Crash of an Ilyushin II-76MD in Ostend

Date & Time: Apr 18, 2001
Type of aircraft:
Operator:
Registration:
UR-78821
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Ostend - Algiers - Conakry
MSN:
00934 96914
YOM:
1989
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The four engine aircraft was engaged in a cargo flight from Ostend to Conakry with an intermediate stop in Algiers, carrying eight crew members and a load consisting of 32 tons of paint and medical supplies for the Guinean market. During the takeoff roll on runway 26 at Ostend Airport, an engine fire warning light came on in the cockpit panel. The captain decided to abandon the takeoff procedure and initiated an emergency braking maneuver. Unable to stop within the remaining distance, the aircraft overran for about 40 metres then lost its nose gear and came to rest on its left wing, damaging both left engine nacelles and the wingtip as well as the fuselage that was bent upward the cockpit area. All eight crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
No technical anomalies were found on the aircraft and the engine fire warning light came on by error.

Crash of a Cessna 208B Grand Caravan in Tembo

Date & Time: Apr 14, 2001
Type of aircraft:
Operator:
Registration:
ZS-OCZ
Flight Phase:
Survivors:
Yes
MSN:
208B-0617
YOM:
1997
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Tembo Airstrip, while in initial climb, the pilot encountered problems to gain sufficient height as the engine lost power. He attempted an emergency landing when the aircraft crash landed in an open field located about one km from the airfield, bursting into flames. All nine occupants escaped uninjured while the aircraft was destroyed by fire.

Crash of an Antonov AN-12BK in Nouadhibou

Date & Time: Apr 10, 2001
Type of aircraft:
Registration:
3C-AWU
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nouakchott – Nouadhibou – Lisbon
MSN:
8 34 58 04
YOM:
1968
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Nouadhibou Airport, while in initiale climb, one of the engine caught fire. The crew reduced his altitude and attempted an emergency landing in a beach located 6 km from the airport. The aircraft crash landed and came to rest, bursting into flames. All six occupants escaped uninjured while the aircraft was destroyed by fire.
Probable cause:
Engine fire during initial climb for unknown reasons.

Crash of a Piper PA-46-500TP Malibu Meridian in Vero Beach: 2 killed

Date & Time: Apr 9, 2001 at 1208 LT
Registration:
N262MM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Vero Beach - Daytona Beach
MSN:
46-97040
YOM:
2001
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1514
Captain / Total hours on type:
33.00
Copilot / Total flying hours:
378
Aircraft flight hours:
45
Circumstances:
Witnesses observed N262MM taxi to runway 29 left and the pilot perform what appeared to be a normal engine runup. The airplane then taxied onto runway 29 left for takeoff. The wind was from the east, making the takeoff with a tail wind. During the takeoff, the engine seemed to operate at a steady level, but appeared to be low on power. The flight lifted off about halfway down the runway and the landing gear was retracted. The airplane climbed slowly and turned slowly to the left. The airplane then entered a 60-80 degree left bank followed by the airplane rolling level and the wings rocking back and forth. The airplane was now on a southerly heading and the nose dropped. The airplane then collided with trees about 15-20 feet above the ground, fell to the ground, and burst into flames. Witnesses stated they saw no smoke or flames coming from the airplane prior to impact with the trees. At the time of the accident the landing gear was retracted and the engine was running. Transcripts of recorded communications show that at 1205:40, the local controller instructed the flight to taxi into position and hold on runway 29 left. At 1206:43, N262MM was cleared for takeoff and a north bound departure was approved. At 1208:03, the passenger transmitted "we need to land we have to turn around". The local controller cleared the flight to return to the airport when able. At 1208:20, the passenger transmitted "two mike mike we're going down we're going down", followed by "over the golf (unintelligible)". The local controller responded "copy over the golf course". No further transmissions were received from the flight. Analysis of background noise contained on the ATC recordings show that at the time the passenger on N262MM transmitted to controllers that they were ready for takeoff and when he acknowledged the takeoff clearance, the propeller was rotating at 1,261 and 1,255 respectively. When the passenger transmitted to controllers after takeoff, that they needed to land, the propeller was rotating at 1,980 rpm. When the passenger transmitted we have to turn around, shortly after the above transmission, the propeller was rotating at 2,017 rpm. When the passenger made his last transmission stating they were going down, the propeller rpm was 1,965. The maximum propeller speed at takeoff is 2,000 rpm. Additional evidence was found indicating electrical arcing and progressive fatigue cracking in the engine’s P3 line, which could result in a rapid rollback of engine power. Simulator testing showed that a P3 line failure would result in the engine decelerating from full takeoff power (2,000 propeller rpm) and stabilizing at an idle power setting in less than 9 seconds. However, the sound spectrum analysis of the first radio transmission indicated the propeller rpm was 1,980, and two subsequent radio transmissions, the last of which was made 17 seconds after the initial transmission, detected the propeller rpm at near takeoff speed. Thus, there was no evidence of dramatic rpm loss, making the P3 line failure an unlikely cause of the accident. Postcrash examination of the aircraft structure, flight controls, engine, and propeller, showed no evidence of failure or malfunction. Witnesses indicated the flight used about 3,650 feet of runway for takeoff or about half of the 7,296 foot long runway. Charts contained in the Piper PA-46-500TP, Pilot's Operating Handbook, indicated that for the conditions at the time of the accident, the airplane should have used about 2,000 feet of runway for the ground roll during the takeoff with no wing flaps extended. The charts also show that the airplane indicated stall speed at 60 degrees of bank angle with the landing gear and wing flaps retracted is 111 knots.
Probable cause:
The pilot's excessive bank angle and his failure to maintain airspeed while returning to the airport after takeoff due to an unspecified problem resulting in the airplane stalling and colliding with trees during the resultant uncontrolled descent.
Final Report:

Crash of a Douglas DC-3A-S1C3G off San Juan

Date & Time: Apr 4, 2001 at 1220 LT
Type of aircraft:
Operator:
Registration:
N19BA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
San Juan - San Juan
MSN:
4986
YOM:
1942
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8795
Captain / Total hours on type:
1200.00
Copilot / Total flying hours:
1300
Aircraft flight hours:
39832
Circumstances:
The flight crew stated that while making a missed approach after a practice instrument landing system approach, the right engine failed. The captain took control of the airplane from the copilot. The captain stated that while he performed the emergency procedures for engine failure, he noticed the left engine was not producing power. He then made a forced landing in water east of the airport. He stated that just before impact, he feathered the left propeller. The copilot stated he observed the captain activate the propeller feathering button for the left engine as he performed the emergency procedures for the right engine failure. The reason for failure of the right engine was not determined.
Probable cause:
The captain's activation of the left propeller feathering button after failure of the right engine for undetermined reasons resulting in loss of all engine power and the airplane making a forced landing in water.
Final Report:

Crash of an Antonov AN-24 in Adar Yeil: 14 killed

Date & Time: Apr 4, 2001
Type of aircraft:
Operator:
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Adar Yeil – Khartoum
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
26
Pax fatalities:
Other fatalities:
Total fatalities:
14
Circumstances:
Just after liftoff, while climbing in a sandstorm, the crew lost control of the airplane that crashed near the runway end. Sixteen people were rescued while 14 others were killed, among them 13 high ranking Army officers and Ibrahim Shamsul-Din, vice-minister of Defence.

Crash of a Cessna 501 Citation I/SP in Green Bay: 1 killed

Date & Time: Apr 2, 2001 at 1628 LT
Type of aircraft:
Registration:
N405PC
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Green Bay – Fort Myers
MSN:
501-0150
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4548
Captain / Total hours on type:
245.00
Aircraft flight hours:
5856
Circumstances:
At 1623:41, the pilot requested taxi clearance. The Green Bay (GRB) tower (ATCT) told the pilot to taxi to runway 18. At 1626:47 the pilot said that he was ready for takeoff. The ATCT local controller (LC) told the pilot, "proceed on course, cleared for takeoff". At 1627:33, radar showed the airplane began to accelerate down runway 18. At 1628:17 the LC told the pilot to contact departure control. The pilot responded, "ah papa charlie we have a little problem here we're going to have to come back." The LC asked the pilot, "what approach would you like?" The pilot responded, "like to keep the vis." At 1628:35, the LC asked the pilot, "like the contact approach that what you're saying?" There was no response from the pilot. At 1628:50, GRB radar showed the airplane on a heading of 091 degrees, at an altitude of 855 feet msl (160 feet agl), and at an airspeed of 206 knots. The airplane was 1.28 miles southeast of the airport radar. Radar contact with the airplane was lost at 1628:55. A witness to the accident said, "It was snowing moderately at that time. The road was wet but not slippery. Crossing the intersection of Morning Glory Rd. & Main St., I noted a white private jet flying from the south. It was flying at approximately a 75-80 degree angle perpendicular to the ground with its left wing down & teetering slightly." The witness said, "It then crossed Main Street with the lower wing tip approximately 20 to 30 feet above the power wires. The plane became more perpendicular to the ground at a 90 degree angle with the left wing down & (and) lost altitude crashing into the Morning Glory Dairy warehouse building." An examination of the airplane revealed no anomalies. At 1638, GRB weather was reported as ceilings of 200 feet broken, 800 feet overcast, visibility 1/2 statute mile with snow and fog, temperature 32 degrees F, dew point 32 degrees F, winds 120 degrees at 3 knots, and an altimeter setting of 29.99 inches Hg. Witnesses at the FBO said the pilot arrived to pick up the airplane after 1600. The pilot was briefed by the mechanic as he did his walk around inspection of the airplane. The pilot then
got into the airplane. The airplane was towed out and the tow bar removed. About two minutes later, the engines started. Less than five minutes after the engines started, the airplane taxied. The NTSB Audio Laboratory reviewed radio communications between ATCT and the pilot to determine from the speech evidence the pilot's level of psychological stress and workload. The examination indicated the pilot's speech characteristics were consistent with an increased stress/workload that might accompany a developing emergency. Referring to the pilot's final transmissions, "His unusually long reaction time suggests that he was distracted by competing cockpit priorities and/or was having a difficult time determining his answer, while his fast speech and microphone keying provide further evidence of an urgency to return to other cockpit activities." The report states that the pilot's statements remained rational and showed good word choice and grammar. "These factors, along with the relatively small change in fundamental frequency, suggest that the pilot did not reach an extreme level of stress."
Probable cause:
The pilot not maintaining aircraft control while maneuvering after takeoff and the pilot's inadequate preflight planning and preparation. Factors relating to the accident were the pilot's diverted attention while maneuvering after takeoff, the pilot's attempted VFR flight into instrument meteorological conditions, the pilot's visual lookout not being possible, the low ceiling, snow, and fog, the airplane's low altitude, and the building.
Final Report:

Crash of a De Havilland DHC-3 Otter in Decatur

Date & Time: Mar 31, 2001 at 1215 LT
Type of aircraft:
Registration:
N120BA
Flight Phase:
Survivors:
Yes
Schedule:
Decatur - Decatur
MSN:
115
YOM:
1956
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
33000
Captain / Total hours on type:
169.00
Aircraft flight hours:
6633
Circumstances:
The pilot and 21 jumpers were aboard the airplane for the local skydiving flight. The airplane took off to the north on the wet grass runway. Jumpers reported that during the initial takeoff climb, the aircraft assumed a "very steep angle of attack," and described the pilot "winding the wheel on the lower right side of the chair clockwise, frantically," and "busy with a wheel between the seats." The airplane impacted trees and terrain approximately 250 yards east of the runway. The pilot reported that the "airplane flew through a dust devil" and did not have enough altitude for a complete recovery. The pilot stated the winds were northerly at 6 to 8 knots with "extreme" turbulence. The nearest weather observation facility reported clear skies with calm wind. Takeoff weight and center of gravity (CG) were calculated at 9,118.05 lbs and 161.92 inches. The AFM listed the maximum gross weight at 8,000 pounds and the aft CG limit at 152.2 inches. Further, an AFM WARNING stated: C. G. POSITION OF THE LOADED AIRCRAFT MUST BE CHECKED AND VERIFIED PRIOR TO TAKE-OFF, AND APPROPRIATE TRIM SETTINGS SHOULD BE USED; OTHERWISE ABNORMAL STICK FORCES AND POSITIONS MAY RESULT. The elevator trim wheel is located on the righthand side of the pilot's seat. Post-accident examination of the airplane revealed that there were 16 seatbelts in the cabin section and 2 seatbelts in the cockpit. Additionally, a placard installed in the cockpit stated, in part, THIS AIRPLANE IS LIMITED TO THE OPERATION OF NINE PASSENGERS OR LESS. Regarding the discrepancy between the placarded 9 passenger limit and the 21 jumpers aboard, the pilot stated that parachute jumpers are not considered to be passengers and therefore, he did not have to comply with the placarded limit.
Probable cause:
The pilot's failure to maintain aircraft control during the takeoff/initial climb. Contributing factors were the pilot's exceeding aircraft weight and balance limits and the dust devil.
Final Report:

Crash of a Socata TBM-700 in Denver: 1 killed

Date & Time: Mar 26, 2001 at 0719 LT
Type of aircraft:
Registration:
N300WC
Flight Phase:
Survivors:
No
Schedule:
Denver – Santa Monica
MSN:
82
YOM:
1993
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1024
Captain / Total hours on type:
136.00
Aircraft flight hours:
5139
Circumstances:
The airplane was fueled to capacity and placed in a heated hangar about one hour before departure. The instrument rated pilot obtained a weather briefing, filed an IFR flight plan, and obtained an IFR clearance. Low ceiling, reduced visibility, and ice fog prevented control tower personnel from observing the takeoff. Radar (NTAP) and on-board GPS data indicated the airplane began drifting to the left of runway centerline almost immediately after takeoff. The airplane made a climbing left turn, achieving a maximum altitude of 7,072 feet and completing 217 degrees of turn, before beginning a descending left turn. The airplane impacted terrain on airport property. Autopsy/toxicology protocols were unremarkable. There was no evidence of preimpact failure/malfunction of the airframe, powerplant, propeller, or flight controls. The autopilot and servos, pitot-static system, and flight instruments were tested and all functioned satisfactorily. The pilot's shoulder harness was found attached to the seatbelt, but the male end of the seatbelt buckle was broken.
Probable cause:
The pilot's spatial disorientation, which led to his failure to maintain aircraft control. A contributing factor was the pilot's decision to intentionally fly into known adverse weather that consisted of low ceilings, obscuration, and ice fog.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Orléans

Date & Time: Mar 22, 2001 at 1835 LT
Operator:
Registration:
PH-ABD
Flight Phase:
Survivors:
Yes
Schedule:
Orléans - Paris
MSN:
31-7305048
YOM:
1973
Flight number:
TLP2B
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1110
Captain / Total hours on type:
688.00
Copilot / Total flying hours:
327
Copilot / Total hours on type:
50
Aircraft flight hours:
9820
Circumstances:
On 22 March 2001 at about 17h35, the PA-31-350 Chieftain registered PH-ABD, call sign Tulip 2B, began its takeoff from runway 23 at Orléans-Saint Denis de l’Hôtel for an IFR departure to Paris-Le Bourget. The flight was passenger charter flight TLP2B. The pilot flying, who was the co-pilot seated in the left seat, was unable to perform the rotation. He aborted the takeoff but braking failed to stop the aircraft before the end of the runway. The runway surface was wet. Marks were left by the tyres from one hundred metres before the end of the runway. The aircraft ran across grass soaked with water. The nose gear broke and the aircraft came to a stop about one hundred and eighty metres after the end of the runway. The crew had forgotten to remove the flight control locking device.
Probable cause:
The accident was caused by the crew’s failure to perform pre-flight actions and checks relating to unblocking and free movement of the flight controls and flight control surfaces. This failure was able to develop to the point of being the cause of the accident as a result of the absence of precise CRM procedures.
Final Report: