Ground accident of a Saab 340A in Nassau

Date & Time: Jan 7, 2010 at 1145 LT
Type of aircraft:
Operator:
Registration:
C6-SBE
Flight Phase:
Survivors:
Yes
Schedule:
Nassau - Marsh Harbour
MSN:
99
YOM:
1987
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Two crew took place in the cockpit to prepare the aircraft for a scheduled commercial service to Marsh Harbour. In unknown circumstances, all three landing gear retracted, causing the aircraft to fall on the ground. Both occupants were uninjured while the aircraft was damaged beyond repair. It is unknown if the retraction of the undercarriage was the consequence of a mechanical failure or a mishandling from the crew.

Crash of a Boeing 737-800 in Kingston

Date & Time: Dec 22, 2009 at 2222 LT
Type of aircraft:
Operator:
Registration:
N977AN
Survivors:
Yes
Schedule:
Washington DC - Miami - Kingston
MSN:
29550/1019
YOM:
2001
Flight number:
AA331
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
148
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
American Airlines Flight AA331, a Boeing 737-823 in United States registration N977AN, carrying 148 passengers, including three infants, and a crew of six, was being operated under the provisions of 14 Code of Federal Regulations (CFR) Part 121. The aircraft departed Miami (KMIA) at 20:22 Eastern Standard Time (EST) on 22 December 2009 (01:22 Universal Coordinated Time (UTC) on 23 December 2009) on an instrument flight rules (IFR) flight plan, on a scheduled flight to Norman Manley International Airport (NMIA), ICAO identifier: MKJP, Kingston, Jamaica. The aircraft landed at NMIA on runway 12 in the hours of darkness at 22:22 EST (03:22 UTC) in Instrument Meteorological Conditions (IMC) following an Instrument Landing System (ILS) approach flown using the heads up display (HUD) and becoming visual at approximately two miles from the runway. The aircraft touched down at approximately 4,100 feet on the 8,911 foot long runway in heavy rain and with a 14 knot left quartering tailwind. The crew was unable to stop the aircraft on the remaining 4,811 feet of runway and it overran the end of the runway at 62 knots ground speed. The aircraft broke through a fence, crossed above a road below the runway level and came to an abrupt stop on the sand dunes and rocks between the road and the waterline of the Caribbean Sea. There was no post-crash fire. The aircraft was destroyed, its fuselage broken into three sections, while the left landing gear collapsed. The right engine and landing gear were torn off, the left wingtip was badly damaged and the right wing fuel tanks were ruptured, leaking jet fuel onto the beach sand. One hundred and thirty four (134) passengers suffered minor or no injury, while 14 were seriously injured, though there were no life-threatening injuries. None of the flight crew and cabin crew was seriously injured, and they were able to assist the passengers during the evacuation.
Probable cause:
Jamaican Director General of Civil Aviation Col. Oscar Derby, stated in the week following the accident, that the jet touched down about halfway down the 8,910-foot (2,720 m) runway. He also noted that the 737-800 was equipped with a head-up display. Other factors that were under investigation included "tailwinds, and a rain soaked runway;" the runway in question was not equipped with rain-dispersing grooves common at larger airports. The aircraft held a relatively heavy fuel load at the time of landing; it was carrying enough fuel for a round trip flight back to the US. The FDR later revealed that the aircraft touched down some 4,100 feet (1,200 m) down the 8,910-foot (2,720 m) long runway. Normally touchdown would be between 1,000 feet (300 m) and 1,500 feet (460 m). The aircraft was still traveling at 72 miles per hour (116 km/h) when it departed the end of the runway. The aircraft landed with a 16 miles per hour (26 km/h) tailwind, just within its limit of 17 miles per hour (27 km/h).
Final Report:

Crash of a Swearingen SA227AC Metro III in Cap Haïtien

Date & Time: Dec 20, 2009 at 1200 LT
Type of aircraft:
Operator:
Registration:
C6-JER
Survivors:
Yes
Schedule:
Nassau – Cap Haïtien
MSN:
AC-588B
YOM:
1984
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7400
Circumstances:
On Sunday December 20, 2009 at approximately 1700 UTC a fixed wing, multi engine, Fairchild SA-227AC Metro-liner III aircraft landed at Cap Haïtien Int’l Airport, Haiti, with its landing gear retracted. The pilot reported on two occasions whilst the aircraft was configured with flaps and gear extended, upon reduction in power preparing to land, the aircraft had a very high nose up attitude. The pilot further stated that after two go around, the decision was made to land the aircraft with its landing gear retracted. The aircraft landed on Runway 05. According to the pilot, the crew and all 19 passengers onboard suffered no injuries.
Final Report:

Crash of a Dassault Falcon 20D in Matthew Town: 2 killed

Date & Time: Dec 17, 2009 at 1930 LT
Type of aircraft:
Operator:
Registration:
N28RK
Flight Type:
Survivors:
No
Schedule:
Oranjestad – La Isabela – Fort Lauderdale
MSN:
206
YOM:
1969
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
26525
Copilot / Total flying hours:
4800
Circumstances:
On December 17, 2009 at approximately 7:30 pm local (2330UTC), N28RK a Dassault Sud, Falcon Fan Jet, Mystere 20, Series D aircraft which departed Joaquin Balaguer Int’l Airport (MDJB) in the Dominican Republic, for Ft Lauderdale Executive Airport, (FXE) Ft Lauderdale, Florida, USA, crashed in a remote area of Matthew Town, Great Inagua, Bahamas. The accident occurred approximately 11.5 miles due east of Great Inagua International Airport at coordinates N 20˚ 58’ 30” latitude and W 073˚ 40’ 00.7” longitude. The aircraft made contact with the terrain on a heading of approximately 105 degrees magnetic. The accident occurred in area that was not accessible by land and the investigation team had to be airlifted by helicopter to the site. Witnesses on the island of Great Inagua reported hearing a loud bang that rattled doors and windows of their homes, but they did not report seeing the aircraft fall from the sky. The aircraft was under the command of Captain Harold Roy Mangels and First Office Freddy Castro. The aircraft reportedly departed Aruba, in the Netherland Antilles and made a fuel stop at Dr. Joaquin Balaguer Int’l Airport, Santo Domingo in the Dominican Republic. The final destination filed by the crew was Ft. Lauderdale Executive Airport, Ft Lauderdale Florida. The accident occurred approximately 6 mile off the filed flight path. ATC records and instructions were for the aircraft N28RK to maintain 28,000 ft (FL280). The aircraft transponder was reported as inoperative. It begun a rapid descent, with no report of an emergency declared or mayday call out. Investigation of the crash site indicates the airplane made contact with the terrain at a high rate of speed and approximately a 45 degree angle. The aircraft was destroyed on impact. The crew of a United States Coast Guard helicopter was on a training mission in the Great Inagua area at the time of the accident. They reported hearing a loud bang and noticed a huge explosion and fireball emanating from the ground in an area close to their location. The crew of the US Coast Guard helicopter reported that they did not see any in-flight fire prior to the fireball that they saw. The post impact fire engulfed approximately five (5) acres of trees and brush in the National Wildlife Refuge at Great Inagua. The coast guard helicopter crew stated that they discontinued their training mission and went to the site to investigate. Upon arrival at the site the crew reported that they lowered rescue personnel to the ground to investigate and search for survivors, but, due to the heat and extent of the fire on the ground, they had to discontinue the search. They reported the accident to authorities at Great Inagua. This information was further passed along to the National Transportation Safety Board who alerted the accident investigation unit of the Bahamas Civil Aviation Department. Night time conditions prevailed at the time of the accident. The crew of the aircraft received fatal injuries. A search of the area discovered no distinguishable human remains. Approximately less than 1% of what is believed to be possible human flesh / internal body parts were recovered. In addition clothing (piece of a pant with belt buckle fastened) was recovered, which possibly may have been worn by a member of the crew at the time of the accident. All recovered remains and clothing retrieved were gathered by officers of the Royal Bahamas Police Force that accompanied the investigation team and sent to the Forensic Science Laboratory at the Royal Bahamas Police Force, Nassau Bahamas for DNA analysis and possible identification. The aircraft broke into many pieces after contact with the terrain. Debris was spread over a large area of rough terrain. What remained of the aircraft post impact was either not found or possibly further destroyed by the post impact fire. The “four corners” of the airplane were confirmed in the area downstream of where the initial ground impact occurred. However, engine cowling parts were found prior to the point of initial ground impact. This may suggest an aircraft over-speed condition prior to ground impact. Less than 10% of the aircraft was recovered. An explosion occurred when N28RK made contact with the terrain. A post impact fire ensued. Approximately 5 acres of the national park was destroyed by the fire. Parts of the aircraft including personal effect, aircraft parts and furnishing, seat and seat cushions were also destroyed in the post impact fire.
Probable cause:
The probable cause of this accident has been determined as loss of control. Insufficient wreckage of the aircraft were recovered to make a conclusive determination as to the cause of the accident.
Final Report:

Crash of a Cessna T303 Crusader in Punta Ocote: 1 killed

Date & Time: Dec 5, 2009 at 1830 LT
Type of aircraft:
Operator:
Registration:
HK-4324-G
Flight Type:
Survivors:
Yes
MSN:
303-00019
YOM:
1981
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Sole on board, the pilot was performing an illegal flight with a bag containing 25 kg of cocaine. While trying to land on a private airstrip in Punta Ocote, the twin engine aircraft hit tree tops and crashed on a road, killing an 18 years old motorcyclist. The aircraft was destroyed by a post crash fire and the pilot escaped uninjured.

Crash of a Britten-Norman BN-2A-8 Islander off Kralendijk: 1 killed

Date & Time: Oct 22, 2009 at 1017 LT
Type of aircraft:
Operator:
Registration:
PJ-SUN
Survivors:
Yes
Schedule:
Willemstad – Kralendijk
MSN:
377
YOM:
1973
Flight number:
DVR014
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1738
Captain / Total hours on type:
565.00
Aircraft flight hours:
16670
Circumstances:
On 22 October the pilot concerned got up at 05.00 and drove towards the airport at about 05.30. After preparing the aircraft, with registration PJ-SUN, he piloted two return flights from Curaçao International Airport (hereinafter to be referred to as Hato airport) to Bonaire International Airport (hereinafter to be referred to as Flamingo airport). No problems occurred during these four flights. The departure for the next flight, “DVR014”, was planned at 09.30. The nine passengers booked for this flight, who had already had their luggage weighed, had to wait before they could board because the pilot had ordered the aircraft to be refuelled prior to this flight. The refuelling invoice of flight DVR014 specifies that fuel was taken up between 09.28 and 09.38. The luggage of these passengers and some additional cargo consisting of a few boxes had already been loaded on to the aircraft. The passengers were welcomed by the pilot when they boarded. The pilot informed them they should keep their waist belts fastened during the flight and that the safety cards were located in the seat pockets. From the passenger statements it can be deduced that these instructions were not heard by all of the passengers. The pilot and the passenger seated next to him fastened their waist and shoulder belts. Approximately ten minutes after the estimated time of departure, after having received the required approval from the Hato Tower air traffic control tower (hereinafter to be referred to as Hato Tower) via the on-board radio the engines were started without any problems. The flight manual engine ground checks were not extensively performed because these are part of the first flight of the day engine checks in accordance with the General Operating Manual. Around 09.47 the PJ-SUN took off for a flight with visual flight rules (VFR) to Bonaire. After take-off the aircraft climbed to flight level 035 (FL035). Some of the passengers had flown for some years, several times in a week with Divi Divi Air. From the passenger statements it can be deduced that the pilot brought the aircraft into level flight at FL035 and reduced the power from climb power to cruise power. The passenger next to the pilot stated that engine power ceased the moment that the pilot was adjusting (one of) the levers on the throttle quadrant. Some passengers reported they felt a jolt that moment. Some passengers reported the engine sputtered shortly before it ceased. No sound from which a mechanical problem was heard and no smoke was detected. Passengers stated that the pilot increased the left engine power, feathered the right propeller and trimmed away the forces to the rudder pedals due to the failure of the right engine. They also reported that the pilot attempted to restart the right engine two or three times but to no avail. Around 09.52 the pilot reported to the Hato Tower controller: Divi 014 requesting to switch to Flamingo, priority landing with Flamingo, have lost one of the engines. The controller acknowledged this message. The pilot continued the flight to Bonaire flying with the left engine running and contacted Flamingo Tower air traffic control (hereinafter to be referred to as Flamingo Tower) at 09.57 and reported: 014, Islander inbound from Curaçao, showing, I got one engine out, so we are landing with one engine, no emergency at this stage, I’m maintaining altitude at, 3000 feet, we request priority to landing runway 10, currently 24 miles out, estimating at, 18. The Flamingo Tower controller authorized the approach to runway 10. The air traffic controller requested the pilot to report when he left 3000 feet altitude, which he immediately did. The radar data shows that the PJ-SUN descended approximately 140 feet per minute on average from the moment the engine failed up to the emergency landing. According to the statements of a few of the passengers, the aircraft pitch attitude increased during the descent of the aircraft and it was higher than usual. The indicated airspeed on the airspeed indicator was lower than when flying with two working engines. The pilot did not inform the passengers regarding the failure of the right engine or his intentions. A few passengers were concerned and started to put on the life jackets having retrieved them from under their seats. The passenger next to the pilot could not find his life jacket, while others had some trouble opening the plastic bags of the life jackets. They also agreed on a course of action for leaving the aircraft in case of an emergency landing in the water. At 10.08 the pilot informed the Flamingo Tower that he was approaching and was ten nautical miles away, flying at 1000 feet and expected to land in ten minutes. At 10.12 the pilot reported the distance to be eight nautical miles and that he was having trouble with the altitude which was 600 feet at that moment. The traffic controller authorized the landing. At 10.14 the pilot reported to be six nautical miles away and flying at an altitude of 300 feet. During the last radio contact at 10.15 the pilot indicated to be at five nautical miles distance flying at 200 feet and that he was still losing altitude. The pilot was going to perform an emergency landing near Klein Bonaire. The aircraft subsequently turned a little to the left towards Klein Bonaire. According to a few passengers, the pilot turned around towards them and indicated with hand signals that the aircraft was about to land and he gave a thumbs-up signal to ask whether everyone was ready for the approaching emergency landing. There were life jackets for all people on-board. The pilot, the passenger seated next to him and two passengers seated in the back row did not have their life jackets on. The passengers in rows two through to four had put on their life jackets. One passenger had put on his life jacket back to front. According to the statements of the passengers, the stall warning (loud tone) was activated on and off during this last part of the flight. A short time before the emergency landing until the moment of impact with the water the stall warning was continuously audible. From the statements of the passengers it follows the all cabin doors were closed throughout the descent and the landing. The passenger’ statements differ in describing the last part of the flight until the impact of the aircraft with the water surface. One passenger stated that the aircraft fell down from a low height and impacted the water with a blow. Other passengers mentioned a high or low aircraft pitch attitude during impact. Most of the passengers stated that during impact the left wing was slightly down. The aircraft hit the water at 10.17 at a distance of approximately 0.7 nautical miles from Klein Bonaire and 3.5 nautical miles west of Bonaire. The left front door broke off from the cabin and other parts of the aircraft on impact. The aircraft was lying horizontally in the water. The height of the waves was estimated 0.5 meter by one of the passengers. The cabin soon filled with water because the left front door had broken off and the windscreen had shattered. The passenger behind the pilot was trapped, but was able to free herself from this position. All nine passengers were able to leave the aircraft without assistance using the left front door opening and the emergency exits. A few passengers sat for a short time on the wings before the aircraft sank. The passengers formed a circle in the water. The passengers who were not wearing life jackets kept afloat by holding onto the other passengers. One passenger reported that the pilot hit his head on the vertical door/window frame in the cockpit or the instrument panel at impact causing him to lose consciousness and may even have been wounded. The attempts of one or two passengers to free the pilot from his seat were unsuccessful. A few minutes after the accident, the aircraft sank with the pilot still on-board. Approximately five minutes after the emergency landing, two boats with recreational divers who were nearby arrived on the scene. Divers from the first boat tried to localise the sunken aircraft based on indications from the passengers. The people on the other boat took nine passengers out of the water and set course to Kralendijk where they arrived at approximately 10.37. The police and other emergency services personnel were awaiting the passengers on the quay. Six passengers were transported to the hospital where they were discharged after an examination. The other three went their own way.
Probable cause:
The following factors were identified:
1. After one of the two engines failed, the flight continued to Bonaire. By not returning to the nearby situated departure airport, the safest flight operation was not chosen.
- Continuing to fly after engine failure was contrary to the general principle for twin-engine aircraft as set down in the CARNA, that is, to land at the nearest suitable airport.
2. The aircraft could not maintain horizontal flight when it continued with the flight and an emergency landing at sea became unavoidable.
- The aircraft departed with an overload of 9% when compared to the maximum structural take-off weight of 6600 lb. The pilot who was himself responsible (self-dispatch and release) for the loading of the aircraft was aware of the overloading or could have been aware of this. A non-acceptable risk was taken by continuing the flight under these conditions where the aircraft could not maintain altitude due to the overloading.
3. The pilot did not act as could be expected when executing the flight and preparing for the emergency landing.
- The landing was executed with flaps up and, therefore, the aircraft had a higher landing speed.
- The pilot ensured insufficiently that the passengers had understood the safety instructions after boarding.
- The pilot undertook insufficient attempts to inform passengers about the approaching emergency landing at sea after the engine failure and, therefore, they could not prepare themselves sufficiently.

Contributing factors:
Divi Divi Air
4. Divi Divi Air management paid insufficient supervision to the safety of amongst others the flight operation with the Britten-Norman Islanders. This resulted in insufficient attention to the risks of overloading.
Findings:
- The maximum structural take-off weight of 6600 lb was used as limit during the flight operation. Although this was accepted by the oversight authority, formal consent was not
granted for this.
- A standard average passenger weight of 160 lb was used on the load and balance sheet while the actual average passenger weight was significantly higher. This meant that passenger weight was often lower on paper than was the case in reality.
- A take-off weight of exactly 6600 lb completed on the load and balance sheet occurred in 32% of the investigated flights. This is a strong indication that the luggage and fuel weights completed were incorrect in these cases and that, in reality, the maximum structural take-off weight of 6600 lb was exceeded.
- Exceedances of the maximum structural landing weight of 6300 lb occurred in 61% of the investigated flights.
- The exceedance of the maximum allowed take-off weight took place on all three of the Britten-Norman Islander aircraft in use and with different pilots.
- Insufficient attention was paid to aircraft weight limitations during training.
- Lack of internal supervision with regard to the load and balance programme.
- Combining management tasks at Divi Divi Air, which may have meant that insufficient details were defined regarding the related responsibilities.
5. The safety equipment and instructions on-board the Britten-Norman Islander aircraft currently being used were not in order.
Findings:
- Due to the high noise level in the cabin during the flight it is difficult to communicate with the passengers during an emergency situation.
- The safety instruction cards did not include an illustration of the pouches under the seats nor instructions on how to open these pouches. The life jacket was shown with two and not a single waist belt and the life jackets had a different back than the actual life jackets on-board.
Directorate of Civil Aviation Netherlands Antilles (currently the Curaçao Civil Aviation Authority)
6. The Directorate of Civil Aviation’s oversight on the operational management of Divi Divi Air was insufficient in relation to the air operator certificate involving the Britten-Norman Islander aircraft in use.
Findings:
- The operational restrictions that formed the basis for using 6600 lb were missing in the air operator certificate, in the certificate of airworthiness of the PJ-SUN and in the approved General Operating Manual of Divi Divi Air. The restrictions entail that flying is only allowed during daylight, under visual meteorological conditions, and when a route is flown from where a safe emergency landing can be executed in case of engine failure.
- The required (demonstrable) relation with the actual average passenger weight was missing in relation to the used standard passenger weight for drawing up the load and balance sheet.
- The failure of Divi Divi Air’s internal supervision system for the load and balance programme.
- Not noticing deviations between the (approved) safety instruction cards and the life jackets on-board during annual inspections.
- The standard average passenger weight of 176 lb set after the accident offers insufficient security that the exceedance of the maximum allowed take-off weight of flights with Antillean airline companies that fly with the Britten-Norman Islander will not occur.

Other factors:
Recording system of radio communication with Hato Tower
7. The recording system used for the radio communication with Hato Tower cannot be used to record the actual time. This means that the timeline related to the radio communication with Hato Tower cannot be exactly determined.
The alerting and the emergency services on Bonaire
8. There was limited coordination between the different emergency services and, therefore, they did not operate optimally.
Findings:
- The incident site command (Copi) that should have taken charge of the emergency services in accordance with the Bonaire island territory crisis plan was not formed.
- Insufficient multidisciplinary drills have been organized and assessed for executive officials who have a task to perform in accordance with the Bonaire island territory crisis plan and the airport aircraft accident crisis response plan in controlling disasters and serious accidents. They were, therefore, insufficiently prepared for their task.
9. The fire service and police boats could not be deployed for a longer period of time.
Final Report:

Crash of a PZL-Mielec AN-2TP in Managua

Date & Time: Oct 14, 2009 at 1600 LT
Type of aircraft:
Operator:
Registration:
75
Flight Type:
Survivors:
Yes
Schedule:
Managua - Managua
MSN:
1G214-02
YOM:
1985
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft departed Managua-Augusto Cesar Sandino Airport for a local post maintenance check flight following an engine overhaul. On board were five engineers and pilots. On final approach, the engine failed. The pilot-in-command attempted an emergency landing when the aircraft crashed in an open field and came to rest upside down about 800 metres short of runway threshold. All five occupants escaped with minor injuries and the aircraft was damaged beyond repair.
Probable cause:
Engine failure for unknown reasons.

Crash of a PZL-Mielec AN-28 in Las Minas

Date & Time: Oct 9, 2009
Type of aircraft:
Operator:
Registration:
YV1769
Flight Type:
Survivors:
Yes
MSN:
AJE001-02
YOM:
1995
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was damaged beyond repair during a landing in the area of Las Minas while engaged in an illegal contraband flight. There were no injuries but the aircraft was damaged beyond repair. A load of 4 tons of cocaine was found on board.

Crash of a Casa 212 Aviocar 200 in Fonds-Verrettes: 11 killed

Date & Time: Oct 9, 2009
Type of aircraft:
Operator:
Registration:
FAU-531
Flight Phase:
Survivors:
No
Site:
Schedule:
Port-au-Prince - Port-au-Prince
MSN:
187
YOM:
1981
Flight number:
UN146
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The twin engine aircraft departed Port-au-Prince-Toussaint Louverture (ex François Duvalier) Airport on a border patrol mission on behalf of the MINUSTAH, the United Nations Mission for Stabilization in Haiti. On board were nine passengers and two pilots, among them Uruguayan and Jordan soldiers. In unknown circumstances, the aircraft struck the slope of a mountain located some 20 km west of Fonds-Verrettes. The aircraft was totally destroyed and all 11 occupants were killed.

Crash of a Cessna 401A off Salt Cay

Date & Time: Jul 24, 2009
Type of aircraft:
Operator:
Registration:
VQ-TLG
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
401A-0114
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While flying around Salt Cay, the pilot was forced to attempt an emergency landing and ditched the airplane offshore. He was rescued while the aircraft came to rest in shallow water and was damaged beyond repair.