Crash of a Cessna 340A in Santa Monica: 2 killed

Date & Time: Nov 13, 2001 at 1836 LT
Type of aircraft:
Registration:
N2RR
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Santa Monica – Van Nuys
MSN:
340A-0643
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6200
Aircraft flight hours:
1036
Circumstances:
During an aborted nighttime takeoff, the airplane continued off the end of the 4,987-foot-long runway, vaulted an embankment, and impacted a guardrail on an airport service road 30 feet below. According to the manufacturer's pilot operating handbook, the takeoff distance required for the ambient conditions was 1,620 feet and the accelerate-stop distance was 2,945 feet. Several witnesses reported observing the airplane traveling along the runway at an unusually high speed, with normal engine sound, and without becoming airborne; followed by an abrupt reduction in engine power and the sound of screeching tires. Skid marks were present on the last 1,000 feet of the runway. In the wreckage, the gust lock/control lock was found engaged in the pilot's control column.
Probable cause:
The pilot's failure to remove the control gust lock prior to takeoff and his failure to abort the takeoff with sufficient runway remaining to stop the airplane on the runway.
Final Report:

Crash of an Airbus A300-600 in New York: 265 killed

Date & Time: Nov 12, 2001 at 0916 LT
Type of aircraft:
Operator:
Registration:
N14053
Flight Phase:
Survivors:
No
Site:
Schedule:
New York - Santo Domingo
MSN:
420
YOM:
1988
Flight number:
AA587
Crew on board:
9
Crew fatalities:
Pax on board:
251
Pax fatalities:
Other fatalities:
Total fatalities:
265
Captain / Total flying hours:
8050
Captain / Total hours on type:
1723.00
Copilot / Total flying hours:
4403
Copilot / Total hours on type:
1835
Aircraft flight hours:
37550
Aircraft flight cycles:
14934
Circumstances:
On November 12, 2001, about 0916:15 eastern standard time, American Airlines flight 587, an Airbus Industrie A300-605R, N14053, crashed into a residential area of Belle Harbor, New York, shortly after takeoff from John F. Kennedy International Airport, Jamaica, New York. Flight 587 was a regularly scheduled passenger flight to Las Americas International Airport, Santo Domingo, Dominican Republic, with 2 flight crewmembers, 7 flight attendants, and 251 passengers aboard the airplane. The airplane's vertical stabilizer and rudder separated in flight and were found in Jamaica Bay, about 1 mile north of the main wreckage site. The airplane's engines subsequently separated in flight and were found several blocks north and east of the main wreckage site. All 260 people aboard the airplane and 5 people on the ground were killed, and the airplane was destroyed by impact forces and a post crash fire. Flight 587 was operating under the provisions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.
Probable cause:
The in-flight separation of the vertical stabilizer as a result of the loads beyond ultimate design that were created by the first officer's unnecessary and excessive rudder pedal inputs. Contributing to these rudder pedal inputs were characteristics of the Airbus A300-600 rudder system design and elements of the American Airlines Advanced Aircraft Maneuvering Program.
Final Report:

Crash of a Cessna F406 Caravan II in Johannesburg: 3 killed

Date & Time: Nov 2, 2001 at 0320 LT
Type of aircraft:
Registration:
ZS-OIG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Johannesburg - Windhoek
MSN:
406-0041
YOM:
1989
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1956
Captain / Total hours on type:
1001.00
Circumstances:
The aircraft departed Johannesburg International Airport at 0119Z on an international cargo flight to Eros, an aerodrome located on the outskirts of Windhoek the capital of Namibia. There were two pilots and a passenger onboard the aircraft as well a substantial amount of cargo, consisting mainly of express freight parcels and two heavy steel bars approximately 3 metres in length each. The aircraft crashed approximately 106 seconds after commencing its take-off roll, impacting the ground in a left wing low attitude approximately 700 metres South of the threshold of runway 03R at Johannesburg International Airport in a marshy area. All three occupants onboard were fatally injured and the aircraft was destroyed.
Probable cause:
The accident resulted due to a loss of control (aircraft becoming uncontrollable in the pitch and roll axis), which occurred approximately 35 to 40 seconds after lift-off/rotation. It was induced and aggravated by a 16% overload condition as well as the exceedance of the certified aft CG limitation of the aircraft. The investigation revealed that the aircraft was overloaded by approximately 16% 699.6kg). The cargo was not secured, nor was there a seat or a restraining device in the aircraft for the passenger that was onboard the ill-fated flight. The last Mandatory Periodic Inspection prior to the accident was certified on 30 May 2001 at 4 353.1 airframe hours, by AMO No. 273. Since the inspection was certified a further 96.6 hours were flown. The Certificate of Airworthiness for the aircraft was invalid at the time of the accident, as both engines have exceeded their TBO (time between overhaul) by approximately 185 hours.
Final Report:

Crash of a Yakovlev Yak-40 in Osh

Date & Time: Oct 21, 2001
Type of aircraft:
Operator:
Registration:
EX-87470
Flight Phase:
Survivors:
Yes
Schedule:
Osh – Bishkek
MSN:
9441537
YOM:
1974
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Osh Airport, the captain decided to abort for unknown reasons. Unable to stop within the remaining distance, the aircraft verran and came to rest in a ravine. All 36 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a Cessna 208 Caravan I in Dillingham: 10 killed

Date & Time: Oct 10, 2001 at 0926 LT
Type of aircraft:
Operator:
Registration:
N9530F
Flight Phase:
Survivors:
No
Schedule:
Dillingham – King Salmon
MSN:
208-0088
YOM:
1986
Flight number:
KS350
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
3100
Captain / Total hours on type:
869.00
Aircraft flight hours:
10080
Circumstances:
The airplane was parked outside on the ramp the night before the accident and was subjected to rain, snow, and temperatures that dropped below 32 degrees F. Other pilots whose airplanes were also parked outside overnight stated that about 1/4 to 1/2 inch of snow/frost covered a layer of ice on their airplanes the morning of the accident. Because of these conditions, ramp personnel deiced the accident airplane with a heated mixture of glycol and water. The PenAir ramp supervisor who conducted the deicing stated that he believed the upper surface of the wing was clear of ice but that he did not physically touch the wing to check for the presence of ice. Investigators were unable to determine whether the accident pilot visually or physically checked the wing and tail surfaces for contamination after the accident airplane was deiced. However, the airplane's high-wing configuration would have hindered the pilot's ability to see residual clear ice on the surface of the wing after the deicing procedures. Company records indicate that the certificated commercial pilot completed his initial CE-208 flight training 2 months before the accident and had accumulated a total of 74 hours in this make and model of airplane. The airplane, with the pilot and nine passengers onboard, crashed shortly after takeoff from runway 01. A witness observed that the airplane's flight appeared to be normal until the airplane suddenly pitched up, rolled 90 degrees to the left, and yawed to the left. The airplane then descended nose-down until it disappeared from view. Data from the engine monitoring system revealed that the maximum altitude obtained during the accident flight was about 651 feet mean sea level. The airplane crashed in a level attitude. Investigators found no evidence of pre-impact failures in the structure, flight control systems, or instruments. Further, examination of the engine and propeller revealed no pre-impact failures and that the engine was running when the airplane hit the ground.
Probable cause:
An in-flight loss of control resulting from upper surface ice contamination that the pilot-in-command failed to detect during his preflight inspection of the airplane. Contributing to the accident was the lack of a preflight inspection requirement for CE-208 pilots to examine at close range the upper surface of the wing for ice contamination when ground icing conditions exist.
Final Report:

Crash of a McDonnell Douglas MD-87 in Milan: 114 killed

Date & Time: Oct 8, 2001 at 0810 LT
Type of aircraft:
Operator:
Registration:
SE-DMA
Flight Phase:
Survivors:
No
Schedule:
Milan - Copenhagen
MSN:
53009
YOM:
1991
Flight number:
SK686
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
104
Pax fatalities:
Other fatalities:
Total fatalities:
110
Captain / Total flying hours:
5842
Captain / Total hours on type:
232.00
Copilot / Total flying hours:
4355
Copilot / Total hours on type:
1978
Aircraft flight hours:
25573
Aircraft flight cycles:
16562
Circumstances:
A brand new Cessna 525A CitationJet 2, D-IEVX, arrived at Milan-Linate following a flight from Köln. The Cessna was to carry out a return flight to Paris-Le Bourget, carrying two pilots, a Cessna sales manager and a prospective customer. The plane arrived at 06:59 and was taxied to the General aviation apron, also known as 'West apron'. It was a foggy morning at Milan and one of the passenger flights parked on the North apron was SAS MD-87 "Lage Viking" which was being prepared for flight SK686 to Copenhagen, scheduled to depart at 07:35. At 07:41, the pilot of the MD-87 contacted Linate Ground Control for his engine start clearance, as the boarding of 104 passengers had been completed. The Ground controller cleared the pilot to start engines and advised that the slot time for takeoff of the flight was at 08:16. Thirteen minutes later flight 686 was cleared to taxi to runway 36R: "Scandinavian 686 taxi to the holding position Cat III, QNH 1013 and please call me back entering the main taxiway." A few minutes later, the Cessna pilot requested permission to start the engines. The ground controller then gave start-up clearance. The ground controller then requested flight 686 to contact the Tower controller. From this moment on the crew of the MD-87 and the crew of the Cessna were tuned on two different radio frequencies. At 08:05 the pilots of the Cessna received taxi clearance: "Delta Victor Xray taxi north via Romeo 5, QNH 1013, call me back at the stop bar of the ... main runway extension." The pilot acknowledged by saying: "Roger via Romeo 5 and ... 1013, and call you back before reaching main runway." The Cessna started to taxi from the General Aviation parking position, following the yellow taxi line. After reaching the position where the yellow taxi line splits into two diverging directions, the pilot erroneously took the taxi line to right and entered taxiway R6. At 08:09 the Ground controller cleared the Cessna to continue its taxi on the North apron. At the same time the Tower controller cleared the MD-87 for takeoff: "...Scandinavian 686 Linate, clear for take off 36, the wind is calm report rolling, when airborne squawk ident." The pilot advanced the throttles and acknowledged the clearance: "Clear for takeoff 36 at when...airborne squawk ident and we are rolling, Scandinavian 686." When the MD-87 was speeding down the runway, the Cessna crossed the runway holding sign and entered the active runway 18L/36R. At 08.10:21 the nose landing gear of the MD-87 had left the ground and main gears were extending the shock absorbers but the main wheels were still on the ground at an airspeed of 146 knots (270,5 km/h). At that moment the MD-87 crew probably saw a glimpse of the Cessna through the fog and reacted with additional large nose-up elevator. At that moment the MD-87 collided with the CitationJet. The right wing of the MD-87 sustained damage at the leading edge and the right hand main landing gear leg broke off. It damaged the right flap and struck the no. 2 engine which then separated from the pylon. The pilot of the MD-87 gradually advanced the throttles and then the aircraft was airborne for a total of 12 seconds, reaching an estimated height of about 35 feet (11 meters). The left hand engine suffered a noticeable thrust reduction as a result of debris ingestion, which became insufficient to sustain flight. The airspeed had increased up to 166 knots (307,6 km/h), but the MD-87 descended abruptly making contact with the runway with the left hand maingear, the truncated right hand maingear leg and the tip of the right hand wing. Prior to touch down the pilot reduced engine thrust and after ground contact the engine reverse levers were activated and deployed (on the left hand engine only). Maximum available reverse thrust was selected and the brakes applied. The plane skidded past the grass overrun area, across a service road, crashing sideways into a baggage handling building, which partly collapsed. This building was located 20 m/67 feet to the right of the runway, and 460 m/1500 feet from the runway end.
Probable cause:
After analysis of evidence available and information gathered, it can be assumed that the immediate cause for the accident has been the runway incursion in the active runway by the Cessna. The obvious consideration is that the human factor related action of the Cessna crew - during low visibility conditions - must be weighted against the scenario that allowed the course of events that led to the fatal collision; equally it can be stated that the system in place at Milano Linate airport was not geared to trap misunderstandings, let alone inadequate procedures, blatant human errors and faulty airport layout.
The following list highlights immediate and systemic causes that led to the accident:
- The visibility was low, between 50 and 100 meters;
- The traffic volume was high;
- The lack of adequate visual aids;
- The Cessna crew used the wrong taxiway and entered the runway without specific clearance;
- The failure to check the Cessna crew qualification;
- The nature of the flight might have exerted a certain pressure on the Cessna crew to commence the flight despite the prevailing weather conditions;
- The Cessna crew was not aided properly with correct publications (AIP Italy - Jeppesen), lights (red bar lights and taxiway lights), markings (in deformity with standard format and unpublished, S4) and signs (non existing, TWY R6) to enhance their situational awareness;
- Official documentation failing to report the presence of unpublished markings (S4, S5, etc) that were unknown to air traffic controllers, thus preventing the ATC controller from interpreting the unambiguous information from the Cessna crew, a position report mentioning S4;
- Operational procedures allowing high traffic volume (high number of ground movements) in weather conditions as were current the day of the accident (reduced visibility) and in the absence of technical aids;
- Radio communications were not performed using standard phraseology (read back) or were not consistently adhered to (resulting in untraced misunderstandings in relevant radio communications);
- Radio communications were performed in Italian and English language;
- Air Traffic Control (ATC) personnel did not realize that Cessna was on taxiway R6;
- The ground controller issued a taxi clearance towards Main apron although the reported position S4 did not have any meaning to him;
- Instructions, training and the prevailing environmental situation prevented the ATC personnel from having full control over the aircraft movements on ground.
Furthermore:
- The aerodrome standard did not comply with ICAO Annex 14; required markings, lights and signs did either not exist (TWY R6) or were in dismal order and were hard to recognize especially under low visibility conditions (R5-R6), other markings were unknown to operators (S4);
- No functional Safety Management System was in operation;
- The competence maintenance and requirements for recent experience for ATC personnel did not fully comply with ICAO Annex 1;
- The LVO implementation by ENAV (DOP 2/97) did not conform with the requirements provided in the corresponding and referenced ICAO DOC 4976.
The combined effect of these factors, contemporaneously present on the 8th of October 2001 at Milano Linate, have neutralized any possible error corrective action and therefore allowed the accident.
Final Report:

Crash of a Let L-410UVP-E in Guatemala City: 8 killed

Date & Time: Sep 18, 2001 at 0642 LT
Type of aircraft:
Operator:
Registration:
TG-CFE
Flight Phase:
Survivors:
Yes
Schedule:
Guatemala City – San Pedro Sula
MSN:
86 17 05
YOM:
1986
Flight number:
ATL870
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
8
Aircraft flight hours:
2467
Aircraft flight cycles:
4001
Circumstances:
After takeoff from runway 01 at Guatemala City-La Aurora Airport, while climbing to a height of 200 feet, the twin engine aircraft rolled left and right then stalled and crashed beside the runway, about 550 metres from its end. The copilot and four passengers were injured while eight other occupants including the captain were killed. The aircraft was totally destroyed.
Probable cause:
It was determined that the aircraft stalled during initial climb because the passengers seats were not properly allocated, causing the center of gravity to be outside the permissible limit. The following contributing factors were identified:
- The Atlantic Airlines company, at the date of the accident, did not have sufficiently trained administrative and operational personnel for a safe operation.
- The poor allocation of the passengers inside the cabin affected lift, causing the aircraft to stall. Due to its low height, it was impossible to expect a stall recovery. This shows that the aircraft collapsed completely without move on the ground and being destroyed by the weight of the engines and their wings that were full of fuel.
- Lack of crew training, especially the copilot who was not rated on this type of aircraft. Thus, he was not able to assist the captain in an emergency situation but only reading the checklist.
- The engines were operating normal at the time of impact and they were running in normal takeoff conditions.
- No evidence of mechanical failure was found.
- The accident shows that the aircraft was operating normally, but that due to aerodynamic circumstances, it entered a stall and crashed on the ground abruptly and uncontrollably.

Crash of a Beechcraft 1900C in Saint John's

Date & Time: Sep 14, 2001 at 2118 LT
Type of aircraft:
Operator:
Registration:
C-GSKC
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
UB-27
YOM:
1984
Flight number:
SLQ621
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On take off from runway 11 at St. John's, the crew felt the nose of the aircraft rise to a high-pitch attitude. The aircraft climbed to about 150 to 200 feet, and was about to enter cloud when the crew reduced power. The crew lowered the nose, and force-landed the aircraft on the runway. The main gear, wings, engines and fuselage sustained substantial structural damage. Weather conditions at the time of the crash were reported as: winds 090° at 25 knots gusting to 35 knots, horizontal visibility 1/2 statute mile in light rain and fog, vertical visibility 100 feet, temperature 15° Celsius, dew point 15° Celsius, altimeter 29.31 Hg., pressure dropping.

Crash of a Beechcraft UC-45-J Expeditor in Swan Lake: 3 killed

Date & Time: Sep 13, 2001 at 1735 LT
Type of aircraft:
Operator:
Registration:
N45N
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Swan Lake – Mayo
MSN:
5715
YOM:
1943
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
700
Captain / Total hours on type:
200.00
Circumstances:
The privately owned and operated Beech UC45-J was flying out of an outfitter's camp located near Swan Lake, Yukon Territory. The aircraft departed the clay-and-gravel strip for Mayo with one pilot, two passengers, luggage, and a reported load of 800 pounds of moose and caribou meat. The aircraft accelerated down the runway in a normal fashion, with the tail becoming airborne first. The aircraft left the surface of the runway and began a steep climb, followed by a yaw and bank to the left. The aircraft entered the Pleasant Creek valley off the end of the runway in a near-vertical, nose-down attitude. An explosion occurred, followed by a plume of smoke. Two persons immediately attempted to rescue the pilot and the passengers but discovered the aircraft partly submerged in the creek and engulfed in flames from the post-crash fire. There were no survivors.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The meat was loaded into the aircraft on a slippery surface and not adequately secured.
2. The manner in which the meat was loaded and secured most likely allowed the load to shift to the rear of the cabin during take-off. This rearward shift resulted in the loss of pitch control and an aerodynamic stall from which the pilot could not recover.
Other Findings:
1. The aircraft's C of G was most likely at or aft of the aft limit before engine start.
Final Report:

Crash of a Let L-410UVP-E in Chichén Itzá: 19 killed

Date & Time: Sep 12, 2001 at 1620 LT
Type of aircraft:
Operator:
Registration:
XA-ACM
Flight Phase:
Survivors:
No
Schedule:
Chichén Itzá – Cozumel
MSN:
89 24 01
YOM:
1989
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
19
Captain / Total flying hours:
7100
Copilot / Total flying hours:
1000
Aircraft flight hours:
1903
Aircraft flight cycles:
3654
Circumstances:
Shortly after takeoff from Chichén Itzá Airport runway 28, while climbing to a height of about 500 feet, the aircraft rolled to the right, stalled and crashed in a wooded area located about one km past the runway end, bursting into flames. The aircraft was totally destroyed by a post crash fire and all 19 occupants were killed, among them US and Canadian citizens and three Mexican, both pilots and a local tourist guide.
Probable cause:
It was determined that the aircraft rolled through 2,100 of the 2,800 metres of runway 28 and that the right engine failed while its propeller autofeathered. Investigations were unable to determine the exact cause of the right engine failure. Nevertheless, appropriate flight techniques were not applied by the crew.