Crash of a Lockheed KC-130F Hercules in Twentynine Palms

Date & Time: Feb 11, 2002
Type of aircraft:
Operator:
Registration:
148895
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Twentynine Palms - Twentynine Palms
MSN:
3619
YOM:
1961
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
20960
Circumstances:
The crew departed Twentynine Palms on a local training flight. Shortly after takeoff, the engine n°1 failed. The aircraft encountered difficulties to gain height when the engine n°4 lost power. The crew attempted an emergency landing in a sandy area located about 4,5 km past the runway end. All eight crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Failure of the engine n°1 during initial climb and a loss of power on the engine n°4 for unknown reasons. As the aircraft was operated at its MTOW, the crew was unable to maintain a positive rate of climb.

Crash of a Learjet C-21A at Ellsworth AFB: 2 killed

Date & Time: Feb 2, 2002 at 1430 LT
Type of aircraft:
Operator:
Registration:
84-0097
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ellsworth AFB - Ellsworth AFB
MSN:
35-543
YOM:
1984
Flight number:
Pacer 43
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The mishap aircraft, call sign Pacer 43, was conducting pattern work operations during an off-station training mission at Ellsworth AFB, SD (RCA). Shortly before impact, the mishap crew was conducting a simulated single-engine approach to runway 31 at Ellsworth AFB. Subsequent analysis showed that there was a significantly greater amount of fuel in the left wing and left wing tip tank than the right. The gross fuel imbalance resulted from an unmonitored transfer of fuel from the right wing and right wing tip tank to the left that was initiated by the crew approximately nine and one-half minutes before impact. As the aircraft approached the point when it would normally transition to a flare, it leveled off and began a climbing turn to the west, toward the tower. It did not touch down prior to the turn, but veered left immediately during the flare, and then rolled back to wings level momentarily as it climbed. The heavier left wing, and application of power to the right engine for the go-around, caused the aircraft to roll back into a steeper left turn, stayed in a climbing left turn with the bank continuing to increase until il rolled through more than 90 degrees of bank. As the aircraft reached the highest point of the climb (approximately 450 feet), the bank angle was more than 90 degrees, and perhaps slightly inverted as the nose dropped and the aircraft began to descend. The aircraft impacted the ground in a grassy field.
Probable cause:
The crew's failure to follow flight manual procedures for fuel transfer. As a result, the mishap aircraft experienced a fuel imbalance significant enough to cause the aircraft to enter an unsafe roll to the left from which the pilot was not able to recover.

Crash of a Pilatus PC-6/B2-H2M-1 Turbo Porter in Altenrhein

Date & Time: Jan 29, 2002
Operator:
Registration:
V-615
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
635
YOM:
1967
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On takeoff, the pilot lost control of the airplane that crashed in a grassy area beside the runway. The pilot, sole on board, was uninjured and the aircraft was damaged beyond repair.

Crash of a Boeing 737-291 in Pekanbaru

Date & Time: Jan 14, 2002 at 1015 LT
Type of aircraft:
Operator:
Registration:
PK-LID
Flight Phase:
Survivors:
Yes
Schedule:
Pekanbaru - Batam
MSN:
20363
YOM:
1969
Flight number:
JT386
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
96
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17266
Copilot / Total flying hours:
3700
Copilot / Total hours on type:
2500
Aircraft flight hours:
68133
Aircraft flight cycles:
66998
Circumstances:
The flight was a second route of four routes on a first day of two days schedule flight for the crew. All crew have flight schedule on the previous day and returned to Jakarta. The first flight was from Jakarta to Pekanbaru with departure schedule on 08.00 LT (01.00 UTC). All crew did the pre-flight check completely but did not check the audio warning and departed Jakarta on schedule. The flight was normal and landed in Pekanbaru on schedule. There was no problem reported. Transit in Pekanbaru for about 30 minutes and the flight was ready to continue the next flight to Batam. At 10.15 LT (03.05) the boarding process has been completed and all flight documents have ready. First Officer asked for start clearance and received weather information in Syarif Kasim Airport. The weather was fine, wind calm and clear. After start completed, the aircraft taxi to the beginning of runway 18. Flight crews have set the V1, VR, V2 and V2+15 speed bugs according to the load sheet. Take off power decide to use “reduced take off power” with assumed temperature 35o C while the actual temperature was 27° C. flight Attendant have completed the passenger briefing includes rearrange seat for the seats near the “over wing exit windows”. The checklist was done, but flight crews were not sure the indication of flap setting. When ready for take off, flight crew gave a warning to the flight attendants to take their seats. First Officer acted as “Pilot Flying”. PIC opened the power and adjusted to the required take off power setting. The aircraft rolled normal and there was no abnormal indication. PIC called “V1” and “ROTATE” at speed bugs value setting, and the First Officer rotated the control column and set to 150 ANU (Aircraft Nose Up) pitch. The aircraft’s nose was lifted up but the aircraft did not airborne. Flight attendant who was sitting at the rear felt that the nose was higher than normal. Officer also felt stick shaker, warning for approaching stall. First Officer suddenly noticed a warning light illuminated and cross-checked. He found than the warning came from the problem on the air conditioning system. Both pilots also felt pain in the ear. Recognizing this situation, PIC decided to continue the take off and called to the First Officer “disregard”. Realized that the aircraft did not airborne PIC added the power by moving power levers forward. The speed was increasing and passed the speed bug setting for V2+15 ( ± 158 KIAS) but the aircraft did not get airborne. PIC noticed that the runway end getting closer and he thought that the aircraft would not airborne, he decided to abort the take off and called “STOP”. PIC retarded the power levers to idle and set to reverse thrust, extended the speed brake and applied brake. Nose of the aircraft went down hard and made the front left door (L1) opened and 2 trolleys at front galley move forward and blocked the cockpit door. Flight crew turns the aircraft slightly to the right to avoid approach lights ahead. The aircraft moved out or the runway to the right side of the approach lights. After hit some trees the aircraft stopped at ± 275 meters from the end of runway on heading 285°. One passenger had serious injury and the rest had minor injury, all crew were safe and not injured. No one killed in this accident, while the aircraft considered total loss.
Probable cause:
Findings:
1. The flight crews have proper qualification to fly the aircraft.
2. The aircraft did not exceed its Maximum Take-Off Weight limitation specified in the AOM.
3. Cockpit area microphone did not function at the time of the accident. Therefore, the only sounds/conversations recorded were only when there were radio transmissions.
4. FDR data show that the engines operated normally.
5. FDR data show similar trajectory with an aircraft of the type and loading condition tried to take-off with zero flap.
6. The aircraft flap system was found to function normally. Therefore, should the flap selector moved to non-zero position, the flap should move to the selected position.
7. The crew did not perform Before Take-off Checklist as stated in the Boeing 737-200 Pilot’s Handbook, Chapter Normal Operating Procedures.
8. The aural warning system, except its circuit breaker, function normally. Therefore, the cause of the absence of take-off warning is the wear out latch on the CB that caused it to open.
9. The food trolley safety lock and food trolley safety strap on the front galley did not function properly that the trolley loose upon impact and blocking the cockpit door.
10. The escape slides fail to deploy. All the slides have no expiration date or marked last inspection date-as regulated in CASR 121.309.
11. Shear pins on the engines mounting function properly to separate the engine from the wing and therefore minimize the risk of fire in the accident.
Final Remarks:
Since there is no indication that flaps system failure or flap asymmetry contributes in the failure of flap to travel to take-off configuration, the most probable cause for the failure is the improper execution of take-off checklist. Failure of the maintenance to identify the real problem on the aural warning CB, causes the CB to open during the accident and therefore is a contributing factor to the accident.
Final Report:

Crash of a Canadair CL-604 Challenger in Birmingham: 5 killed

Date & Time: Jan 4, 2002 at 1207 LT
Type of aircraft:
Operator:
Registration:
N90AG
Flight Phase:
Survivors:
No
Schedule:
Birmingham - Bangor - Duluth
MSN:
5414
YOM:
1999
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
10000
Captain / Total hours on type:
800.00
Copilot / Total flying hours:
20000
Copilot / Total hours on type:
800
Aircraft flight hours:
1594
Aircraft flight cycles:
797
Circumstances:
Following ATC clearance, engine start was at 1156 hrs and N90AG was cleared to taxi at 1201 hrs. All radio calls during the accident flight were made by the commander, seated in the right cockpit seat. During taxi, the crew completed their normal Before Takeoff Checks; these included confirmation that the control checks had been completed and that anti-ice might be required immediately after takeoff. Flap 20 had been selected for takeoff and the following speeds had been calculated and briefed by the pilots: V1 137 kt; VR 140 kt; V2 147 kt. By 1206 hrs, the aircraft was cleared to line up on Runway 15. At 1207 hrs, N90AG was cleared for takeoff with a surface wind of 140°/8 kt. The pilot in the left seat was handling the controls. Takeoff appeared normal up to lift-off. Rotation was started at about 146 kt with the elevator position being increased to 8°, in the aircraft nose up sense, resulting in an initial pitch rate of around 4°/second. Lift-off occurred 2 seconds later, at about 153 kt and with a pitch attitude of about 8° nose-up. Once airborne, the elevator position was reduced to 3° aircraft nose-up whilst the pitch rate increased to about 5°/second. Immediately after lift-off, the aircraft started to bank to the left. The rate of bank increased rapidly and 2 seconds after lift-off the bank angle had reached 50°. At that point, the aircraft heading had diverged about 10° to the left. Opposite aileron, followed closely by right rudder, was applied as the aircraft started banking; full right aileron and full right rudder had been applied within 1 second and were maintained until the end of the recording. As the bank angle continued to increase, progressively more aircraft nose-up elevator was applied. Stick-shaker operation initiated 3.5 seconds after lift-off and the recorders ceased 2 seconds later. The aircraft struck the ground, inverted, adjacent to the runway. The last recorded aircraft attitude was approximately 111° left bank and 13° nose-down pitch; the final recorded heading was about 114° (M). The aircraft was destroyed by impact forces and a post crash fire and all five occupants were killed, among them John Shumejda, President of the Massey-Ferguson Group and Ed Swingle, Vice President. The aircraft was leased by AGCO Massey-Ferguson.
Probable cause:
Causal factors:
1. The crew did not ensure that N90AG’s wings were clear of frost prior to takeoff.
2. Reduction of the wing stall angle of attack, due to the surface roughness associated with frost contamination, to below that at which the stall protection system was effective.
3. Possible impairment of crew performance by the combined effects of a non-prescription drug, jet-lag and fatigue.
Final Report:

Crash of a Britten-Norman BN-2B-26 Islander in Bremerhaven: 8 killed

Date & Time: Dec 26, 2001 at 1013 LT
Type of aircraft:
Registration:
D-IAAI
Flight Phase:
Survivors:
Yes
Schedule:
Bremerhaven - Wangerooge
MSN:
2167
YOM:
1985
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
The departure from Bremerhaven to the Wangerooge Island was delayed for 30 minutes due to snow showers over the airport. Prior to departure, the pilot manually removed snow from the windshield, leading edge and wings. After takeoff from runway 34, the twin engine aircraft climbed slowly to a height of about 195 feet then stalled and crashed in the Weser River. The crew of a ferry was quickly on the scene to rescue a passenger while eight other occupants were killed.
Probable cause:
It was determined that the snow over the wings was not properly removed prior to takeoff, causing a loss of lift and disturbing the airflow. There were no defined procedures about deicing in the Standard Operating Procedures (SOP) manual of the operator.

Crash of a Cessna 560 Citation V in Zurich: 2 killed

Date & Time: Dec 20, 2001 at 2206 LT
Type of aircraft:
Operator:
Registration:
HB-VLV
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Zurich - Bern
MSN:
560-0077
YOM:
1990
Flight number:
EAB220
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4761
Captain / Total hours on type:
250.00
Copilot / Total flying hours:
1110
Copilot / Total hours on type:
401
Aircraft flight hours:
3559
Aircraft flight cycles:
3528
Circumstances:
At 19:43:49 UTC the crew of EAB 220 called clearance delivery (CLD) for the first time and asked if their flight plan to Bern-Belp was available. The answer was in the affirmative and the CLD air traffic controller informed the crew that they would need authorisation for the landing in Bern-Belp. Once it had been clarified that this authorisation had been obtained, EAB 220 called back a little later. CLD informed the pilots that their departure was planned from runway 34. However, they would have to expect a delay at that time, as arrivals and departures were being handled in batches. EAB 220 was scheduled in the next batch for take-off. CLD intimated to the crew an approximate departure time of 20:30 UTC. When the crew called back at 20:13:49 UTC to ask for any news, CLD informed them that departure would now take place in about 45 minutes. Since visual conditions were deteriorating due to the thickening fog, air traffic control had to increase the separation between arriving aircraft. As a result, flight EAB 220’s estimated departure time was delayed to about 21:00 UTC. At 20:24:38 UTC CLD transmitted to the crew a departure clearance. Flight EAB 220 was assigned the standard instrument departure (SID) “WILLISAU 3N” and transponder code 1403. In addition, a departure time of 21:07 UTC was estimated. The CEO of Eagle Air Ltd. had applied in Bern-Belp for a special authorisation for a late landing after 21:00 UTC and obtained a slot until 21:30 UTC at the latest. Since the departure of HB-VLV in Zurich was being further and further delayed, the crew found themselves under increasing time pressure. The crew were in contact with the CEO several times; at the time, the latter was performing the function of the dispatcher. In order to ensure the arrival of HB-VLV in Bern-Belp by 21:30 UTC at the latest, he also telephoned the duty manager in Zurich control tower and urged him several times for an earlier departure time. After a frequency change to apron control, the apron controller cleared EAB 220 to start its engines at 20:43:50 UTC. Approximately at the same time, an airport manager observed that HB-VLV’s right-hand engine was running, although only one pilot was present in the cockpit. He was sitting in the right-hand seat. The other crew member, probably the commander, was using a scraper to remove ice deposits from the left wing. The eye witness later observed how this crew member occupied the left-hand position in the cockpit, shortly before taxiing. Since the pilots were eager to leave their stand in the General Aviation Centre (GAC) Sector 1 as quickly as possible, they were cleared to taxi as far as the holding point for runway 28 just 2 minutes later. There they had to wait for a taxiing Saab 2000 to pass in the opposite direction. EAB 220 was then instructed by the apron controller to continue taxiing to the holding point for runway 34 via taxiways ALPHA, INNER and ECHO. One minute after taxi clearance had been given, the crew of EAB 220 again asked for the wording of this clearance: “Swiss Eagle 220, sorry for that, can you say the clearance again?” It must remain open whether HB-VLV had missed the intersection in the direction of the INNER taxiway. It is clear, however, that the apron controller had to intervene shortly afterwards with a correction: “220, continue on taxiway INNER, INNER, and then ECHO to Holding Point 34, Echo 9”. At 20:56:50 UTC flight EAB 220 made contact with Aerodrome Control (ADC) and stated that the aircraft was on Echo 9 just before the start of runway 34. The air traffic controller (ATCO) requested the crew to wait short of runway 34, since approaches were still taking place in the opposite direction on runway 16. At 21:04:51 UTC ADC cleared the aircraft to line up on runway 34. The crew taxied onto runway 34 and – after they had received take-off clearance at 21:05:54 UTC – initiated a rolling take-off by setting take-off power. At this time, meteorological visibility was 100 m with partial fog. Since the left-hand engine was run up within six seconds to 102 percent of take-off power and the right-hand engine to 58 percent, for a few seconds during the acceleration phase the aircraft veered on the runway to such an extent that it’s heading changed 10 degrees to the right. The crew were only able to bring the aircraft back into alignment with the runway by making a major nose-wheel control correction and by distinctly reducing the thrust of the left-hand engine. Afterwards the two engines were brought synchronously to take-off power and the take-off continued. Flight EAB 220 lifted off from runway 34 at 21:06:40 UTC. Shortly after take-off, the commander of EAB 220 acknowledged the request to change frequency to departure control. At about the same time various members of the airport fire-fighting services, who were inside and in front of the fire-fighting unit satellite “North” between runways 34 and 32, heard noises and saw visual indications of a low-flying aircraft. Immediately afterwards the noise of a crash and the flash of a fire were noted. At 21:07 UTC the aircraft impacted onto the frozen ground 400 m to the south-east of the end of runway 34 and skidded in a northerly direction, leaving a trail of debris. The main body of the wreck finally came to rest 500 m beyond the site of initial impact on runway 14/32. The rescue services reached the burning wreck after a few minutes. DFDR data revealed that the autopilot was disengaged during the whole flight.
Probable cause:
The accident is attributable to the fact that the crew of HB-VLV did not continue their climb after take-off. As a result the aircraft came in a descent and collided with the terrain.
The investigation determined the following causal factor for the accident:
• With a high degree of probability the crew lost spatial orientation after take-off, leading to an unintentional loss of altitude.
The following factors contributed to the accident:
• The copilot’s basic training in instrument flying did not include night instrument take-offs.
• The crew’s method of working was adversely affected by great time pressure.
• Executing the take-off as a rolling take-off was not adapted to the prevailing meteorological conditions.
• There was no system in the aircraft which triggers an alarm in the event of a loss of altitude after take-off (GPWS).
• The instrumentation on the copilot’s side of the aircraft involved in the accident was not optimal.
Final Report:

Crash of a Let L-410UVP-E near Medellín: 16 killed

Date & Time: Dec 16, 2001 at 1025 LT
Type of aircraft:
Operator:
Registration:
HK-4175X
Flight Phase:
Survivors:
No
Site:
Schedule:
Medellín – Quibdó
MSN:
86 16 18
YOM:
1986
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
16
Captain / Total flying hours:
10482
Captain / Total hours on type:
2340.00
Copilot / Total flying hours:
250
Copilot / Total hours on type:
42
Aircraft flight hours:
1863
Circumstances:
After takeoff from Medellín-Enrique Olaya Herrera Airport runway 01, the crew initiated a turn to the right and continued to climb. In poor visibility due to clouds, at an altitude of 9,200 feet, the twin engine aircraft struck the slope of Mt El Silencio near San Antonio de Prado. The aircraft was destroyed by impact forces and a post crash fire and all 16 occupants were killed. At the time of the accident, weather was poor with towering cumulus and rain falls.
Probable cause:
Controlled flight into terrain after the crew failed to comply with the departure route and the company standard operating procedures.
Final Report:

Crash of a Beechcraft C90 King Air in Toowoomba: 4 killed

Date & Time: Nov 27, 2001 at 0837 LT
Type of aircraft:
Operator:
Registration:
VH-LQH
Flight Phase:
Survivors:
No
Schedule:
Toowoomba – Goondiwindi
MSN:
LJ-644
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3693
Captain / Total hours on type:
385.00
Aircraft flight hours:
6931
Circumstances:
On 25 June 2004, the Australian Transport Safety Bureau released its final investigation report into an accident which occurred on 27 November 2001 at Toowoomba aerodrome, Qld, involving a Beech Aircraft Corporation King Air C90 aircraft, registered VH-LQH, which experienced an engine failure shortly after takeoff. The aircraft was destroyed and all four occupants sustained fatal injuries.
Probable cause:
In light of a further review of the evidence, the ATSB has reconsidered its original finding that the initiating event of the engine failure of VH-LQH was a blade release in the compressor turbine and proposes that an alternative possibility could have been that the initiating event occurred in the power turbine. Notwithstanding this possibility, in either scenario, the remainder of the findings and safety recommendations contained in the original ATSB report are still relevant.
Final Report:

Crash of a Learjet 25B in Pittsburgh: 2 killed

Date & Time: Nov 22, 2001 at 1305 LT
Type of aircraft:
Operator:
Registration:
N5UJ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Pittsburgh - Boca Raton
MSN:
25-088
YOM:
1972
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5952
Captain / Total hours on type:
3030.00
Copilot / Total flying hours:
1240
Copilot / Total hours on type:
300
Aircraft flight hours:
10004
Circumstances:
A commercial pilot, who observed the airplane during the takeoff attempt, stated that it used "lots" of runway, and that the nose lifted "too early and way too slow." The airplane "struggled" to get in the air, and it appeared tail heavy, with "extreme" pitch, about 45 degrees nose-up. It also appeared that the only thing keeping the nose up was ground effect. The airplane became airborne for "a very short time," then sank to the ground, and veered off the left side of the runway. The nose was "up" the whole time, the airplane never "rolled off on a wing," and the wings never wobbled. The engines were "really loud," like a "shriek," and engine noise was "continuous until impact." Another witness at a different location confirmed the extreme nose high takeoff attitude and the brief time the airplane was airborne. It seemed odd to him that an airplane with that much power used so much runway. A runway inspection revealed no evidence of foreign objects or aircraft debris. Tire tracks from the airplane's main landing gear veered off the left side of the paved surface, at a 20-degree angle, about 3,645 feet from the runway's approach end. They continued for about 775 feet, then turned back to parallel the runway for another 650 feet, before ending about 50 feet prior to a chain link fence. There was no evidence that the nose wheel was on the ground prior to the fence. The fence, which was about 1,300 feet along the airplane's off-runway ground track and 200 feet to the left of the runway edge stripe, was bent over in the direction of travel. Ground scars began about 150 feet beyond the fence, and the main wreckage came to rest 300 feet beyond the beginning of the ground scars. The first officer advised a witness that he'd be making the takeoff; however, the pilot at the controls during the accident sequence could not be confirmed. When asked prior to the flight if he'd be making a high-performance takeoff, the captain replied that he didn't know. There was no evidence of mechanical malfunction.
Probable cause:
The (undetermined) pilot-at-the-controls' early, and over rotation of the airplane's nose during the takeoff attempt, and his failure to maintain directional control. Also causal, was the captain's inadequate remedial action, both during the takeoff attempt and after the airplane departed the runway.
Final Report: