn calculations, this quantity of fuel would not have been sufficient to complete the round-trip flight on the main fuel tanks alone. The outboard auxiliary fuel tanks held 40 gallons per side. The left fuel selector was found positioned to the inboard main fuel tank and the right fuel selector was found positioned to the outboard auxiliary fuel tank. The airplane flight manual for the airplane stipulates that only the main fuel tanks be used for takeoff and landing. No fuel was obtained for the return flight.
Probable cause:
The pilot's failure to follow the before take-off checklist which led to an improper selection of the auxiliary fuel tanks for the takeoff leading to the subsequent fuel starvation of the left engine. Additional causes were the pilot not maintaining minimum controllable airspeed which resulted in a loss of control of the airplane. The trees and the pilot's unsuccessful attempt to restart the engine by selecting the main fuel tank were contributing factors in the accident.
Final Report:

Crash of an Antonov AN-12BP in Menongue: 4 killed

Date & Time: May 16, 2003
Type of aircraft:
Operator:
Registration:
T-307
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Menongue - Luanda
MSN:
9 34 66 08
YOM:
1969
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The aircraft departed Luanda on a cargo flight to Menongue, carrying four crew members and a load of fuel drums. While in cruising altitude, one of the engine failed but the crew was able to continue and to land normally at Menongue Airport. Later, the crew decided to fly back to Luanda on three engines for maintenance instead of getting a technical crew to the airfield the next day. Shortly after takeoff, while climbing, a second engine failed, causing the aircraft to stall and to crash. All four crew members were killed.
Probable cause:
Engine failure for unknown reasons.

Crash of a Cessna 208B Super Cargomaster in Lorain

Date & Time: May 15, 2003 at 1710 LT
Type of aircraft:
Operator:
Registration:
N208AD
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lorain - Anderson
MSN:
208B-0063
YOM:
1987
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3500
Captain / Total hours on type:
1500.00
Aircraft flight hours:
12059
Circumstances:
The pilot departed in a Cessna 208B, and shortly after takeoff, he experienced a power loss. He set up for a forced landing and during the ground roll, the nose wheel sunk into the soft terrain and the airplane nosed over. Fuel was found in both wings; however, the fuel line between the fuel selector and the engine contained only trace amounts of fuel. One fuel selector was found in the OFF position, and the other fuel selector was mid-range between the OFF and ON positions. The airplane was equipped with an annunciator warning light and horn to warn if either fuel selector was turned off. The annunciator was popped out and did not make contact with the annunciator panel. The warning horn was checked and found to be inoperative, and the electrical circuitry leading to the horn was checked and found to be operative. The engine was test run with no problems noted. According to the Pilot's Operating Handbook, the position of the fuel selectors are to be checked three times before takeoff: including cabin preflight, before engine start, and before takeoff. The pilot reported that he departed with both fuel selectors on and had not touched them when the power loss occurred. A representative of Cessna Aircraft Company reported that there was sufficient fuel forward of the fuel selector valves to takeoff and fly for a few miles prior to experiencing fuel exhaustion.
Probable cause:
The pilot's failure to verify the position of the fuel selectors prior to takeoff, which resulted in a power loss due to fuel starvation. A factor was the failure of the fuel selector warning horn.
Final Report:

Crash of a Cessna 411 in Corona: 1 killed

Date & Time: May 4, 2003 at 1453 LT
Type of aircraft:
Operator:
Registration:
N1133S
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Corona – Santa Monica
MSN:
411-0202
YOM:
1966
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3901
Captain / Total hours on type:
412.00
Aircraft flight hours:
4915
Circumstances:
The pilot lost control of his twin engine airplane and collided with terrain while returning to the departure airport after reporting an engine problem. Shortly after takeoff, about 4,000 feet msl, the pilot reported to ATC that he had an engine problem and would return to the airport. The radar plot reveals a steady descent of the airplane from 4,000 feet msl to the accident site, approximately 2 miles from the designated airport. Ground witnesses reported that they saw the airplane flying very low, about 500 feet agl, seconds prior to the accident apparently heading toward the departure airport. The witnesses reported consistent observations of the airplane "wobbling," then going into a steep knife-edge left bank before it dove into the ground. Witnesses at the airport said that the pilot sought out help in getting his radios operating prior to takeoff, telling the witness, "it's been four and a half months since I've been in an airplane, I can't even figure out how to put the radios back in." No fueling records were found for the airplane at the departure airport. The last documented fueling of the airplane was on October 31, 2002, with the addition of 56.2 gallons. Witnesses reported that the airplane did not take on any fuel immediately prior to the flight on May 4th. The flight was the first flight since the airplane received its annual inspection 2 months prior to the accident, and, it was the pilot's first flight after 4 months of inactivity. It is a common practice for maintenance personnel to pull the landing light circuit breakers during maintenance to prevent the fuel transfer pumps, which are wired through the landing light system, from operating continuously. The fuel transfer pumps move fuel from the forward part of the main fuel tank to the center baffle area where it is picked up and routed to the engine. It is conceivable that these circuit breakers were not reset by the pilot for this flight. Wreckage examination revealed a post accident fire on the right wing of the airplane and no fire on the left wing. Additionally, only a small amount of fuel was identified around the left wing tanks after the accident, and no hydraulic deformation was observed to the left main tank or the internal baffles. The landing gear bellcrank indicates that the landing gear was in the down position. The engine and propeller post impact signatures indicate that the left engine was operating at a low power setting (wind milling), while the right engine and propeller indicate a high power setting. Disassembly and inspection of the internal propeller hub components showed that the left propeller was not feathered. The left engine is the critical engine and loss of power in that engine would make directional control more difficult at slower speeds. The airplane owners manual states that "climb or continued level flight at a moderate altitude is improbable with the landing gear extended or the propeller windmilling." The single engine flight procedure delineated in the manual dictates a higher than normal altitude for a successful single engine landing approach.
Probable cause:
The failure of the pilot to properly configure the airplane for a one engine inoperative condition (including his failure to feather the propeller of the affected engine, retract the landing gear, and maintain minimum single engine speed). Factors related to the accident were fuel starvation of the left engine, due to an inadequate fuel supply in the left tanks, inoperative fuel transfer pumps, and the pilot's decision to take off without fueling.
Final Report:

Crash of a Vickers 836 Viscount in Democratic Republic of Congo

Date & Time: Apr 27, 2003
Type of aircraft:
Operator:
Registration:
9Q-CGL
Flight Phase:
Survivors:
Yes
MSN:
435
YOM:
1960
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The exact circumstances of this accident remains unknown. While landing on a 900 meters long gravel runway somewhere in DRC, one of the four engine was damaged. The crew later decided to takeoff on a three-engine configuration but a second engine failed during takeoff. The aircraft stalled and crashed near the runway end. There were no casualties.
Probable cause:

Crash of a Piper PA-46-350P Malibu Mirage near Lop Buri: 3 killed

Date & Time: Apr 26, 2003 at 1430 LT
Operator:
Registration:
HS-AKS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bangkok – Chiang Mai
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The single engine aircraft departed Bangkok-Don Mueang on a private flight to Chiang Mai with two passengers and one pilot on board. During climbout in marginal weather conditions, the pilot was cleared to climb to 11,000 feet when control was lost. The aircraft crashed in a cornfield located near Lop Buri. All three occupants were killed. There was some thunderstorm activity in the area at the time of the accident.

Crash of a Rockwell Shrike Commander 500S in Mount Pleasant

Date & Time: Apr 14, 2003 at 1140 LT
Operator:
Registration:
N19WL
Flight Phase:
Survivors:
Yes
Schedule:
Mount Pleasant - Mount Pleasant
MSN:
500-3160
YOM:
1973
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4578
Captain / Total hours on type:
280.00
Aircraft flight hours:
11617
Circumstances:
According to the pilot, he requested the refueler to top off his fuel tanks with "100 low lead fuel". After refueling, the pilot performed a preflight including taking fuel samples from under the wings, draining the rear fuel drain, and checking the fuel cap for security. The engine start, run-up, and taxi were uneventful. The airplane departed runway 17 and was in a positive rate of climb. At approximately 200 feet AGL the airplane began to lose power. Shortly after the pilot ensured that the throttle, propeller, and mixture controls were in the full forward position, the airplane lost power in both engines. The pilot executed an emergency off field landing. Examination of the wreckage revealed that the left wing had broken off and the aft cabin area was crushed. According to the refueler, he stated that he mistakenly used the Jet-A fuel truck instead of the AVGAS 100 low lead truck, and pumped 58 gallons of Jet-A into the airplane. Examination of the fuel samples taken from both engines revealed the left and right engine contained 70 percent of jet A fuel.
Probable cause:
The improper refueling of the airplane by airport personnel with the incorrect fuel grade that resulted in a total loss in engine power on both engines during initial climb. A factor was the inadequate preflight inspection by the pilot in command.
Final Report:

Crash of a Yakovlev Yak-40 in Urganch

Date & Time: Apr 9, 2003
Type of aircraft:
Operator:
Registration:
UK-87367
Flight Phase:
Survivors:
Yes
MSN:
9341731
YOM:
1973
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During takeoff roll on runway 13/31, the crew noticed a loss of power on the left engine and decided to abort. The aircraft could not be stopped within the remaining distance and overran. It lost its right main gear and came to rest few dozen metres further. All occupants escaped uninjured while the aircraft was damaged beyond repair.