Crash of a Boeing 727-259 in Trinidad

Date & Time: Feb 1, 2008 at 1035 LT
Type of aircraft:
Operator:
Registration:
CP-2429
Survivors:
Yes
Schedule:
La Paz – Cobija
MSN:
22475/1690
YOM:
1980
Country:
Crew on board:
8
Crew fatalities:
Pax on board:
151
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from La Paz, the crew started the descent to Cobija Airport when he was informed by ATC that a landing was impossible due to poor weather conditions at destination. The crew decided to divert to the Trinidad-Jorge Heinrich Arauz Airport which is located about 600 km southeast of Cobija Airport. On final approach to Trinidad Airport, the crew reported technical problems and was forced to attempt an emergency landing. The aircraft crash landed in a dense wooded and marshy area located 4 km short of runway. All 159 occupants were rescued but the aircraft was damaged beyond repair.
Probable cause:
The crew was forced to attempt an emergency landing due to fuel exhaustion. The crew decided to divert to Trinidad Airport which is located 600 km southeast of Cobija Airport while weather conditions were considered as good at Rio Branco Airport located 160 km northeast of Cobija.

Crash of a De Havilland DHC-8-202 in Bogotá

Date & Time: Jan 28, 2008 at 2302 LT
Operator:
Registration:
HK-3997
Survivors:
Yes
Schedule:
Maracaibo – Bogotá
MSN:
391
YOM:
1994
Flight number:
ARE053
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
37
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14992
Captain / Total hours on type:
5552.00
Copilot / Total flying hours:
555
Copilot / Total hours on type:
6
Aircraft flight hours:
19565
Circumstances:
Following an uneventful flight from Maracaibo, the crew completed a night approach and landing on runway 13L at Bogotá-El Dorado Airport. After touchdown, the crew initiated the braking procedure but due to a technical issue on the left engine, the aircraft was unable to stop within the remaining distance. It overran, went through a perimeter fence and came to rest in a grassy area with its left main gear folded. All 41 occupants were evacuated, among them two passengers were seriously injured. The aircraft was damaged beyond repair.
Probable cause:
Carrying out a landing with an unresolved issue on the left engine, causing the aircraft to be unable to stop within the remaining distance available. The failure to correct the maintenance reports in a satisfactory manner and the failure to properly follow-up on repetitive entries were considered as contributing factors.
Final Report:

Crash of a Casa 212 Aviocar 200 in Long Apung: 3 killed

Date & Time: Jan 26, 2008 at 0936 LT
Type of aircraft:
Operator:
Registration:
PK-VSE
Flight Type:
Survivors:
No
Schedule:
Tarakan – Long Apung
MSN:
412/92N
YOM:
1993
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
21019
Captain / Total hours on type:
14234.00
Copilot / Total flying hours:
16849
Copilot / Total hours on type:
16849
Aircraft flight hours:
11750
Aircraft flight cycles:
13749
Circumstances:
On 26 January 2008, a Casa 212-200 aircraft, registered PK-VSE, was being operated by PT. Dirgantara Air Service as a cargo charter flight from Tarakan Airport to Long Apung Airport. There were 3 persons on board; two pilots and one aircraft maintenance engineer/load master. The aircraft was certified as being airworthy prior to departure. The aircraft departed from Tarakan at 0011 UTC (08:11 local time), and the estimated time arrival at Long Apung was 0136. At 0411 the pilot of another aircraft received a distress signal and informed air traffic services at Tarakan. Searchers subsequently found the aircraft wreckage at an elevation of 2,766 feet, about 3.4 NM from Long Apung Airport. The coordinates of the accident site were 01° 39.483′ S and 115° 00.265′ E near Lidung Payau Village, Malinau, East Kalimantan. The accident site was on the left downwind leg of the runway 35 circuit.
Probable cause:
The following findings were identified:
• The aircraft was certified as being airworthy prior to departure.
• All crew members held appropriate and valid flight crew licenses.
• The pilots continued flight into instrument meteorological conditions.
• The aircraft impacted terrain in controlled flight.
• The cargo was not adequately restrained.
Causes:
The crew did not appear to have awareness of the aircraft’s proximity with terrain until impact with terrain was imminent. The pilot attempted to continue the flight in instrument meteorological
conditions, below the lowest safe altitude.
Final Report:

Ground accident of a Boeing 727-247 in Pointe-Noire

Date & Time: Jan 25, 2008
Type of aircraft:
Registration:
9L-LEF
Flight Phase:
Survivors:
Yes
MSN:
21482/1341
YOM:
1978
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While parked at Pointe-Noire Airport, the aircraft was struck by an Antonov AN-12 registered EK-11660 and operated by Aéro-Service that just completed a cargo flight from Brazzaville with 6 crew members on board. Following a normal landing, the crew of the AN-12 vacated the runway and while approaching the apron, they lost control of the aircraft that collided with the parked Boeing 727. All six crew members on board the AN-12 were injured, both pilots seriously. Both aircraft were damaged beyond repair. The Boeing 727 was empty at the time of the ground collision.
Probable cause:
It is believed that the loss of control was the consequence of a brakes failure.

Crash of an Antonov AN-12BP in Pointe-Noire

Date & Time: Jan 25, 2008
Type of aircraft:
Operator:
Registration:
EK-11660
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Brazzaville – Pointe-Noire
MSN:
5 3 432 09
YOM:
1965
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Brazzaville on a cargo flight to Pointe-Noire, carrying six crew members and a load of various goods. Following a normal landing, the crew vacated the runway and while approaching the apron, they lost control of the aircraft that collided with a parked Boeing 727-246 registered 9L-LEF and operated by Canadian Airways Congo. All six crew members on board the AN-12 were injured, both pilots seriously. Both aircraft were damaged beyond repair. The Boeing 727 was empty at the time of the ground collision.
Probable cause:
It is believed that the loss of control was the consequence of a brakes failure.

Crash of a Casa C-295M in Mirosławiec: 20 killed

Date & Time: Jan 23, 2008 at 1907 LT
Type of aircraft:
Operator:
Registration:
019
Flight Type:
Survivors:
No
Schedule:
Warsaw– Powidz – Poznań-Krzesiny – Mirosławiec – Świdwin – Krakow
MSN:
S-043
YOM:
2007
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
20
Aircraft flight hours:
300
Circumstances:
The aircraft departed Warsaw at 1651LT on a flight to Krakow with intermediate stops in Powidz, Poznań-Krzesiny, Mirosławiec and Świdwin, carrying 36 passengers and a crew of four. They were returning to their base after intending the 50th Annual Aviation Safety Conference held in Warsaw. Nine passengers deplaned at Powidz and 11 others at Poznań-Krzesiny AFB. On approach to Mirosławiec by night, the crew encountered poor weather conditions with a ceiling at 300 feet, visibility 2 sm and mist. On short final, the aircraft was unstable. With a rate of descent of 6,000 feet per minute and at a speed of 148 knots, the aircraft impacted trees and crashed in a wooded area located 1,300 metres short of runway threshold, bursting into flames. The aircraft was totally destroyed and all 20 occupants were killed.
Crew:
Maj Jarosław Haładus,
Adj Robert Kuźma,
Adj Michał Smyczyński,
Sgt Janusz Adamczyk.
Passengers:
Gen Brig Andrzej Andrzejewski,
Col Dariusz Maciąg,
Col Jerzy Piłat,
Lt Col Wojciech Maniewski,
Lt Col Zbigniew Książek,
Lt Col Dariusz Pawlak,
Lt Col Zdzisław Cieślik,
Maj Robert Maj,
Maj Mirosław Wilczyński,
Maj Grzegorz Jułga,
Maj Piotr Firlingier,
Maj Krzysztof Smołucha,
Cpt Karol Szmigiel,
Cpt Paweł Zdunek,
Cpt Leszek Ziemski,
Cpt Grzegorz Stepaniuk,

Probable cause:
Inadvertent loss of spatial and situational awareness by the aircraft crew during final stages of PAR approach, which, within 12 seconds period before crash, resulted in the aircraft’s bank increasing unmonitored and accompanying altitude loss, while the flight crew apparently was trying to establish visual contact with runway and approach lights.

Among the secondary causes the Board listed:
- Improper flight crew selection for the flight:
- The PIC did not have any previous experience on this version of CASA C-295 aircraft, which was additionally equipped with 2 IRS/GPS LN-100G units instead of 2 TOPSTAR 100-2 GPS receivers, and, ironically, with EGPWS Mk. V - unfortunately lack of cryptographic modules in GPS receivers, which made IRS/GPS LN-100G system almost useless (IRS alone with no GPS enhancement) caused flight crew to use handheld GPS receivers (Garmin GPSMAP 196),
- The SIC was not rated in CASA C-295 aircraft for night/IMC operations,
- Poor flight crew coordination and cooperation (poor MCC & CRM):
- improper altimeter setting procedures,
- probably both pilots were looking for visual cues and nobody was observing flight instruments in the very last seconds before they crash),
- Poor weather conditions in vicinity of Miroslawiec AB; ceiling 300 feet, visibility 2 sm, in mist. Icing was excluded as a factor.
- Spatial disorientation of the flight crew,
- EGPWS Audio warning was inhibited (the flight crew missed EGPWS test before departure from Warsaw, even though it was a checklist item, and never corrected the problem - the PIC was not familiar with the system - he has never flown before CASA C-295M equipped with EGPWS) - in result no audio warning of excessive bank angle, high terrain closure rate and high sink rate was available to the flight crew, as well as no automatic height above ground callouts were given,
- The flight crew failed to monitor radio-altimeter indication during both approaches,
- Both pilots concentrated their attention outside of the cockpit during final seconds before crash and did not scan flight instruments.
- The military PAR controller did a poor job during the approach, he let for the non-stabilized approach, he was not compensating properly for left crosswind of 20 kts and allowed the aircraft to stay high above glide slope during both PAR approaches, he also was not fully aware of altimeter setting (QNH or QFE) and altitude reports by flight crew– improper values QNH/QFE were used by the flight crew during first approach, additionally PIC has set his altimeter to QFE, while SIC to QNH. During the approach the controller’s instructions were hesitant and inconsistent, probably making the flight crew to believe their approach was going well.
- The military PAR controller was giving improper suggestions to the flight crew - he was questioning them during final stage of approach whether they see approach or runway lights or not, instead of continuous talking them down to the runway threshold,
- Altimeter indications were improperly interpreted by the flight crew,
- Improperly performed search for visual contact by the flight crew during final stage of approach,
- Improper, lacking weather situation analysis performed by the PIC before the flight,
- The flight crew did not properly set DH/MDA (they did the same error on previous two legs before crash).

Contributing factors were:
- The SIC was not rated in CASA C-295 aircraft for night/IMC operations (the SIC total flight time was 800 hours including 100 hours in CASA C-295M),
- The PIC has no previous experience on the accident version of CASA C-295 aircraft, (although he logged 800+ hours in another version of CASA C-295M aircraft used by Polish AF and his total flight time was 2500 hours),
- Because of lack of GPS enhancement to IRS, the flight crew used Garmin GPSMAP 196 handheld GPS receiver,
- The PIC had no previous experience in PAR approaches in IMC, close to minimums, which in Miroslawiec AB were reported to be aprox. ceiling 270 feet and visibility of 3300 feet,
- The military PAR controller had no previous experience in conducting PAR approaches of aircraft other than Sukhoi Su-22,
- The aircraft was improperly vectored to final approach by military APP controller (the same person performing PAR controller duties) which resulted in rushed, non-stabilized first approach, because the aircraft started descent on final approach segment being twice as high as glide slope,
- Lack of instrument approach procedures meeting ICAO standards at Polish military airports, including Miroslawiec AB, published in Aeronautical Information Publication (AIP),
- Use of different units by pilots and controller (the aircraft’s altimeters were scaled in feet and hPa, while the controller was using meters and millimeters of Hg, there was also misunderstanding regarding use of QNH and QFE),
- Even though the aircraft was equipped with ILS receiver, the ILS equipment at Miroslawiec AB was inoperative (it was installed in 2001, but since then has never worked properly, and therefore was not used, despite several repair attempts - now, 2 months after the crash, it is reported to work properly - the crew had available only military PAR (unable to meet ICAO standards), assisted with 2 military NDBs located 4 km and 1 km from the threshold of runway 30),
- The information on minimum weather conditions and available navaids in Miroslawiec AB were improperly disseminated (dispatch personnel had no information the ILS in Miroslawiec AB was inoperative).

Crash of a Boeing 777-236ER in London

Date & Time: Jan 17, 2008 at 1242 LT
Type of aircraft:
Operator:
Registration:
G-YMMM
Survivors:
Yes
Schedule:
Beijing - London
MSN:
30314/342
YOM:
2001
Flight number:
BA038
Region:
Crew on board:
16
Crew fatalities:
Pax on board:
136
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12700
Captain / Total hours on type:
8450.00
Copilot / Total flying hours:
9000
Copilot / Total hours on type:
7000
Aircraft flight hours:
28675
Aircraft flight cycles:
3957
Circumstances:
G-YMMM was on a scheduled return flight from Beijing, China, to London (Heathrow) with a flight crew consisting of a commander and two co-pilots; the additional co-pilot enabled the crew to take in-flight rest. There had been no reported defects with G-YMMM during the outboard flight from London (Heathrow) to Beijing, China. The flight plan for the return sector, produced by the aircraft’s operator, required an initial climb to 10,400 m (FL341) with a descent to 9,600 m (FL315) because of predicted ‘Extreme Cold’ at POLHO (a waypoint that lies on the border between China and Mongolia). Having checked the flight plan and the weather in more detail the crew agreed on a total fuel load for the flight of 79,000 kg. The startup, taxi, takeoff at 0209 hrs and the departure were all uneventful. During the climb, Air Traffic Control (ATC) requested that G-YMMM climb to an initial cruise altitude of 10,600 m (FL348). The crew accepted this altitude and, due to the predicted low temperatures, briefed that they would monitor the fuel temperature en route. The initial climb to altitude was completed using the autopilot set in the Vertical Navigation (VNAV) mode. Approximately 350 nm north of Moscow the aircraft climbed to FL380; this step climb was carried out using the Vertical Speed (VS) mode of the autoflight system. Another climb was then carried out whilst the aircraft was over Sweden, this time to FL400, and again this was completed in VS mode. During the flight the crew monitored the fuel temperature displayed on the Engine Indication and Crew Alerting System (EICAS) and noted that the minimum indicated fuel temperature en route was -34˚C. At no time did the low fuel temperature warning annunciate. The flight continued uneventfully until the later stages of the approach into Heathrow. The commander was flying at this time and during the descent, from FL400, the aircraft entered the hold at Lambourne at FL110; it remained in the hold for approximately five minutes, during which it descended to FL90. The aircraft was radar vectored for an Instrument Landing System (ILS) approach to Runway 27L at Heathrow and subsequently stabilised on the ILS with the autopilot and autothrottle engaged. At 1,000 ft aal, and 83 seconds before touchdown, the aircraft was fully configured for the landing, with the landing gear down and flap 30 selected. At approximately 800 ft aal the co-pilot took control of the aircraft, in accordance with the briefed procedure. The landing was to be under manual control and the co-pilot intended to disconnect the autopilot at 600 ft aal. Shortly after the co-pilot had assumed control, the autothrottles commanded an increase in thrust from both engines. The engines initially responded but, at a height of about 720 ft, 57 seconds before touchdown, the thrust of the right engine reduced. Some seven seconds later, the thrust reduced on the left engine to a similar level. The engines did not shut down and both engines continued to produce thrust above flight idle, but less than the commanded thrust. At this time, and 48 seconds before touchdown, the co-pilot noted that the thrust lever positions had begun to ‘split’. On passing 500 ft agl there was an automatic call of the Radio Altimeter height, at this time Heathrow Tower gave the aircraft a landing clearance, which the crew acknowledged. Some 34 seconds before touchdown, at 430 ft agl, the commander announced that the approach was stable, to which the co-pilot responded “just”. Seven seconds later, the co-pilot noticed that the airspeed was reducing below the expected approach speed of 135 kt. On the Cockpit Voice Recorder (CVR) the flight crew were heard to comment that the engines were at idle power and they attempted to identify what was causing the loss of thrust. The engines failed to respond to further demands for increased thrust from the autothrottle and manual movement of the thrust levers to fully forward. The airspeed reduced as the autopilot attempted to maintain the ILS glide slope. When the airspeed reached 115 kt the ‘airspeed low’ warning was annunciated, along with a master caution aural warning. The airspeed stabilised for a short period, so in an attempt to reduce drag the commander retracted the flaps from flap 30 to flap 25. In addition, he moved what he believed to be an engine starter/ignition switch on the overhead panel. The airspeed continued to reduce and by 200 ft it had decreased to about 108 kt. Ten seconds before touchdown the stick shaker operated, indicating that the aircraft was nearing a stall and in response the co-pilot pushed the control column forward. This caused the autopilot to disconnect as well as reducing the aircraft’s nose-high pitch attitude. In the last few seconds before impact, the commander attempted to start the APU and on realising that a crash was imminent he transmitted a ‘MAYDAY’ call. As the aircraft approached the ground the co-pilot pulled back on the control column, but the aircraft struck the ground in the grass undershoot for 27L approximately 330 m short of the paved runway surface and 110 m inside the airfield perimeter fence. During the impact and short round roll the nose landing gear (NLG) and both the main landing gears (MLG) collapsed. The right MLG separated from the aircraft but the left MLG remained attached. The aircraft came to rest on the paved surface in the undershoot area of Runway 27L. The commander attempted to initiate an evacuation by making an evacuation call, which he believed was on the cabin Passenger Announcement (PA) system but which he inadvertently transmitted on the Heathrow Tower frequency. During this period the co-pilot started the actions from his evacuation checklist. Heathrow Tower advised the commander that his call had been on the tower frequency so the commander repeated the evacuation call over the aircraft’s PA system before completing his evacuation checklist. The flight crew then left the flight deck and exited the aircraft via the escape slides at Doors 1L and 1R. The cabin crew supervised the emergency evacuation of the cabin and all occupants left the aircraft via the slides, all of which operated correctly. One passenger was seriously injured, having suffered a broken leg, as a result of detached items from the right MLG penetrating the fuselage. Heathrow Tower initiated their accident plan, with a crash message sent at 1242:22 hrs and fire crews were on scene 1 minute and 43 seconds later. The evacuation was completed shortly after the arrival of the fire vehicles. After the aircraft came to rest there was a significant fuel leak from the engines and an oxygen leak from the disrupted passenger oxygen bottles, but there was no fire. Fuel continued to leak from the engine fuel pipes until the spar valves were manually closed.
Probable cause:
Whilst on approach to London (Heathrow) from Beijing, China, at 720 feet agl, the right engine of G-YMMM ceased responding to autothrottle commands for increased power and instead the power reduced to 1.03 Engine Pressure Ratio (EPR). Seven seconds later the left engine power reduced to 1.02 EPR. This reduction led to a loss of airspeed and the aircraft touching down some 330 m short of the paved surface of Runway 27L at London Heathrow. The investigation identified that the reduction in thrust was due to restricted fuel flow to both engines. It was determined that this restriction occurred on the right engine at its FOHE. For the left engine, the investigation concluded that the restriction most likely occurred at its FOHE. However, due to limitations in available recorded data, it was not possible totally to eliminate the possibility of a restriction elsewhere in the fuel system, although the testing and data mining activity carried out for this investigation suggested that this was very unlikely. Further, the likelihood of a separate restriction mechanism occurring within seven seconds of that for the right engine was determined to be very low.
The investigation identified the following probable causal factors that led to the fuel flow restrictions:
1) Accreted ice from within the fuel system released, causing a restriction to the engine fuel flow at the face of the FOHE, on both of the engines.
2) Ice had formed within the fuel system, from water that occurred naturally in the fuel, whilst the aircraft operated with low fuel flows over a long period and the localised fuel temperatures were in an area described as the ‘sticky range’.
3) The FOHE, although compliant with the applicable certification requirements, was shown to be susceptible to restriction when presented with soft ice in a high concentration, with a fuel temperature that is below -10°C and a fuel flow above flight idle.
4) Certification requirements, with which the aircraft and engine fuel systems had to comply, did not take account of this phenomenon as the risk was unrecognised at that time.
Final Report:

Crash of a Rockwell Aero Commander 500B in Tulsa: 1 killed

Date & Time: Jan 16, 2008 at 2243 LT
Operator:
Registration:
N712AT
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Tulsa - Oklahoma City
MSN:
500-1118-68
YOM:
1961
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4373
Captain / Total hours on type:
695.00
Aircraft flight hours:
17888
Circumstances:
The commercial pilot departed on a night instrument flight rules flight in actual instrument meteorological in-flight conditions. Less than 2 minutes after the airplane departed the airport, the controller observed the airplane in a right turn and instructed the pilot to report his altitude. The pilot responded he thought he was at 3,500 feet and he thought he had lost the gyros. The pilot said he was trying to level out, and when the controller informed the pilot he observed the airplane on radar making a 360-degree right turn , the pilot said "roger." Three minutes and 23 seconds after departure the pilot said "yeah, I'm having some trouble right now" and there were no further radio communications from the flight. The on scene investigation disclosed that both wings and the tail section had separated from the airframe. All fractures of the wing and wing skin were typical of ductile overload with no evidence of preexisting failures such as fatigue or stress-corrosion. The deformation of the wings indicated an upward failure due to positive loading. No anomalies were noted with the gyro instruments, engine assembly or accessories
Probable cause:
The pilot's loss of control due to spatial disorientation and the pilot exceeding the design/stress limits of the aircraft. Factors contributing to the accident were the pilot's reported gyro problem, the dark night conditions , and prevailing instrument meteorological conditions.
Final Report:

Crash of a Beechcraft C90B King Air in Port Said: 2 killed

Date & Time: Jan 15, 2008 at 1320 LT
Type of aircraft:
Registration:
SU-ZAA
Flight Type:
Survivors:
No
Schedule:
Cairo - Port Said
MSN:
LJ-1353
YOM:
1994
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew departed Cairo-Intl Airport in the morning on a training flight to Port Said. Following four successful touch-and-go manoeuvres, the crew completed a 5th circuit. On approach, the aircraft apparently caught fire (engine explosion?), lost height and crashed in an open field, bursting into flames. Both pilots were killed.

Crash of a Beechcraft 1900C in Lihue: 1 killed

Date & Time: Jan 14, 2008 at 0508 LT
Type of aircraft:
Operator:
Registration:
N410UB
Flight Type:
Survivors:
No
Schedule:
Honolulu - Lihue
MSN:
UC-070
YOM:
1989
Flight number:
AIP253
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3098
Captain / Total hours on type:
1480.00
Aircraft flight hours:
19123
Circumstances:
The pilot was flying a night, single-pilot, cargo flight over water between two islands. He had routine contact with air traffic control, and was advised by the controller to maintain 6,000 feet at 0501 hours when the airplane was 11 miles from the destination airport. Two minutes later the flight was cleared for a visual approach to follow a preceding Boeing 737 and advised to switch to the common traffic advisory frequency at the airport. The destination airport was equipped with an air traffic control tower but it was closed overnight. The accident flight's radar-derived flight path showed that the pilot altered his flight course to the west, most likely for spacing from the airplane ahead, and descended into the water as he began a turn back toward the airport. The majority of the wreckage sank in 4,800 feet of water and was not recovered, so examinations and testing could not be performed. As a result, the functionality of the altitude and attitude instruments in the cockpit could not be determined. A performance study showed, however, that the airspeed, pitch, rates of descent, and bank angles of the airplane during the approach were within expected normal ranges, and the pilot did not make any transmissions during the approach that indicated he was having any problems. In fact, another cargo flight crew that landed just prior to the accident airplane and an airport employee reported that the pilot transmitted that he was landing on the active runway, and was 7 miles from landing. Radar data showed that when the airplane was 6.5 miles from the airport, at the location of the last recorded radar return, the radar target's mode C altitude report showed an altitude of minus 100 feet mean sea level. The pilot most likely descended into the ocean because he became spatially disoriented. Although visual meteorological conditions prevailed, no natural horizon and few external visual references were available during the visual approach. This increased the importance of monitoring flight instruments to maintain awareness of the airplane attitude and altitude. The pilot's tasks during the approach, however, included maintaining visual separation from the airplane ahead and lining up with the destination runway. These tasks required visual attention outside the cockpit. These competing tasks probably created shifting visual frames of reference, left the pilot vulnerable to common visual and vestibular illusions, and reduced his awareness of the airplane's attitude, altitude and trajectory.
Probable cause:
The pilot's spatial disorientation and loss of situational awareness. Contributing to the accident were the dark night and the task requirements of simultaneously monitoring the cockpit instruments and the other airplane.
Final Report: