Crash of a BAe ATP in Chennai

Date & Time: Jun 15, 2007 at 0850 LT
Type of aircraft:
Operator:
Registration:
VT-FFB
Flight Type:
Survivors:
Yes
Schedule:
Bombay – Bangalore – Madras
MSN:
2039
YOM:
1991
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a cargo flight from Bombay to Madras with an intermediate stop in Bangalore. On final approach to Madras Airport, the aircraft nosed down and landed nose first. Upon impact, the nose gear collapsed and the aircraft slid on its nose for few dozen metres before coming to rest. A fire erupted but was quickly extinguished. Both pilots escaped uninjured while the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-3 Otter in Mayo: 1 killed

Date & Time: Jun 2, 2007 at 1755 LT
Type of aircraft:
Operator:
Registration:
C-GZCW
Flight Phase:
Flight Type:
Survivors:
No
MSN:
108
YOM:
1956
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4000
Captain / Total hours on type:
202.00
Circumstances:
The Black Sheep Aviation and Cattle Company de Havilland DHC-3T Turbo Otter (registration C-GZCW, serial number 447) had been loaded with a cargo of lumber at Mayo, Yukon. The aircraft was taxied to the threshold of Runway 06 and the pilot began the take-off roll at 1755 Pacific daylight time. At lift-off, the aircraft entered an extreme nose-up attitude and began to rotate to the right. Shortly thereafter, the aircraft struck the airport ramp. The pilot, who was the sole occupant of the aircraft, was fatally injured. A small post-impact fire was extinguished by first responders.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The aircraft was loaded in a manner that resulted in the centre of gravity being aft of the rearward limit.
2. Because the cargo was not properly secured, it shifted towards the rear of the aircraft, resulting in the centre of gravity moving further aft, causing the aircraft to pitch up and stall.
Final Report:

Crash of a Short C-23 Sherpa in Dodoma

Date & Time: Jun 1, 2007
Type of aircraft:
Operator:
Registration:
JW9036
Flight Type:
Survivors:
Yes
Schedule:
Sumbawanga – Dodoma
MSN:
3121
YOM:
1986
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Dodoma Airport, both engines failed simultaneously. The captain attempted an emergency landing in a cornfield located near the Kizota district. Upon landing, the aircraft lost its nose gear and slid for few dozen metres before coming to rest. All 13 occupants escaped with minor injuries and the aircraft was damaged beyond repair.

Crash of a Carvair ATL-98 in Nixon Fork Mine

Date & Time: May 30, 2007 at 1200 LT
Operator:
Registration:
N898AT
Flight Type:
Survivors:
Yes
Schedule:
Fairbanks - Nixon Fork Mine
MSN:
42994
YOM:
1946
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
21658
Captain / Total hours on type:
13600.00
Aircraft flight hours:
55753
Circumstances:
The captain was making a VFR landing approach to a remote mining airstrip in a modified Douglas DC-4 airplane at the end of a cross-country nonscheduled cargo flight. The modified airplane had a raised cockpit above the fuselage to accommodate an upward swinging nose door. During the landing flare/touchdown, the airplane undershot the runway threshold, and right main landing gear struck the lip of the runway. The right main landing gear was torn off, which allowed the nose and right wing to collide with the runway surface. The right wing was torn off the fuselage and caught fire. The fuselage, containing the cargo of fuel bladders, slid to a stop and rolled about 90 degrees to the left. The pilot indicated that due to the additional cockpit height of the modified airplane, versus a standard Douglas DC-4 airplane, the airplane was lower than he perceived.
Probable cause:
An undershoot and collision with the runway when the pilot misjudged the distance/altitude during the landing flare/touchdown.
Final Report:

Crash of a Cessna 421A Golden Eagle I in Chesterfield

Date & Time: May 23, 2007 at 1540 LT
Type of aircraft:
Registration:
N4082L
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Chesterfield - Cahokia
MSN:
421A-0082
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15450
Captain / Total hours on type:
1200.00
Aircraft flight hours:
2835
Circumstances:
Shortly after takeoff the pilot experienced a loss of power on the right engine. He attempted to return to the airport to land, but determined that he was not going to reach the runway so he elected to land on a dirt field. He flew under power lines that were in his flight path and attempted to flare the airplane prior to it impacting the terrain. The airplane was equipped with Teledyne Continental GTSIO-520 engines. Post accident examination of the right engine revealed that all of the teeth on the starter adapter gear and several of the teeth on the crankshaft gear were missing. Several gear teeth and metal filings were located in the oil sump. The torsional damper to shaft gear woodruff key was sheared. The torsional damper was placed on a test bench to determine the damping time. The consecutive tests averaged a damping time of 6.9 seconds. The damping time of a new damper is min/max 1.5 to 3.125 seconds. Metallurgical examination revealed 15 starter gear teeth and 11 crankshaft gear teeth were fractured near their root. No indications of preexisting cracking were noted. At least two of the starter gear teeth and several of the crankshaft gear teeth displayed spalling and wear at the pitch line of the teeth. On June 13, 1994, Teledyne Continental issued a Mandatory Service Bulletin, MSB94-4, addressing the possible failure of the starter adapter gear and/or crankshaft gear on GTSIO-520 and GIO-550 engines. On October 31, 2005, Teledyne Continental issued revision, MSB94-4G. The service bulletin called for an inspection of the starter adapter viscous damper and shaft gear backlash every 100 hours of engine operation, and a visual inspection of the starter adapter shaft and crankshaft gear teeth for spalling, pitting, and wear, every 400 hours of engine operation. The Federal Aviation Administration (FAA) issued Airworthiness Directive (AD) 2005-20-04, effective November 1, 2005, requiring compliance with the Teledyne Continental Mandatory Service Bulletin. Maintenance records showed the mandatory service bulletin had been complied with when the right engine was overhauled and installed in March 2001. There was no indication in the maintenance records that either the mandatory service bulletin or the AD had been complied with since the engine was installed. The engine had a total time of 541.9 hours at the time of the accident. The pilot did not follow the published emergency procedures.
Probable cause:
Maintenance personnel failed to comply with an Airworthiness Directive which resulted in the total failure of the starter adapter gear teeth and the crankshaft gear teeth and the pilot failed to follow the published emergency procedures. Contributing to the accident were the low altitude at which the loss of power occurred, the power lines, and the unsuitable terrain which prevented the pilot from adequately flaring the airplane and resulted in the subsequent hard landing.
Final Report:

Crash of a Canadair RegionalJet CRJ-100ER in Toronto

Date & Time: May 20, 2007 at 1235 LT
Operator:
Registration:
C-FRIL
Survivors:
Yes
Schedule:
Moncton – Toronto
MSN:
7051
YOM:
1994
Flight number:
AC8911
Country:
Crew on board:
37
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft, with 3 crew members and 37 passengers on board, was operating as Air Canada Jazz Flight 8911 from Moncton, New Brunswick, to Toronto/Lester B. Pearson International Airport, Ontario. At 1235 eastern daylight time, the aircraft landed on Runway 06R with a 90º crosswind from the left, gusting from 13 to 23 knots. The aircraft first contacted the runway in a left-wing-down sideslip. The left main landing gear struck the runway first and the aircraft sustained a sharp lateral side load before bouncing. Once airborne again, the flight and ground spoilers deployed and the aircraft landed hard. Both main landing gear trunnion fittings failed and the landing gear collapsed. The aircraft remained upright, supported by the landing gear struts and wheels. The aircraft slid down the runway and exited via a taxiway, where the passengers deplaned. There was no fire. There were no injuries to the crew; some passengers reported minor injuries as a result of the hard landing.
Probable cause:
Findings as to Causes and Contributing Factors:
1. On final approach, the captain diverted his attention from monitoring the flight, leaving most of the decision making and control of the aircraft to the first officer, who was significantly less experienced on the aircraft type. As a result, the first officer was not fully supervised during the late stages of the approach.
2. The first officer did not adhere to the Air Canada Jazz standard operating procedures (SOPs) in the handling of the autopilot and thrust levers on short final, which left the aircraft highly susceptible to a bounce, and without the bounce protection normally provided by the ground lift dump (GLD) system.
3. Neither the aircraft operating manual nor the training that both pilots had received mentioned the importance of conducting a balked or rejected landing when the aircraft bounces. Given the low-energy state of the aircraft at the time of the bounce, the first officer attempted to salvage the landing.
4. When the thrust levers were reduced to idle after the bounce, the GLD system activated. The resultant sink rate after the GLD system deployed was beyond the certification standard for the landing gear and resulted in the landing gear trunnion fitting failures.
5. There was insufficient quality control at the landing gear overhaul facility, which allowed non-airworthy equipment to enter into service. The condition of the shock struts would have contributed to the bounce.
Findings as to Risk:
1. Several passengers took carry-on items with them as they exited the aircraft, despite being instructed not to do so.
2. The location of the stored megaphone did not allow the flight attendant to have ready access after the passengers started moving to the exit door.
Final Report:

Crash of a Cessna 404 Titan II in Goroka

Date & Time: May 19, 2007
Type of aircraft:
Operator:
Registration:
P2-ALK
Survivors:
Yes
MSN:
404-0222
YOM:
1978
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight, the pilot started the approach to Goroka Airport in poor weather conditions. After landing on runway 17R, the aircraft was unable to stop within the remaining distance. It overran and came to rest few dozen metres further. All four occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Boeing 737-8AL near Douala: 114 killed

Date & Time: May 5, 2007 at 0008 LT
Type of aircraft:
Operator:
Registration:
5Y-KYA
Flight Phase:
Survivors:
No
Schedule:
Abidjan – Douala – Nairobi
MSN:
35069/2079
YOM:
2006
Flight number:
KQ507
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
108
Pax fatalities:
Other fatalities:
Total fatalities:
114
Captain / Total flying hours:
8682
Copilot / Total flying hours:
831
Aircraft flight hours:
2100
Aircraft flight cycles:
734
Circumstances:
During the night of 4th May 2007, the B737-800, registration 5Y-KYA, operating as flight KQ507 from Abidjan international Airport, Ivory Coast, to the Jomo Kenyatta Airport in Nairobi (Kenya), made a scheduled stop-over at the Douala international Airport. The weather was stormy. The aircraft took off and climbed into the dark night. There were no external visual references, yet no instrument scanning was done by the crew. At 1000 feet climbing, the pilot flying released the flight controls for 55 seconds without having engaged the autopilot. The bank angle of the airplane increased continuously by itself very slowly up to 34° right and the captain appeared unaware of the airplane’s changing attitude. Just before the "Bank Angle" warning sounds, the captain grabbed the controls, appeared confused about the attitude of the airplane, and made corrections in an erratic manner increasing the bank angle to 50° right. At about 50° bank angle, the autopilot was engaged and the inclination tended to stabilize; then movements of the flight controls by the pilot resumed and the bank angle increased towards 70° right. A prolonged right rudder input brought the bank angle to beyond 90°. The aircraft descended in a spiral dive until it crashed at approximately 0008LT (May 5) in a mangrove swamp located 5,5 km southeast of Douala Airport. The aircraft disintegrated on impact and all 114 occupants were killed.
Probable cause:
The airplane crashed after loss of control by the crew as a result of spatial disorientation (non recognized or subtle type transitioning to recognized spatial disorientation), after a long slow roll, during which no instrument scanning was done, and in the absence of external visual references in a dark night. Inadequate operational control, lack of crew coordination, coupled with the non-adherence to procedures of flight monitoring, confusion in the utilization of the AP, have also contributed to cause this situation.
Final Report:

Crash of a Cessna 550 Citation II in Dillon: 2 killed

Date & Time: May 3, 2007 at 1037 LT
Type of aircraft:
Operator:
Registration:
N22HP
Flight Type:
Survivors:
No
Schedule:
Rockford - Dillon
MSN:
550-0103
YOM:
1986
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5057
Captain / Total hours on type:
1200.00
Aircraft flight hours:
10526
Circumstances:
Radar data indicated that the airplane descended on a straight track from flight level (FL) 380 in accordance with the pilot's clearance to descend to 13,000 feet and begin the VOR (very high frequency omni-directional radio range) approach to the destination airport. The last transmission from the pilot was an acknowledgment of the cancellation of radar service and an instruction to switch to the airport advisory frequency. At that time, the airplane was at a mode C reported altitude of 14,000 feet. The airplane maintained a steady descent rate for the next minute and leveled off at 13,000 feet. About 2 1/2 minutes later, the airplane began a turn to the right to head outbound for the procedure turn on the approach and descended to 12,900 feet. The approach procedure specified a minimum altitude of 8,200 feet in the procedure turn. The airplane lost 1,600 feet in the next 10 seconds, and this was the last radar contact. A witness working in his office at the airport heard a loud engine noise, and then a “plop” noise. He said that the engine noise was loud, then softer, and then loud again. He heard it for 3 to 5 seconds. Another witness saw an airplane below the cloud bases that was turning to the right with a nose low pitch attitude of about 75 to 80 degrees. It made six to seven turns before it disappeared from sight behind terrain, and the radius of the turn got tighter as the airplane descended. Examination of the airframe, systems, and engines revealed no anomalies that would have precluded normal operation. Anti-ice fluid was on the leading edges of the wing and tail anti-ice panels. An Airmen’s Meteorological Information (AIRMET) in effect for an area that included the accident site noted that the freezing level was from 4,000 to 10,000 feet with the potential for icing from the freezing level to 20,000 feet.
Probable cause:
An in-flight loss of control for undetermined reasons.
Final Report:

Crash of a Britten-Norman BN-2A-20 Islander in Hamilton

Date & Time: Apr 28, 2007 at 1105 LT
Type of aircraft:
Operator:
Registration:
N634MA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Hamilton - Selway Lodge
MSN:
464
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13000
Captain / Total hours on type:
2750.00
Aircraft flight hours:
16257
Circumstances:
During the initial climb after takeoff, just after the aircraft passed 400 feet above ground level (agl), the pilot shut off the fuel boost pumps in preparation for the en route climb. Soon thereafter, one of the engines lost power without warning, and because he was carrying a heavy load, he immediately feathered the propeller and started looking for a place to put the aircraft down. Because there was rising terrain and scattered houses south of the airport, he had to maneuver to get to an open area. During the forced landing on the uneven terrain, one of the landing gear legs collapsed, and the aircraft impacted the terrain and slid into a power pole. A post-accident teardown inspection of the engine and the aircraft systems did not reveal any anomalies that would have resulted in the failure of the engine that lost power.
Probable cause:
The loss of power in one engine, for undetermined reasons, soon after establishing the takeoff departure climb. Factors include rough/uneven terrain.
Final Report: