Crash of a Piper PA-46-350P Malibu Mirage in Parma: 3 killed

Date & Time: Apr 23, 2008 at 1710 LT
Operator:
Registration:
D-EPOE
Flight Type:
Survivors:
No
Schedule:
Parma - Parma
MSN:
46-22180
YOM:
1995
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Copilot / Total flying hours:
705
Aircraft flight hours:
1434
Circumstances:
The single engine aircraft departed Parma-Giuseppe Verdi Airport at 1635LT on a local training flight, carrying one passenger (a PA-46 rated pilot), a pilot under supervision and one instructor. The goal of the flight was to revalidate the PA-46 licence of the pilot-in-command. Following a successful emergency landing and a touch-and-go, the crew followed a new circuit and was cleared for a new approach to runway 20 in VFR conditions. On short final, while completing a left turn to join the approach path, the aircraft stalled, collided with power lines and crashed near a roundabout located about 1,100 metres short of runway 20. The aircraft was destroyed and all three occupants were killed.
Probable cause:
A loss of control as a result of an aerodynamic stall while completing a left turn due to an insufficient speed. During the last turn facing the setting sun, the pilot-in-command reduced the engine power excessively, possibly after suffering a loss of situational awareness. The short distance between the aircraft and the ground did not allow the crew to expect a stall recovery.
Final Report:

Crash of a BAe 146-200 in Bucharest

Date & Time: Apr 22, 2008 at 1817 LT
Type of aircraft:
Operator:
Registration:
YR-BEB
Survivors:
Yes
Schedule:
Timişoara – Bucharest
MSN:
E2220
YOM:
1993
Flight number:
RMV204
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
67
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Timişoara, the crew initiated the approach to Bucharest-Otopeni-Henri Coanda Airport in poor weather conditions. After touchdown, the crew encountered difficulties to stop the aircraft. On a wet runway surface, the aircraft deviated to the right, causing the right main gear to be torn off while contacting soft ground. The airplane came to rest, straddling on the runway edge. All 73 occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of an Embraer EMB-110P1 Bandeirante in Coari

Date & Time: Apr 21, 2008 at 1500 LT
Operator:
Registration:
PT-OCV
Survivors:
Yes
Schedule:
Manaus – Carauari
MSN:
110-359
YOM:
1981
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16442
Captain / Total hours on type:
2519.00
Copilot / Total flying hours:
1132
Copilot / Total hours on type:
364
Circumstances:
The twin engine aircraft departed Manaus-Eduardo Gomes Airport on a flight to Carauari, carrying 15 passengers and two pilots. About 50 minutes into the flight, while cruising at an altitude of 8,500 feet, the right engine failed. The crew elected several times to restart it but without success. After the crew informed ATC about his situation, he was cleared to divert to Coari Airport located about 37 km from his position. Because the aircraft was overloaded and one engine was inoperative, the crew was approaching Coari Airport runway 28 with a speed higher than the reference speed. The aircraft landed too far down the runway, about 700 metres past the runway 28 threshold (runway 28 is 1,600 metres long). After touchdown, directional control was lost. The airplane veered off runway to the left and while contacting a drainage ditch, the undercarriage were torn off and the aircraft came to rest 20 metres further. All 17 occupants were evacuated, among them nine were injured. The aircraft was damaged beyond repair.
Probable cause:
The failure of the right engine was the result of the failure of the fuel pump due to poor maintenance and a possible use beyond prescribed limits. The presence of iron oxide inside and outside the fuel pump as well as the lack of cleanliness of the internal components indicates a probable lack of maintenance. When the right engine stopped running, the generator No. 1 was then responsible for powering the aircraft's electrical system. As the latter was not in good working order, the primary generator could not withstand the overload and ceased to function, leaving only the battery to power the entire electrical system. To maintain power to critical systems, the crew would have had to select the backup power system. Since after the engine stopped, there was no monitoring of the electrical system, the pilots only realized the failure of the electrical system when they attempted to extend the landing gears. The emergency hydraulic system was then used to lower the gears, after which the crew did not return the system selection valve to the 'normal' position, resulting in the brakes and the steering systems to be inoperative after landing. The chain of failures may be associated with not reading the checklist when performing procedures after the engine failure.
The following contributing factors were identified:
- Poor flight preparation,
- The crew failed to follow the SOP's, and took the decision to initiate the flight with an aircraft that was overloaded by 503 kilos,
- When the emergency situation presented itself to the crew, they failed to follow the checklist,
- On an organizational level, the company did not have an effective personnel training system in place, so that the crew did not have sufficient skills to respond to emergency situations,
- Because the aircraft was overloaded and that one engine was inoperative, the crew was forced to complete the approach with a speed higher than the reference speed,
- An improper use of the controls allowed the aircraft to land 700 meters past the runway 28 threshold, reducing the landing distance available,
- The crew focused their attention on the failure of the right engine and did not identify the failure of the electrical system, which delayed their tasks assignment, all made worse by the failure to comply with the checklist,
- The operations cleared the crew to start the flight despite the fact that the aircraft was overloaded on takeoff based on weight and balance documents,
- The crew did not prepare the flight according to published procedures and did not consider the total weight of the aircraft in relation to the number of passengers on board and the volume of fuelin the tanks, which resulted in an aircraft to be overloaded by 503 kilos and contributed to the failure of the right engine,
- A lack of maintenance on the part of the operator.
Final Report:

Crash of an Ilyushin II-62M in Saint Domingo

Date & Time: Apr 20, 2008 at 1430 LT
Type of aircraft:
Operator:
Registration:
CU-T1283
Survivors:
Yes
Schedule:
Santo Domingo - Havana
MSN:
4053823
YOM:
1991
Flight number:
CU201
Crew on board:
8
Crew fatalities:
Pax on board:
109
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Few minute after takeoff from Santo Domingo-Las Américas Airport, while cruising at an altitude of 25,000 feet, some 83 km from Santo Domingo, the captain informed ATC about the explosion of the engine n°2 and that a cabin decompression occurred. The crew was cleared for an immediate return and the aircraft landed uneventful few minutes later. All 117 occupants evacuated safely. However, the aircraft was considered as damaged beyond repair due to severe damages to the engines n°2 and n°1 as well as the fuselage because debris of the engine n°2 punctured the fuselage and came to rest in the cabin.

Crash of an Antonov AN-32B in Chişinău: 8 killed

Date & Time: Apr 11, 2008 at 2217 LT
Type of aircraft:
Registration:
ST-AZL
Flight Type:
Survivors:
No
Schedule:
Chişinău – Antalya – Khartoum
MSN:
30 09
YOM:
1992
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
8
Aircraft flight hours:
2668
Aircraft flight cycles:
1954
Circumstances:
Following a maintenance program in Chişinău, the aircraft was ferried back to Khartoum via Antalya. On board were four passengers, four crew members and a load consisting of 2 tons of oil and various equipments. Shortly after takeoff, while in initial climb, the crew informed ATC about the failure of the transponder and was cleared for an immediate return. Too low on final approach, the aircraft struck the ILS antenna and crashed in a field located 200 metres short of runway, bursting into flames. All 8 occupants, among them 4 technicians, were killed. The aircraft was totally destroyed by a post crash fire.
Probable cause:
The accident was the consequence of a premature descent on part of the crew, combined with an incorrect evaluation of the altitude while completing a visual approach by night. The crew had little experience with night flights, which was considered as a contributing factor.

Crash of a Grumman G-21A Goose in Unalaska

Date & Time: Apr 9, 2008 at 1630 LT
Type of aircraft:
Operator:
Registration:
N741
Survivors:
Yes
Schedule:
Akutan - Unalaska
MSN:
B097
YOM:
1944
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7040
Captain / Total hours on type:
320.00
Aircraft flight hours:
12228
Circumstances:
The airline transport pilot was on an approach to land on Runway 30 at the conclusion of a visual flight rules (VFR)scheduled commuter flight. Through a series of radio microphone clicks, he activated threshold warning lights for vehicle traffic on a roadway that passes in front of the threshold of Runway 30. Gates that were supposed to work in concert with the lights and block the runway from vehicle traffic were not operative. On final approach, the pilot, who was aware that the gates were not working, noticed a large truck and trailer stopped adjacent to the landing threshold. As he neared the runway, he realized that the truck was moving in front of the threshold area. The pilot attempted to go around, but the airplane's belly struck the top of the trailer and the airplane descended out of control to the runway, sustaining structural damage. The truck driver reported that, as he approached the runway threshold, he saw the flashing red warning lights, but that the gates were not closed. He waited for about 45 seconds and looked for any landing traffic and, seeing none, drove onto the road in front of the threshold. As he did so, he felt the airplane impact the trailer, and saw it hit the runway. The accident truck's trailer is about 45 feet long and 13 feet tall. The Federal Aviation Administration (FAA) Facility Directory/Alaska Supplement recommends that pilots maintain a 25-foot minimum threshold crossing height. The NTSB's investigation revealed that the gate system had been out of service for more than a year due to budgetary constraints, and that there was no Notice to Airman (NOTAM) issued concerning the inoperative gate system. The FAA certificated airport is owned and operated by the State of Alaska. According to the Airport Certification Manual, the airport manager is responsible to inspect, maintain, and repair airport facilities to ensure safe operations. Additionally, the airport manager is responsible for publishing NOTAM's concerning hazardous conditions. A 10-year review of annual FAA certification and compliance inspection forms revealed no discrepancy listed for the inoperative gates until 16 days after the accident.
Probable cause:
The pilot's failure to maintain clearance from a truck while landing, and the vehicle operator's decision to ignore runway warning signals. Contributing to the accident was an inoperative vehicle gate system and the failure of airport management to adequately maintain the gate system and issue a NOTAM.
Final Report:

Crash of a Pilatus PC-6/B2-H4 Turbo Porter in Iquitos

Date & Time: Apr 7, 2008 at 1245 LT
Operator:
Registration:
FAP-320/OB-1165
Flight Type:
Survivors:
Yes
Schedule:
Iquitos - Iquitos
MSN:
720
YOM:
1974
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft was completing a local training flight at Iquitos-Moronacocha Airport, carrying five pilots. On short final, the single engine airplane lost height, struck the ground and crashed near the runway threshold. All five occupants were injured and the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-6 Twin Otter 200 in Comodoro Rivadavia

Date & Time: Apr 4, 2008
Operator:
Registration:
T-84
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
214
YOM:
1969
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Comodoro Rivadavia Airport, while climbing, the crew encountered an unexpected situation and was forced to attempt an emergency landing. The aircraft crash landed in a desert area located about 10 km from the airport. While all six occupants escaped uninjured, the aircraft was damaged beyond repair.

Crash of a Cessna F406 Caravan II in Mwanza: 2 killed

Date & Time: Apr 3, 2008 at 1624 LT
Type of aircraft:
Operator:
Registration:
5H-AWK
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mwanza - Mwanza
MSN:
406-0030
YOM:
1989
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2900
Captain / Total hours on type:
600.00
Circumstances:
The crew consisting of one instructor and one pilot under supervision departed Mwanza for a local training flight with approaches and touch-and-go manoeuvres. Shortly after takeoff from runway 12, while climbing to an altitude of 800 feet, the twin engine aircraft rolled to the right then entered a right turn and an uncontrolled descent before crashing on the top of a small hill located 890 metres from the runway 30 threshold. The aircraft was totally destroyed and both pilots were killed, a British instructor and an Australian citizen pilot under training.
Probable cause:
The crew was supposed to conduct several touch-and-go maneuvers and the instructor wanted to simulate an engine failure. Shortly after takeoff from runway 12, the aircraft rolled to the right while the right engine was turning at low RPM, presumably as a result of the instructor's decision to reduce the engine power. Due to a poor reaction by the pilot under supervision and an insufficient altitude to regain control, the aircraft lost altitude and crashed. The crew was supposed to initiate a left turn during initial climb, according to ATC instructions, but due to the power reduction on the right engine, the aircraft banked right then turned right and entered an uncontrolled descent. A wind from 090 gusting at 18 knots remained a contributing factor as it contributed to the aircraft rolling to the right.

Crash of an Embraer EMB-820C Carajá in Lençóis: 2 killed

Date & Time: Mar 31, 2008 at 0630 LT
Operator:
Registration:
PT-VCI
Flight Type:
Survivors:
No
Schedule:
Salvador – Lençóis
MSN:
820-144
YOM:
1986
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
25000
Captain / Total hours on type:
1769.00
Copilot / Total flying hours:
750
Copilot / Total hours on type:
195
Aircraft flight hours:
7293
Circumstances:
The twin engine aircraft departed Salvador Airport at 0525LT on a cargo flight to Lençóis, carrying two pilots and a load of bank documents. On final approach to Lençóis Airport, the crew encountered limited visibility due to marginal weather conditions. The captain decided to continue the approach and completed a turn to the left when the aircraft crashed 2 km from the runway threshold, bursting into flames. The aircraft was totally destroyed and both pilots were killed.
Probable cause:
The decision of the captain to continue the approach under VFR mode in IMC conditions to an airport that was not suitable for IFR operations. The following contributing factors were identified:
- The lack of ground references may have contributed to the commander's spatial disorientation,
- Although the weather conditions made it impossible to land under VFR conditions, the captain insisted on landing, neglecting IFR procedures,
- The captain ignored the copilot's advice and continued with the approach procedure,
- The captain put the aircraft in an attitude that caused it to stall,
- Poor judgment on part of the captain,
- Despite the implementation of a CRM program, the operator was unable to identify that the captain was violating the published procedures.
Final Report: