Crash of a Short 360-300 off Edinburgh: 2 killed

Date & Time: Feb 27, 2001 at 1731 LT
Type of aircraft:
Operator:
Registration:
G-BNMT
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Edinburgh – Belfast
MSN:
3723
YOM:
1987
Flight number:
LOG670A
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
13569
Captain / Total hours on type:
972.00
Copilot / Total flying hours:
438
Copilot / Total hours on type:
72
Circumstances:
The aircraft landed at Edinburgh Airport, Scotland, at 00:03 and was parked there on Stand 31 in conditions including light and moderate snowfall. After preparation for a Royal Mail charter flight 670A to Belfast, start clearance was given at 15:03. At 15:12 hrs the crew advised ATC they were shutting down due to a technical problem. The crew then advised their company that a generator would not come on line. An avionics technician carried out diagnosis during which both engines were ground-run twice. No fault was found and the flight crew requested taxi clearance at 17:10. A normal take off from runway 06 was carried out followed by a reduction to climb power at 1,200 feet amsl. At 2,200 feet amsl the aircraft anti-icing systems were selected on. Three seconds later the torque on each engine reduced rapidly to zero. A MAYDAY call was made by the crew advising that they had experienced a double engine failure. The aircraft was ditched in the Firth of Forth estuary some 100 meters from the shoreline near Granton Harbour. Both pilots were killed. Weather reported just before the accident with a temperature of +2°C, dewpoint of -3°C, visibility of more then 10 km, broken clouds at 4500 feet and cover at 8000 feet.
Probable cause:
The following causal factors were identified:
1) The operator did not have an established practical procedure for flight crews to fit engine intake blanks (‘bungs’) in adverse weather conditions. This meant that the advice contained in the aircraft manufacturer’s Maintenance Manual ‘Freezing weather-precautions’ was not complied with. Furthermore intake blanks were not provided on the aircraft nor were any readily available at Edinburgh Airport.
2) A significant amount of snow almost certainly entered into the engine air intakes as a result of the aircraft being parked heading directly into strong surface winds during conditions of light to moderate snowfall overnight.
3) The flow characteristics of the engine intake system most probably allowed large volumes of snow, ice or slush to accumulate in areas where it would not have been readily visible to the crew during a normal pre-flight inspection.
4) At some stage, probably after engine ground running began, the deposits of snow, ice or slush almost certainly migrated from the plenum chambers down to the region of the intake anti-ice vanes. Conditions in the intakes prior to takeoff are considered to have caused re-freezing of the contaminant, allowing a significant proportion to remain in a state which precluded its ingestion into the engines during taxi, takeoff and initial climb.
5) Movement of the intake anti-icing vanes, acting in conjunction with the presence of snow, ice or slush in the intake systems, altered the engine intake air flow conditions and resulted in the near simultaneous flameout of both engines.
6) The standard operating procedure of selecting both intake anti-ice vane switches simultaneously, rather than sequentially with a time interval, eliminated a valuable means of protection against a simultaneous double engine flameout.
Final Report:

Crash of an Embraer EMB-820C Navajo in Varginha

Date & Time: Feb 22, 2001 at 1935 LT
Operator:
Registration:
PT-LFP
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Varginha – Belo Horizonte
MSN:
820-038
YOM:
1977
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1959
Captain / Total hours on type:
213.00
Copilot / Total flying hours:
658
Copilot / Total hours on type:
276
Circumstances:
The twin engine aircraft departed Varginha-Major-Brigadeiro Trompowsky Airport on a mail flight to Belo Horizonte-Pampulha Airport with two pilots on board. After takeoff, while in initial climb, the right engine lost power. The aircraft lost height and crash landed in an open field. It slid for about 100 metres before coming to rest, bursting into flames. Both pilots escaped with minor injuries and the aircraft was destroyed by fire.
Probable cause:
Loss of power on the right engine for undetermined reasons. The following findings were identified:
- Poor flight preparation on part of the crew,
- The crew did not know the exact weight of the mail/cargo,
- The crew did not have sufficient training/instruction regarding a possible loss of engine power at takeoff,
- Poor engine maintenance as the right engine had experienced power issues in the past that had not been resolved,
- Poor crew coordination,
- When the loss of power occurred on the right engine, the captain asked the copilot to raise the landing gear and preferred to resolve the emergency situation alone,
- Poor evaluation of the aircraft performances on part of the crew in regard of the weight and balance values and CofG.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Mac Gillivray: 1 killed

Date & Time: Feb 20, 2001 at 1900 LT
Registration:
N9176Z
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mac Gillivray – Santa Ana
MSN:
46-22059
YOM:
1989
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12000
Aircraft flight hours:
4194
Circumstances:
The accident occurred during a dark night departure from a private unlighted airstrip. The pilot had landed, assisted by the headlights of a car, on the landing strip/road about 1830. After dropping off a passenger, he departed about 1900. The departure direction was towards a sparsely populated area of rolling hills. Local area residents reported hearing a plane depart, followed by a loss of engine sound, and an impact in a grape vineyard. Examination of the wreckage revealed that the airplane impacted the ground in a nose down attitude. According to maintenance records, the last recorded annual inspection occurred 12 months and about 299.5 flight hours prior to the accident. Approximately 5 months before the accident, the FAA Certified Repair Station (CRS) that performed the maintenance on the airplane had given the pilot/owner a 15-item list of "grounding discrepancies." The discrepancies were: Cracked nose cowling; fraying seat belts; LH mag switch broken; LH window cracked; LH windshield crazed; stall warning inoperative; turbine inlet temperature inoperative; door latch safety inoperative; several hydraulic components leaking; main gear trunion pins worn; several cracks in wing lower skins; fuel leaks; loose rivets on RH flap; wing spar bolts loose; and elevator trim cable frayed. According to the CRS manager, the only item that had been repaired prior to the accident was the cracked nose cowling. However, an engine log entry indicated the TIT gage had also been replaced. Additionally, several witnesses reported that the pilot had been flying the airplane with an inoperative landing gear retract system for about 4 months. During post accident examination of the wreckage, investigators were able to verify that many of the listed discrepancies still existed; however, none of these discrepancies could be directly linked to the accident.
Probable cause:
The pilot/owner/operator's failure to maintain control of the airplane during the takeoff initial climb resulting in an in-flight collision with terrain. Contributing to the accident was the dark night light condition.
Final Report:

Crash of an Antonov AN-26 in Luena

Date & Time: Feb 19, 2001 at 1200 LT
Type of aircraft:
Operator:
Registration:
T-225
Flight Phase:
Flight Type:
Survivors:
Yes
Location:
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Luena Airport, an unexpected situation forced the crew to abandon the takeoff procedure. Unable to stop within the remaining distance, the aircraft overran and came to rest. There were no casualties but the aircraft was damaged beyond repair.

Crash of a Casa NC-212M Aviocar 200 in Pondok Cabe

Date & Time: Feb 11, 2001
Type of aircraft:
Operator:
Registration:
A-9119
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
101
YOM:
1978
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll, the twin engine aircraft deviated to the left, veered off runway and came to rest. All 14 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of an Antonov AN-70 in Omsk

Date & Time: Jan 27, 2001
Type of aircraft:
Operator:
Registration:
UR-NTK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Omsk - Yakutsk
MSN:
77 01 02
YOM:
1997
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
22
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Omsk Airport on a test flight to Yakutsk, carrying 22 passengers and a crew of 11 in order to perform a test flight in low-temperature flight conditions, as part of the Ukrainian manufacturer's certification program. During initial climb, at a height of 20 metres, the engine n°3 lost power. The crew increased power on all three other engines and continued to climb. Less than 25 seconds laters, at a height of about 60 metres, the engine n°1 failed. The captain attempted an emergency landing in a snow covered terrain located 660 metres past the runway end. The aircraft belly landed and came to rest with severe damages to the fuselage (almost broke in two at wings level) and engines. All 33 occupants were rescued, among them four were injured, two seriously.
Probable cause:
The loss of power on engine n°3 was the result of the rupture of a hydraulic line located near the rotor. This failure caused a reduction of the blades' rotation on both propellers (counter-rotating system), creating severe vibrations. The crew increased power on all three remaining engines when a technical malfunction occurred on an electric sensor coupled to the turbine of the engine n°1, causing the automatic control unit to fail and the engine n°1 to stop.

Crash of a Beechcraft F90 King Air in Nashville: 4 killed

Date & Time: Jan 24, 2001 at 1510 LT
Type of aircraft:
Registration:
N17AE
Flight Phase:
Survivors:
No
Schedule:
Nashville – Waukesha
MSN:
LA-80
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1100
Aircraft flight hours:
5480
Circumstances:
Shortly after takeoff at less than 200 feet above ground level the pilot reported an engine failure, and requested to return to the airport. The controller saw the airplane in a right turn, descending, and observed the airplane level its wings just prior to impact with the tips of trees. The airplane collided with terrain approximately 2,000 feet east of the approach end of runway 20L. A post crash fire ensued and consumed a majority of the airplane. Examination of both engines displayed contact signatures to their internal components characteristic of the engines being powered, with the propellers out of feather at the time of impact, and a low power range. Examination of the propellers found the left propeller blades showed more damage then the blades from the right propeller. Both propellers were rotating with considerable rotational energy. However, examination showed that the left propeller had more power then the right.
Probable cause:
The pilot's failure to follow loss of engine power emergency procedures by not feathering the propeller following the loss of engine power for undetermined reasons, resulting in a descent and collision with trees and the ground.
Final Report:

Crash of a Douglas DC-3C-S1C3G in Unalaska: 2 killed

Date & Time: Jan 23, 2001 at 2135 LT
Type of aircraft:
Registration:
N19454
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Unalaska - Anchorage
MSN:
25309
YOM:
1944
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
15000
Copilot / Total flying hours:
3000
Aircraft flight hours:
55877
Circumstances:
A Douglas DC-3 airplane departed an island runway during dark night, VFR conditions without filing a flight plan. The airplane collided with a volcanic mountain at 1,500 feet msl on the runway heading, 4.5 miles from the airport. Earlier in the day, the airplane arrived from Anchorage, Alaska, without a flight plan, having flown along the Alaska Peninsula when VFR flight was not recommended. The crew of the airplane initially planned to remain overnight on the peninsula, but the captain received a request to transport cargo to Anchorage. The airplane was loaded with cargo and fuel, and departed. The crew did not file a flight plan. The end of the departure runway is positioned at the edge of an ocean bay. Beyond the end of the runway, open water and rising volcanic island terrain are present. In the area of intended flight, no illumination of the terrain, or any ground based lighting was present. An obstacle departure procedure for the departure runway recommends a right turn at 2 DME from the runway heading, and then a climb to 7,000 feet. Forty-five minutes after departure, a fire was spotted on the side of a volcano cone, and an ELT signal was detected in the area. No company flight following procedures were found for the accident flight, and the airplane was not reported overdue until the following day. The day after the accident, the airplane wreckage was located on steep, snow-covered terrain. Due to high winds and blowing snow, a rescue team could not get to the accident site until three days after the crash. The captain was the president, the director of operations, and the sole corporate entity of the company. No current maintenance records, flight logs, or pilot logs were located for the company. In the past, the captain's pilot certificate was suspended for 45 days following an accident in a DC-3 airplane when he ran out of gas. Also, the captain's medical certificate had previously been considered for denial after serving 49 months in federal prison for cocaine distribution, but after review, the FAA issued the captain a first class medical. FAA medical records for the captain do not contain any record of monitoring for substance abuse. The first officer's medical had also been considered for denial after an episode of a loss of consciousness. After a lengthy review and an appeal to the NTSB, the FAA issued the first officer a second-class medical. The first officer was part of the flight crew when the captain ran out of gas, and she had two previous aviation accidents. A toxicological examination of the captain, conducted by the FAA, found cocaine and metabolites of cocaine. A toxicological examination of the first officer found two different prescription antidepressant drugs. The FAA prohibits narcotic and mood-altering drug use by pilots.
Probable cause:
The airplane flightcrew's failure to maintain adequate distance/altitude from mountainous terrain during a departure climb to cruise flight, and the captain's impairment from drugs. Factors in the accident were dark night conditions, and the first officer's impairment from drugs.
Final Report:

Crash of a Learjet 35 in Schenectady

Date & Time: Jan 4, 2001 at 1547 LT
Type of aircraft:
Registration:
N435JL
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Schenectady – New York-LaGuardia
MSN:
35-018
YOM:
1975
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2570
Captain / Total hours on type:
1065.00
Copilot / Total flying hours:
1600
Copilot / Total hours on type:
497
Aircraft flight hours:
16302
Circumstances:
The captain stated that prior to departure the flight controls were tested, with no abnormalities noted, and the takeoff trim was set to the "middle of the takeoff range," without referring to any available pitch trim charts. During the takeoff roll, the pilot attempted to rotate the airplane twice, and then aborted the takeoff halfway down the 4,840 foot long runway, because the controls "didn't feel right." The airplane traveled off the departure end of the runway and through a fence, and came to rest near a road. The pilot reported no particular malfunction with the airplane. Examination of the airplane revealed that the horizontal stabilizer was positioned at -4.6 degrees, the maximum nose down limit within the takeoff range. The horizontal stabilizer trim and elevator controls were checked, and moved freely through their full ranges of travel. According to the AFM TAKEOFF TRIM C.G. FUNCTION chart, a horizontal stabilizer trim setting of -7.2 was appropriate with the calculated C.G. of 20% MAC. Additionally, Learjet certification testing data stated that the pull force required at a trim setting of -6.0 degrees, the "middle of the takeoff range", was 33 pounds. With the trim set at the full nose down position (-1.7 degrees), 132 pounds of force was required.
Probable cause:
The pilot's improper trim setting, which resulted in a runway overrun and impact with a fence.
Final Report:

Crash of a Beechcraft B200 Super King Air in Blackbushe: 5 killed

Date & Time: Dec 23, 2000 at 1351 LT
Operator:
Registration:
VP-BBK
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Blackbush - Palma de Mallorca
MSN:
BB-1519
YOM:
1995
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
2664
Captain / Total hours on type:
1243.00
Circumstances:
The aircraft, with the pilot and four passengers on board, departed Blackbushe from Runway 08 in fog with a visibility of less than 500 metres. As the aircraft reached the upwind end of the runway it was seen to bank to the left before disappearing from view. It crashed 13 seconds later into a factory complex where a major fire ensued. All on board were fatally injured. A substantial amount of the aircraft structure was consumed by fire. Engineering examination of that which remained showed that there was no malfunction found within the engines, propellers or controls that would have affected the flight. Analysis of the cockpit voice recorder however showed a reduction in one of the propellers rpm as the aircraft rotated that would have led to thrust asymmetry. Through a combination of lack of visual reference, confusion as to the cause of the power reduction and possible disorientation the pilot lost control of the aircraft and although he may have realised the situation seconds before impact with the ground there was insufficient height available to effect a safe recovery.
Probable cause:
Whilst the CVR does not provide any comments by the pilot as to the problems he was experiencing, spectral analysis of the CVR recording indicates that a significant difference in propeller rpm occurred at rotation when the pilot would normally have removed his right hand from the power levers. There was no evidence of a malfunction in either engine or the propeller control systems thus it is probable that migration of a power lever(s) occurred due to insufficient friction being set on the power lever friction control. The fiction control had been slackened during recent maintenance and it was possible that it was not adjusted sufficiently by the pilot during his checks prior to takeoff. His simulator training had included engine failures but as far as could be established, the pilot had not encountered or been trained for the situation of power lever(s) migration during takeoff. With his level of experience the pilot should have controlled the resultant asymmetric thrust and in reasonable conditions continued the takeoff to a safe height where analysis of the problem could have been carried out. In the event the takeoff was carried out in extremely low visibility conditions leading to the pilot's total loss of any ground references within seconds of lift off. Having controlled the aircraft initially the lack of visual reference with the ground, possible confusion with attitude instrument bank angle display, physical disorientation brought about by cockpit activity and confusion as to the exact nature of the problem led the pilot to lose control of the aircraft at a low altitude. The unusual attitude developed by the aircraft and the reason for the power asymmetry may have been recognised by the pilot several seconds before impact however there was insufficient height available for him to effect a safe recovery. The transition from visual to instrument flight in the low visibility conditions existing at the time of departure was considered to be a major contributory factor in this accident.
Final Report: