Crash of an Antonov AN-32A in Popayán: 3 killed

Date & Time: Apr 19, 2002 at 0853 LT
Type of aircraft:
Operator:
Registration:
HK-4171X
Flight Phase:
Survivors:
Yes
Schedule:
Popayán – Medellín
MSN:
2508
YOM:
1991
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
9798
Captain / Total hours on type:
1548.00
Copilot / Total flying hours:
1069
Copilot / Total hours on type:
855
Aircraft flight hours:
3153
Circumstances:
The aircraft was chartered to transfer groups of prisoners from Medellín to Popayán on behalf of the National Penitentiary and Prison Institute. Fifty prisoners just disembarked at Popayán Airport when the crew departed on a ferry flight to Medellín for a second similar rotation. Popayán Airport is located at an altitude of 1,733 metres and its runway is 1,906 metres long. For unknown reasons, the crew decided to start the takeoff procedure from the intersection, reducing the available takeoff distance to 910 metres. Also, the flaps were deployed to an angle of 25° instead of 15° and the engine power was set at 95% instead of 100% as stipulated in the company procedures for airport located above the altitude of 1,400 metres. During the takeoff roll, at a distance of 150 metres from the runway end, the pilot realized he could not make it so he rejected the takeoff procedure and started an emergency braking manoeuvre. Unable to stop within the remaining distance, the aircraft overran, struck trees and came to rest, broken in two. Three passengers were killed while five other occupants were injured.
Probable cause:
Improper execution by the crew by not following the procedures, instructions and manuals of the aircraft manufacturer and approved to the SELVA company by the UAEAC, specifically when attempting to perform a takeoff in a wrong configuration, with a reduced power setting and an insufficient runway length for the execution of the procedure.
Final Report:

Crash of a Let L-410UVP-E9 in Ngerende

Date & Time: Apr 17, 2002
Type of aircraft:
Registration:
5Y-UAS
Flight Phase:
Survivors:
Yes
Schedule:
Ngerende – Nairobi
MSN:
84 13 24
YOM:
1984
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from a dirt strip (3,900 feet long) at Ngerende, an impala crossed the runway. To avoid a collision, the crew pulled up the control column and started the rotation. Because the airspeed was insufficient, the pilot-in-command put the nose down to gain speed when the aircraft struck the ground and crash landed in a field. All 17 occupants were rescued, among them a passenger was slightly injured. The aircraft was damaged beyond repair.

Crash of a GAF Nomad N.24A in Weston-on-the-Green

Date & Time: Apr 13, 2002 at 0830 LT
Type of aircraft:
Registration:
OY-JRW
Flight Phase:
Survivors:
Yes
Schedule:
Weston-on-the-Green - Weston-on-the-Green
MSN:
117
YOM:
1981
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
581
Captain / Total hours on type:
51.00
Circumstances:
A series of parachute flights had been planned from Weston-on-the-Green. The forecast conditions were good, predicting a surface wind of 360°/10 kt, visibility 30 km, with no significant weather and some strato-cumulus cloud with a base of 3,000 feet. The first flight, which consumed 144 lb of fuel, was completed successfully with 12 parachutists jumping from 12,000 feet. Thirteen parachutists boarded for the second flight and the aircraft was cleared to take off from the dry surface of grass Runway 01 (take off run available 3,194 feet). The surface wind at the time was 360°/15 kt with no significant weather and the temperature was 15°C. The pilot subsequently reported that he checked the condition levers were set to 100% N2, the flaps were set to 10° and that the trim was set in the take off range. He also reported that the company recommended power of 738°C turbine outlet temperature (TOT), and 89 pounds per square inch (psi) manifold pressure were set and achieved during the take off run. This power setting was equivalent to the 'Max Cruise Rating' as specified in the 'Operating Limits' section of the aircraft manual and no take off performance charts or data concerning 'take off distance required' (TODR) and 'accelerate stop distance required' (ASDR) information was available. The maximum take off power available (5 minute limit) was 810°C TOT and 102 psi. At approximately 80 to 83 kt (scheduled rotation speed 71 kt) the pilot pulled back on the control column. He reported that, 'the aircraft felt more nose heavy', 'the aircraft nose did not rise and he perceived that the aircraft was no longer accelerating'. He decided to abort the take off, commenced braking and set the condition levers to the full reverse position. As the aircraft decelerated he turned it to the right in order to avoid trees and bushes ahead. The aircraft struck a small earth mound, whilst still travelling at about 15-20 kt, and came to an abrupt halt. The pilot shut down both engines and selected the fuel and the battery to OFF. The crew and passengers evacuated the aircraft unaided.
Probable cause:
The pilot had successfully completed a similar flight in the same aircraft, in benign meteorological conditions and the available evidence suggests that the aircraft was serviceable. He reported that during the second take off run 'the company recommended take off power of 738°C TOT and 89 psi was set and achieved'. The take off was therefore attempted with only 89 -90% of the maximum power available. This would have had the effect of not only increasing the take off distance but also the 'ASDR' to achieve a successful rejected take off from a speed at or beyond normal rotate speed. With the flap position and trim set correctly for take off the pilot attempted to rotate the aircraft between 80 to 83 kt, at least 9 kt above the scheduled rotation speed of 71 kt. If the aircraft loading had been within the limits of mass and CG prompt rotation of the aircraft should have occurred. This however did not happen and instead the pilot felt the aircraft to be 'more nose heavy than normal'. The exact mass and CG for this flight are uncertain. If the CG position was at the forward limit for the calculated mass, control column forces would have been high but not sufficiently high to prevent a successful takeoff. Extreme forces would only have been encountered if the aircraft CG position was significantly in error. It is therefore considered that for the second takeoff of the day the aircraft CG was significantly forward of the forward CG limit.
Final Report:

Crash of a Piper PA-31T Cheyenne I in Brescia

Date & Time: Apr 12, 2002
Type of aircraft:
Operator:
Registration:
I-SASA
Flight Phase:
Survivors:
Yes
MSN:
31-8004021
YOM:
1980
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed upon takeoff for unknown reasons. There were no casualties.

Crash of a Beechcraft E18S in Juneau: 1 killed

Date & Time: Apr 10, 2002 at 1625 LT
Type of aircraft:
Operator:
Registration:
N686Q
Flight Phase:
Flight Type:
Survivors:
No
MSN:
BA-400
YOM:
1959
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
22820
Circumstances:
The certificated airline transport pilot was departing on a 14 CFR Part 91 personal flight. The purpose of the flight was to deliver a load of wooden roofing shakes to a friend's remote lodge. Witnesses reported that just after takeoff, as the airplane climbed to about 200 to 300 feet above the ground, the airplane abruptly pitched up about 70 degrees, and drifted to the right. The airplane continued to turn to the right as the nose of the airplane lowered momentarily. As the airplane flew very slowly the landing gear was extended. The nose of the airplane pitched up again, the right wing dropped, and the airplane descended. One witness described the descent as: "The wings rocked back and forth as it descended, like a card in the wind, with the nose of the airplane slightly higher." The airplane impacted shallow water in an area of tidal mud flats. A postaccident investigation revealed that the estimated gross weight of the airplane at takeoff was 11,500.8 pounds, 1,400.8 pounds in excess of the airplane's maximum takeoff gross weight. The airplane's center of gravity could not be calculated due to the fact that the exact location/station of the cargo could not be determined. Examination of the airplane revealed no evidence of any preimpact mechanical anomalies.
Probable cause:
The pilot's excessive loading of the airplane that precipitated an inadvertent stall/mush during the initial climb.
Final Report:

Crash of a Cessna 425 Conquest I in San Jose: 3 killed

Date & Time: Mar 6, 2002 at 1035 LT
Type of aircraft:
Operator:
Registration:
N444JV
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
San Jose - La Paz
MSN:
425-0013
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4987
Aircraft flight hours:
4315
Circumstances:
The aircraft was on an IFR clearance and climbing through a cloud layer when it broke up in flight following an in-flight upset. The weather conditions included multiple cloud layers from 4,000 to 13,000 feet, with a freezing level around 7,000 feet msl. An AIRMET was in effect for occasional moderate rime to mixed icing-in-clouds and in-precipitation below 18,000 feet. As the airplane began to intercept a victor airway, climbing at about 2,000 feet per minute (fpm), and passing through 6,700 feet, the airplane began a series of heading and altitude changes that were not consistent with its ATC clearances. The airplane turned right and climbed to 8,600 feet, then turned left and descended to 8,000 feet. The airplane then turned right and climbed to 8,500 feet, where it began a rapidly descending right turn. At 1034:33, as the aircraft was descending through 7,000 feet, the pilot advised ATC "four Juliet victor I just lost my needle give me..." No further transmissions were received from the accident airplane and the last radar return showed it descending through 3,200 feet at about 11,000 fpm. Analysis of radar data shows the airplane was close to Vmo at the last Mode C return. Ground witnesses saw the airplane come out of the clouds in a high speed spiral descent just before it broke up about 1,000 feet agl. Examination of the wreckage showed that all structural failures were the result of overload. The aircraft was equipped with full flight instruments on both the left and right sides of the cockpit; however, the flight director system attitude director indicator and horizontal situation indicator were only on the left side. The aircraft was also equipped for flight into known icing conditions, with in part, heated pitot tubes (left and right sides), static sources, and stall warning vanes. During the on-scene cockpit examination, except for the pitot heat switches, the cockpit controls and switches were found to be configured in positions consistent with the aircraft's phase of flight prior to the in-flight upset. The right pitot heat switch was found in the ON position, while the left switch was in the OFF position. The left pitot heat switch toggle lever was noticeably displaced to the left by impact with an object in the cockpit. With the exception of the left pitot heat, the anti-ice and deice system switches were all configured for flight in icing conditions. The pitot heat switches, noted to be of the circuit breaker type (functions as both a toggle switch and circuit breaker), were removed from the panel and sent to a laboratory for examination and testing. Low power stereoscopic examination of the switches found that the right switch was intact, while the toggle lever mechanism of the left switch was broken loose from the housing. Microscopic examination of the left switches housing fracture surface revealed imbedded debris and wear marks indicative of an old fracture predating the accident. The broken left switch could be electrically switched by physically holding the toggle lever mechanism in the appropriate ON or OFF position. The electrical contact resistance measurements of the left switch varied between 0.3 and 1.4 ohms, and was noted to be intermittently open with the switch in the ON position. Both switches were then disassembled. While particulate debris was found in both switches, the left one had a significant amount of large coarse fibrous lint-like debris. The flexible copper conductor of the left switches circuit breaker section had several broken strands, and the electrical contacts were dirty. The laboratory report concluded that the left switches toggle was bent to the left in the impact sequence; however, the housing fracture predated the accident and allowed an internal build-up of large coarse fibrous lint-like debris. The combined effects of the broken housing, the resulting misalignment of the toggle mechanism, the dirty contacts, and the large coarse lint debris prevented reliable electrical switching of the device and presented the opportunity for intermittently open electrical contacts. Continuity of the plumbing from the pitot tubes and static ports to their respective instruments was verified. Electrical continuity was established from the bus power sources through the circuit breakers and switches to the heating elements of the pitot tubes and static sources. The heating elements were connected to a 12-volt battery and the operation of the heating elements verified.
Probable cause:
The pilot's loss of control and resulting exceedance of the design stress limits of the aircraft, which led to an in-flight structural failure. The pilot's loss of control was due in part to the loss of primary airspeed reference resulting from pitot tube icing, which was caused by the internal failure of the pitot heat switch. Factors in the accident were the pilot's distraction caused by the airspeed reading anomaly and spatial disorientation.
Final Report:

Crash of a Beechcraft 60 Duke in Mexia: 1 killed

Date & Time: Mar 3, 2002 at 1350 LT
Type of aircraft:
Registration:
N7272D
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mexia - DuPage
MSN:
P-124
YOM:
1970
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
25600
Aircraft flight hours:
4363
Circumstances:
The pilot arrived at Mexia-Limestone County Airport (TX06), Mexia, Texas, sometime before 1100. Once onboard the airplane, a witness, and an acquaintance of the pilot, closed and locked the airplane's cabin door for the pilot, and walked away from the airplane. He also reported that after the engines to the airplane were started, the airplane stayed on the ramp and idled for 10 to 15 minutes. No one saw the pilot taxi to the runway, but he taxied to the north end of Runway 18 for a downwind takeoff to the south. Examination of the accident site found the wreckage oriented along a path consistent with an extended centerline of runway 18. The airplane was found along a fence line approximately 1/4 mile from the departure end of Runway 18. The airplane's track was along a 183-degree bearing, and there was a large burn area prior to and around the debris zone along the wreckage path. Examination of the cockpit revealed a 9/16-inch hex-head bolt inserted in the control lock pinhole for the control column. Under normal procedures Cockpit Check in the Duke 60 Airplane Flight Manual, for Preflight Inspection the first item listed is: 1. "Control Locks - REMOVE and STOW". In addition, under normal procedures Before Starting checklist in the Duke 60 Airplane Flight Manual, the fourth item to check is listed as: 4. "Flight Controls - FREEDOM OF MOVEMENT and PROPER RESPONSE"
Probable cause:
The pilot's failure to remove the control lock before the flight and his failure to follow the checklist.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Libourne: 3 killed

Date & Time: Feb 19, 2002 at 1815 LT
Operator:
Registration:
F-GHUY
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Libourne – Toussus-le-Noble
MSN:
421B-0417
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:
1761
Copilot / Total flying hours:
552
Circumstances:
After takeoff from runway 22 at Libourne-Les Artigues-de-Lussac Airport, while initial climb, the twin engine aircraft made a first slight turn to the right then a turn to the left in a strong left bank configuration. It went out of control and crashed in a wooded area located 2 km from the runway end, bursting into flames. All three occupants were killed.
Probable cause:
The accident was due to the loss of control of the aircraft during the initial climb phase, which may be linked to a power asymmetry between the two engines. He was not possible to determine the origin of this asymmetry, nor its effective contribution to the accident.
Final Report:

Crash of a Canadair CL-44D4-2 in Mbuji-Mayi

Date & Time: Feb 17, 2002
Type of aircraft:
Registration:
9Q-CTS
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Mbuji-Mayi – Kinshasa
MSN:
25
YOM:
1961
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Mbuji-Mayi Airport, while climbing, the engine n°1 caught fire. The flight engineer elected to extinguish the fire but without success. The aircraft lost height then rolled to the left to an angle of 85°. The crew extended the flaps to 45° to maintain a rate of descent of 700 feet per minute but due to an asymmetric flap condition, the rate of descent increased to 1,500 feet per minute. After the aircraft rolled to the left to an angle of 110°, at a speed of 98 knots, the captain attempted an emergency landing when the aircraft crash landed in a prairie. All 23 occupants were injured and the aircraft was destroyed.

Crash of a Harbin Yunsunji Y-12 II in Sam Neua

Date & Time: Feb 14, 2002 at 1200 LT
Type of aircraft:
Operator:
Registration:
RDPL-34118
Flight Phase:
Survivors:
Yes
Schedule:
Sam Neua - Vientiane
MSN:
0043
YOM:
1991
Flight number:
QV702
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Just after liftoff, while climbing to a height of about two metres, the twin engine aircraft encountered downdraft. It struck the runway surface, went out of control and veered off runway. It then collided with a fence and came to rest on a road located 17 metres below. All 15 occupants evacuated safely while the aircraft was damaged beyond repair. At the time of the accident, the wind was blowing at 8 knots but apparently changed rapidly and became stronger shortly after rotation.