Crash of a Boeing 747-412 in Taipei: 83 killed

Date & Time: Oct 31, 2000 at 2318 LT
Type of aircraft:
Operator:
Registration:
9V-SPK
Flight Phase:
Survivors:
Yes
Schedule:
Singapore – Taipei – Los Angeles
MSN:
28023/1099
YOM:
1997
Flight number:
SQ006
Country:
Region:
Crew on board:
20
Crew fatalities:
Pax on board:
159
Pax fatalities:
Other fatalities:
Total fatalities:
83
Captain / Total flying hours:
11235
Captain / Total hours on type:
2017.00
Copilot / Total flying hours:
2442
Copilot / Total hours on type:
552
Aircraft flight hours:
18459
Aircraft flight cycles:
2274
Circumstances:
Singapore Airlines Flight 006 departed Singapore for a flight to Los Angeles via Taipei. Scheduled departure time at Taipei was 22:55. The flight left gate B-5 and taxied to taxiway NP, which ran parallel to runway 05L and 05R. The crew had been cleared for a runway 05L departure because runway 05R was closed because of construction work. CAA Taiwan had issued a NOTAM on Aug 31, 2000 indicating that part of runway 05R between Taxiway N4 and N5 was closed for construction between Sept. 13 to Nov. 22, 2000. Runway 05R was to have been converted and re-designated as Taxiway NC effective Nov. 1, 2000. After reaching the end of taxiway NP, SQ006 turned right into Taxiway N1 and immediately made a 180-degree turn to runway 05R. After approximately 6 second hold, SQ006 started its takeoff roll at 23:15:45. Weather conditions were very poor because of typhoon 'Xiang Sane' in the area. METAR at 23:20 included Wind 020 degrees at 36 knots gusting 56 knots, visibility - 600 meters, and heavy rainfall. On takeoff, 3.5 seconds after V1, the aircraft hit concrete barriers, excavators and other equipment on the runway. The plane crashed back onto the runway, breaking up and bursting into flames while sliding down the runway and crashing into other objects related to work being done on runway 05R. The aircraft wreckage was distributed along runway 05R beginning at about 4,080 feet from the runway threshold. The airplane broke into two main sections at about fuselage station 1560 and came to rest about 6,480 feet from the runway threshold.
Probable cause:
Findings related to probable causes:
- At the time of the accident, heavy rain and strong winds from typhoon "Xangsane" prevailed. At 2312:02 Taipei local time, the flight crewmembers of SQ006 received Runway Visual Range (RVR) 450 meters on Runway 05L from Automatic Terminal Information Service (ATIS) "Uniform". At 2315:22 Taipei local time, they received wind direction 020 degrees with a magnitude of 28 knots, gusting to 50 knots, together with the takeoff clearance issued by the local controller.
- On August 31, 2000, CAA of ROC issued a Notice to Airmen (NOTAM) A0606 indicating that a portion of the Runway 05R between Taxiway N4 and N5 was closed due to work in progress from September 13 to November 22, 2000. The flight crew of SQ006 was aware of the fact that a portion of Runway 05R was closed, and that Runway 05R was only available for taxi.
- The aircraft did not completely pass the Runway 05R threshold marking area and continue to taxi towards Runway 05L for the scheduled takeoff. Instead, it entered Runway 05R and CM-1 commenced the takeoff roll. CM-2 and CM-3 did not question CM-1's decision to take off.
- The flight crew did not review the taxi route in a manner sufficient to ensure they all understood that the route to Runway 05L included the need for the aircraft to pass Runway 05R, before taxiing onto Runway 05L.
- The flight crew had CKS Airport charts available when taxing from the parking bay to the departure runway; however, when the aircraft was turning from Taxiway NP to Taxiway NI and continued turning onto Runway 05R, none of the flight crewmembers verified the taxi route. As shown on the Jeppesen "20-9" CKS Airport chart, the taxi route to Runway 05L required that the aircraft make a 90-degree right turn from Taxiway NP and then taxi straight ahead on Taxiway NI, rather than making a continuous 180-degree turn onto Runway 05R. Further, none of the flight crewmembers confirmed orally which runway they had entered.
- CM-1's expectation that he was approaching the departure runway coupled with the saliency of the lights leading onto Runway 05R resulted in CM?1 allocating most of his attention to these centerline lights. He followed the green taxiway centerline lights and taxied onto Runway 05R.
- The moderate time pressure to take off before the inbound typhoon closed in around CKS Airport, and the condition of taking off in a strong crosswind, low visibility, and slippery runway subtly influenced the flight crew's decision?making ability and the ability to maintain situational awareness.
- On the night of the accident, the information available to the flight crew regarding the orientation of the aircraft on the airport was:
- CKS Airport navigation chart
- Aircraft heading references
- Runway and Taxiway signage and marking
- Taxiway NI centerline lights leading to Runway 05L
- Color of the centerline lights (green) on Runway 05R
- Runway 05R edge lights most likely not on
- Width difference between Runway 05L and Runway 05R
- Lighting configuration differences between Runway 05L and Runway 05R
- Para-Visual Display (PVD) showing aircraft not properly aligned with the Runway 05L localizer
- Primary Flight Display (PFD) information
The flight crew lost situational awareness and commenced takeoff from the wrong runway.
The Singapore Ministry of Transport (MOT) did not agree with the findings and released their own report. They conclude that the systems, procedures and facilities at the CKS Airport were seriously inadequate and that the accident could have been avoided if internationally-accepted precautionary measures had been in place at the Airport.
Final Report:

Crash of a Beechcraft 300 Super King Air in Concord

Date & Time: Oct 19, 2000 at 1538 LT
Registration:
N398DE
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Concord - San Jose
MSN:
FA-109
YOM:
1986
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10868
Captain / Total hours on type:
35.00
Aircraft flight hours:
3801
Circumstances:
The twin turboprop airplane overran the runway, impacted two fences, and an occupied automobile after the airline transport pilot attempted to abort a takeoff. The pilot performed a rolling takeoff and was paying close attention to balancing the engine power and keeping runway centerline alignment. As the airplane accelerated, the pilot set the power above 80 percent and began an instrument scan. He then noted the airspeed indicator was reading zero with the needle resting on the peg. After a moment's hesitation, the pilot attempted to abort the takeoff by reducing the power levers to flight idle, and subsequently over the gate to ground fine. He reported to the FAA that he did not place the power controls into the reverse position. Air traffic controllers reported they observed the airplane with its nose wheel off of the ground approximately 3/4 of the way down the 4,602-foot long runway. The aircraft's left and right pitot/static systems were examined and tested after the accident, and no anomalies were noted. The pilot obtained verbal training on rejected/aborted takeoffs for the accident airplane. He obtained his type rating and 14 CFR 135 check-out in the accident airplane approximately 1 month prior to the accident. The pilot had accumulated a total of 10,867.5 hours of flight time, of which 34.7 hours were accumulated in the accident aircraft make and model. The pilot reported his total pilot-in-command flight time in the accident aircraft make and model as 20 hours, all of which were accumulated within the preceding 30 days of the accident. Examination of the airplane, the flight instruments and the pitot/static system found no explanation for the pilot reported lack of airspeed reading. The brakes were found to be fully functional. Review of the performance charts for the airplane disclosed that for the weight and ambient conditions of the takeoff, the airplane required 4,100 feet for an
accelerate-stop distance; the runway was 4,602 feet long.
Probable cause:
The pilot's delayed decision to abort the takeoff and his failure to utilize the propeller's reverse pitch function.
Final Report:

Crash of an Aérospatiale SN.601 Corvette in Toulouse

Date & Time: Oct 16, 2000 at 0700 LT
Operator:
Registration:
F-BUQN
Flight Phase:
Survivors:
Yes
Schedule:
Toulouse - Nantes
MSN:
03
YOM:
1973
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll on runway 33 at Toulouse-Blagnac Airport, at a speed of 50 knots, it is believed that the left main gear collapsed. The aircraft skidded on runway, lost its nose gear and came to rest. All eight occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Piper PA-61P Aerostar (Ted Smith 601) in Burlington

Date & Time: Oct 12, 2000 at 0931 LT
Registration:
C-FAWF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Burlington – Toronto
MSN:
61-0629-7963287
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15000
Captain / Total hours on type:
30.00
Circumstances:
The pilot reported that after rotation, he obtained a positive rate of climb. At 110 knots, with the landing gear retracted and the wing flaps at 10 degrees, he noticed a right roll, a drop in climb performance, and a drop of manifold pressure on the right engine to at least 34 inches. The left engine maintained 42 inches. The pilot decided that, due to a "very minimum climb rate, rising terrain ahead, [and] airspeed not increasing," he would land the airplane in a small field about 1/4 mile and 50 degrees to the left. The pilot abruptly lowered the nose of the airplane and raised the flaps to gain airspeed, then landed with a nose-high attitude and the landing gear partially extended. Post-accident examination of the airplane revealed there was vertical compression to the belly area, the fuselage was spilt across the top at the aft end of the cabin, and both wings were damaged, with the left wing buckled downward just inboard of the engine. Examination also revealed that a clamp on the right engine intake manifold was loose. An estimated takeoff weight placed the airplane 74 pounds over the maximum allowed of 6,200 pounds. The type certificate holder estimated that with the airplane at 6,400 pounds, climbing at 110 kts, and with a partial power loss down to 26 inches on one engine, the rate of climb should have been 1,150 fpm with flaps and landing gear up, and 830 fpm with flaps 10 degrees and landing gear down. Higher terrain was to the east, and lower terrain was to the west. Terrain elevation for a straight-out departure was 25 feet above the runway at 0.5 nm, and 70 feet above the runway at 2.8 nm. The pilot reported his total flight experience as 15,000 hours, which included 13,000 hours in multi-engine airplanes, and 30 hours in make and model, all with the preceding 90 days.
Probable cause:
The pilot's improper in-flight decision to perform a precautionary landing, and his failure to maintain airspeed after he experienced a partial loss of power on one engine. A factor was the partial loss of power on one engine due to an induction air leak.
Final Report:

Crash of a Canadair CL-604-2B16 Challenger in Wichita: 3 killed

Date & Time: Oct 10, 2000 at 1452 LT
Type of aircraft:
Operator:
Registration:
C-FTBZ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Wichita - Wichita
MSN:
5991
YOM:
1994
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
6159
Captain / Total hours on type:
189.00
Copilot / Total flying hours:
6540
Copilot / Total hours on type:
1
Aircraft flight hours:
1226
Circumstances:
On October 10, 2000, at 1452 central daylight time, a Canadair Challenger CL-600-2B16 (CL604) (Canadian registration C-FTBZ and operated by Bombardier Incorporated) was destroyed on impact with terrain and postimpact fire during initial climb from runway 19R at Wichita Mid-Continent Airport (ICT), Wichita, Kansas. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as an experimental test flight. The pilot and flight test engineer were killed. The copilot was seriously injured and died 36 days later.
Probable cause:
The pilot’s excessive takeoff rotation, during an aft center of gravity (c.g.) takeoff, a rearward migration of fuel during acceleration and takeoff and consequent shift in the airplane’s aft c.g. to aft of the aft c.g. limit, which caused the airplane to stall at an altitude too low for recovery. Contributing to the accident were Bombardier’s inadequate flight planning procedures for the Challenger flight test program and the lack of direct, on-site operational oversight by Transport Canada and the Federal Aviation Administration.
Final Report:

Crash of a Beechcraft E18S in Washington Court House: 1 killed

Date & Time: Oct 10, 2000 at 0145 LT
Type of aircraft:
Operator:
Registration:
N2067C
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Washington Court House – Wilmington
MSN:
BA-424
YOM:
1959
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
22500
Captain / Total hours on type:
17000.00
Circumstances:
The airplane was observed to depart normally for a positioning flight conducted during night visual meteorological conditions. In addition, the landing gear was observed to retract after takeoff. A witness who lived near the accident site heard a "loud" engine noise and observed the airplane just above the trees. The airplane then pitched down, impacted the ground, and exploded. The airplane impacted in a soybean field about a 1/2 mile from the departure end of the runway. Two pairs of ground scars were observed at the beginning of the debris path. The initial pair of ground scars were about 2 to 3 feet in length and were located about 380 feet south of the main wreckage. A pair of 10 to 12 foot long ground scars were located about 10 feet forward of the initial ground scars and they contained portions of the left and right engines; respectively. There was no impact damage observed to the portion of the soy bean field located in-between the second ground scar and the main wreckage. Prior to the flight, maintenance personnel replaced a frayed elevator trim cable. The work was supervised and checked by the accident pilot. Examination of the airplane did not reveal any evidence of a preimpact failure; however, a significant portion of the airplane was consumed in a post crash fire. Examination of the propellers revealed damage consistent with engine operation at the time of impact. The pilot reported 22,500 hours of total flight experience, with over 17,00 flight hours in make and model.
Probable cause:
An undetermined event, which resulted in an off airport landing. A factor in this accident was the night light condition.
Final Report:

Crash of a Cessna 207 Skywagon in 47 Mile Creek: 1 killed

Date & Time: Sep 20, 2000 at 0615 LT
Operator:
Registration:
N42472
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
47 Mile Creek – Aniak
MSN:
207-0148
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1788
Captain / Total hours on type:
900.00
Circumstances:
The air taxi pilot had flown to a remote airstrip and lodge in a company airplane to go hunting. He was scheduled the next morning for a flight from his company's base of operations, his original departure airport. According to a hunting guide at the lodge, the pilot departed the lodge's airstrip about 0608, with a load of revenue cargo. A few minutes later, the guide heard the sound of an airplane, and then a loud impact. The guide could not see the wreckage because it was too dark outside. He departed in his own airplane, but entered clouds shortly after takeoff, and had to return. The guide commented he thought the accident pilot was trying to return to the lodge airstrip because of the poor weather and darkness. The wreckage was located on a nearby mountain in daylight hours after the cloud cover had dissipated. Post accident inspection disclosed no evidence of any preimpact mechanical anomalies with the airplane. Official sunrise was 0813; official civil twilight was 0730. The time of the accident was approximately 0615.
Probable cause:
The pilot's decision to initiate visual flight into dark night instrument meteorological conditions. Factors associated with the accident are a low ceiling, a dark night, the pilot's failure to follow regulatory procedures and directives, and his self-induced pressure to return to base to take another flight.
Final Report:

Crash of a PZL-Mielec AN-28 in Tigil

Date & Time: Sep 19, 2000
Type of aircraft:
Operator:
Registration:
RA-28950
Flight Phase:
Survivors:
Yes
Schedule:
Tigil – Petropavlovsk-Kamchatsky
MSN:
1AJ009-16
YOM:
1991
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While taking off from a waterlogged and unpaved runway in Tigil, the crew decided to abort as the aircraft was unable to reach a sufficient speed. Despite the situation, the crew attempted a second takeoff manoeuvre during which control was lost. The aircraft deviated to the left, veered off runway and struck an embankment before coming to rest in a ditch. All 11 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Piper PA-31T Cheyenne in Montpellier: 1 killed

Date & Time: Sep 9, 2000
Type of aircraft:
Operator:
Flight Phase:
Flight Type:
Survivors:
No
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Shortly after takeoff from Montpellier-Candillargues Airport, while in initial climb, the aircraft stalled and crashed near the runway end. The pilot, sole on board, was killed.
Probable cause:
It is believed that the pilot lost control of the airplane following a double engine failure caused by a fuel exhaustion.

Crash of a Piper PA-61P Aerostar (Ted Smith 601) in Northampton

Date & Time: Sep 7, 2000 at 0755 LT
Registration:
N601WK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Northampton – Poughkeepsie
MSN:
61-0792-8063404
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4280
Captain / Total hours on type:
2641.00
Aircraft flight hours:
3595
Circumstances:
The airport consisted of a single runway oriented on a heading of 140/320 degrees. A taxiway oriented on a 120 degree heading intersected the runway at its midpoint. The pilot reported that the visibility was 500-1,000 feet with fog at the time of departure. Before he took off, the pilot asked his passenger to walk the length of the runway to observe any obstructions, due to the reduced visibility. The pilot then taxied to the run-up pad, set the heading of his HSI to 120 degrees, and initiated the takeoff. When the airspeed reached 80 knots, the pilot realized he had initiated the takeoff on the taxiway instead of the runway. He aborted the takeoff and attempted to maneuver the airplane to the runway. The airplane crossed the runway, impacted a tree, and came to rest upright in a cornfield. The weather reported at the time of the accident at an airport 9 miles away was: wind from 320 degrees at 2 knots; visibility 1/16 mile with fog; sky partially obscured; ceiling 200 feet overcast.
Probable cause:
The pilot's improper preflight planning which resulted in an attempted takeoff from a taxiway. A factor in the accident was the fog.
Final Report: