Crash of a Douglas C-54G-15-DO Skymaster in Norman Wells

Date & Time: Jan 5, 2006 at 1704 LT
Type of aircraft:
Operator:
Registration:
C-GXKN
Flight Type:
Survivors:
Yes
Schedule:
Norman Wells – Yellowknife
MSN:
36090
YOM:
1946
Flight number:
BFL1405
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Buffalo Airways Limited Douglas C-54G-DC (DC-4), registration C-GXKN, serial number 36090, departed from Norman Wells, Northwest Territories, at 1749 mountain standard time for a visual flight rules flight to Yellowknife, Northwest Territories, with a crew of four and 2000 pounds of cargo. While climbing through an altitude of approximately 3500 feet above sea level, the crew experienced a failure of the number 2 engine and a nacelle fire. The crew carried out the Engine Fire Checklist, which included discharging the fire bottles and feathering the number 2 propeller. The fire continued unabated. During this period, an uncommanded feathering of the number 1 propeller and an uncommanded extension of the main landing gear occurred. The crew planned for an emergency off-field landing, but during the descent to the landing area, the fuel selector was turned off as part of the Engine Securing Checklist, and the fire self-extinguished. A decision was made to return to the Norman Wells Airport where a successful two-engine landing was completed at 1804 mountain standard time. The aircraft sustained substantial fire damage, but there were no injuries to the four crew members on board.
Probable cause:
Findings as to Causes and Contributing Factors:
1. Airworthiness Directive AD 48-12-01 mandates the replacement of the potentially hazardous fuel line, but the line had not been replaced on this aircraft.
2. A fuel leak from the main fuel inlet line in the engine compartment of this cargo DC-4 caused an in-flight fire that spread into the nacelle and wing.
3. The fuel-fed fire burned for an extended period of time because turning the fuel selector off is not required as part of the primary Engine Fire Checklist.
Final Report:

Crash of a Beechcraft A100 King Air in Sault Sainte Marie

Date & Time: Jan 2, 2006 at 0200 LT
Type of aircraft:
Operator:
Registration:
N700NC
Flight Type:
Survivors:
Yes
Schedule:
Traverse City – Sault Sainte Marie
MSN:
B-138
YOM:
1972
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7620
Captain / Total hours on type:
70.00
Aircraft flight hours:
13033
Circumstances:
The airplane, operated as an emergency medical flight, received substantial damage when it veered off the edge of runway 32 (5,235 feet long by 100 foot wide asphalt, slush and snow covered) and impacted a snow bank during landing roll at a non 14 CFR Part 139 airport. Night instrument meteorological conditions prevailed at the time of the accident. The pilot stated that during a non precision approach while two miles from the runway, he observed it to be completely covered in snow and slush. He continued the approach and upon touchdown the airplane decelerated in deep slush and veered to the left after a rollout of 1,200 feet. The pilot reported that prior to accepting the emergency medical flight, he obtained a weather briefing from a flight service station during which time no notices to airman (NOTAMs) existed that pertained to the destination airport. The pilot reported that he knew the airport was getting rain and was expecting the runway to be clear. He was surprised that the runway was covered with heavy slush. The airport manager stated that the runway was covered with wet, slushy snow as there had been periods of wet snow and rain that occurred late the previous day and evening of the accident. The airport weather observation recorded the presence of light snow in a period of approximately 24 hours before the accident. The pilot "wondered" why no NOTAM was issued relating to the runway condition. The Airport Facility Directory and the FAA's web site provides a list of 14 CFR Part 139 airports which are inherently required to issue NOTAMs. However, Advisory Circular 150/5200-28C states, the management of a public use airport is expected to make known, as soon as practical, any condition on or in the vicinity of an airport, existing or anticipated, that will prevent, restrict, or present a hazard during the arrival or departure of aircraft. Airport management is responsible for observing and reporting the condition of airport movement areas. Public notification is usually accomplished through the NOTAM system. The Aeronautical Information Manual, states that NOTAM information is information that could affect a pilot's decision to make a flight. It includes information such as airport or primary runway closures, changes in the status of navigational aids, ILS's, radar service availability, and other information essential to planned en route, terminal, or landing operations.
Probable cause:
The inadequate in-flight decision to continue the approach to land, directional control not maintained, and the contaminated runway. Contributing factors were flight to destination alternate not performed, a notice to airman not issued by airport personnel relating to snow/slush contamination of the runway, and the snow bank that the airplane impacted during the landing.
Final Report:

Crash of a Beechcraft A100 King Air in La Ronge

Date & Time: Dec 30, 2005 at 1500 LT
Type of aircraft:
Operator:
Registration:
C-GAPK
Flight Type:
Survivors:
Yes
Schedule:
Pinehouse Lake – La Ronge
MSN:
B-198
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
A Beechcraft A100 King Air, C-GAPK was inbound to La Ronge Airport, SK (YVC), from Pinehouse Lake on a medevac flight. On descent into La Ronge the crew noticed ice building on the wing leading edges. At approximately 6 miles back on final the crew operated the wing de-ice boots, however a substantial amount of residual ice remained after application of the boots. It was reported that in the landing flare at about 100 knots, the aircraft experienced an ice-induced stall from an altitude of about 20 feet followed by a hard landing. The right wing and nacelle buckled forward and downward from the landing impact forces to the extent that the right propeller struck the runway surface while the aircraft was taxiing off the runway.

Crash of a Learjet 35A in Truckee: 2 killed

Date & Time: Dec 28, 2005 at 1406 LT
Type of aircraft:
Operator:
Registration:
N781RS
Flight Type:
Survivors:
No
Schedule:
Twin Falls - Truckee - Carlsbad - Monterrey
MSN:
35-218
YOM:
1978
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4880
Captain / Total hours on type:
2200.00
Copilot / Total flying hours:
1650
Copilot / Total hours on type:
56
Aircraft flight hours:
9244
Circumstances:
The airplane collided with the ground during a low altitude, steep banked, base-to-final left turn toward the landing runway during a circling instrument approach. The airplane impacted terrain 1/3-mile from the approach end of runway 28, and north of its extended centerline. A witness, located in the airport's administration building, made the following statement regarding his observations: "I saw the aircraft in and out of the clouds in a close base for [runway] 28. I then saw the aircraft emerge from a cloud in a base to final turn [and] it appeared to be approximately 300-400 feet above the ground. The left wing was down nearly 90 degrees. The aircraft appeared north of the [runway 28] centerline. The aircraft pitched nose down approximately 30-40 degrees and appeared to do a 1/2 cartwheel on the ground before exploding." ATC controllers had cleared the airplane to perform a GPS-A (circling) approach. The published weather minimums for category C and D airplanes at the 5,900-foot mean sea level airport was 3 miles visibility, and the minimum descent altitude was 8,200 feet mean sea level (msl). Airport weather observers noted that when the accident occurred, the visibility was between 1 1/2 and 5 miles. Scattered clouds existed at 1,200 feet above ground level (7,100 feet msl), a broken ceiling existed at 1,500 feet agl (7,400 feet msl) and an overcast condition existed at 2,400 feet agl (8,300 feet msl). During the approach, the first officer acknowledged to the controller that he had received the airport's weather. The airplane overflew the airport in a southerly direction, turned east, and entered a left downwind pattern toward runway 28. A 20- to 30-knot gusty surface wind existed from 220 degrees, and the pilot inadequately compensated for the wind during his base leg-to-final approach turning maneuver. The airplane was equipped with Digital Electronic Engine Controls (DEEC) that recorded specific data bits relating to, for example, engine speed, power lever position and time. During the last 4 seconds of recorded data (flight), both of the power levers were positioned from a mid range point to apply takeoff power, and the engines responded accordingly. No evidence was found of any preimpact mechanical malfunction. The operator's flight training program emphasized that during approaches consideration of wind drift is essential, and a circling approach should not be attempted in marginal conditions.
Probable cause:
The pilot's inadequate compensation for the gusty crosswind condition and failure to maintain an adequate airspeed while maneuvering in a steep turn close to the ground.
Final Report:

Crash of a Socata TBM-700 in Lancaster

Date & Time: Dec 27, 2005 at 1446 LT
Type of aircraft:
Operator:
Registration:
N198X
Flight Type:
Survivors:
Yes
Schedule:
Camarillo - Lancaster
MSN:
138
YOM:
1998
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6296
Captain / Total hours on type:
2921.00
Copilot / Total flying hours:
1126
Copilot / Total hours on type:
15
Aircraft flight hours:
1603
Circumstances:
The airplane stalled on short final approach, and it impacted the ground. The purpose of the flight was for the student to receive dual flight instruction to become more acquainted with the airplane's handling characteristics. The student met with his certified flight instructor and received a briefing regarding the upcoming lesson involving, in part, takeoff and landing practice. The instructor directed his student to perform a simulated engine out approach, and engine power was reduced as the airplane glided toward the airport. The student entered a close in downwind approach and, at the direction of the instructor, then performed a left circling turn onto the base and final approach legs. The landing gear was lowered, and the student questioned the instructor regarding whether they could glide all the way to the runway. The instructor advised his student to maintain 90 knots airspeed. During the descent, as the airplane turned from the close in base leg onto the final approach leg, the instructor told his student "don't bank." The student rolled the wings level. Immediately thereafter, the left bank began a second time and the instructor again said, "Don't bank." The student replied, "I'm not." The instructor applied engine power and right rudder to reduce the left bank. The airplane stopped rolling left, and then rolled into a right bank, whereupon the right wing impacted the ground. At no time did the instructor direct his student to release the airplane's flight controls.
Probable cause:
The student's failure to maintain adequate airspeed, and the instructor's inadequate supervision and delayed remedial action, which resulted in a stall/mush.
Final Report:

Crash of a Cessna 208B Super Cargomaster in Portland

Date & Time: Dec 24, 2005 at 0743 LT
Type of aircraft:
Operator:
Registration:
N753FE
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Portland - Medford
MSN:
208B-0248
YOM:
1991
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4625
Captain / Total hours on type:
2450.00
Aircraft flight hours:
7375
Circumstances:
The pilot stated that during takeoff, "after becoming airborne, the airplane quit accelerating and a positive climb rate was not established." He pushed the power lever all the way forward, but did not feel a response from the airplane. Witnesses reported that the airplane became airborne, but failed to gain altitude and struck an antenna array and a fence off the departure end of the runway. The airplane continued across a slough, struck an embankment and came to rest about 900 feet from the departure end of the runway on a golf course located adjacent to the airport. Examination of the airplane revealed no pre-mishap airframe anomalies. Examination of the engine revealed that the compressor and power turbines displayed moderate circular rubbing damage to the blades suggesting engine operation at impact, likely in the low to mid power range. Examination of the airframe and engine revealed no anomalies that would have prevented the engine from producing power prior to impact. The reason for the partial loss of engine power was not determined.
Probable cause:
A partial loss of engine power for an undetermined reason during the initial takeoff climb resulting in an in-flight collision with objects.
Final Report:

Crash of a PZL-Mielec AN-28 in Zalingei: 2 killed

Date & Time: Dec 24, 2005
Type of aircraft:
Operator:
Registration:
ER-AJE
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Zalingei - Al Fashir
MSN:
1AJ006-12
YOM:
1989
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Zalingei Airport, en route to Al Fashir on behalf of the African Union, the twin engine aircraft crashed in unknown circonstances. Both pilots, Ukrainian and Moldavian citizens, were killed.

Crash of a Mitsubishi MU-2B-36 Marquise in Terrace: 2 killed

Date & Time: Dec 20, 2005 at 1834 LT
Type of aircraft:
Operator:
Registration:
C-FTWO
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Terrace – Vancouver
MSN:
672
YOM:
1975
Flight number:
FCV831
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2111
Captain / Total hours on type:
655.00
Copilot / Total flying hours:
2000
Copilot / Total hours on type:
500
Circumstances:
At 1834 Pacific standard time, the Nav Air Charter Inc. Mitsubishi MU-2B-36 aircraft (registration C-FTWO, serial number 672) took off from Runway 15 at the Terrace Airport for a courier flight to Vancouver, British Columbia. The left engine lost power shortly after take-off. The aircraft descended, with a slight left bank, into trees and crashed about 1600 feet east of the departure end of Runway 15 on a heading of 072° magnetic. The aircraft was destroyed by the impact and a post-crash fire, and the two pilots were fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. During the take-off, the left engine combustion chamber plenum split open due to a fatigue crack. The rupture was so extensive that the engine flamed out.
2. The crew did not feather the left engine or retract the flaps, and the aircraft entered a moderate left-hand turn after take-off; the resulting drag caused the aircraft to descend until it contacted trees.
3. The first officer’s flying skills may have been challenged during the handling of the engine failure, and the checklist was conducted out of sequence, suggesting that there may have been uncertainty in the cockpit. A contributing factor may have been the captain’s unfamiliarity with handling an emergency from the right seat.
4. The use of flap 20 for take-off, although in accordance with company policy, contributed to the difficulty in handling the aircraft during the emergency.
Findings as to Risk:
1. The TPE331 series engine plenum is prone to developing cracks at bosses, particularly in areas where two bosses are in close proximity and a reinforcing weld has been made. Cracks that develop in this area cannot necessarily be detected by visual inspections or even by fluorescent dye-penetrant inspections (FPIs).
2. Because the wing was wet and the air temperature was at 0°C, it is possible that ice may have formed on top of the wing during the take-off, degrading the wing’s ability to generate lift.
3. Being required to conduct only flap 20 take-offs increases the risk of an accident in the event of an engine problem immediately after take-off.
Other Finding:
1. The plenum manufactured with a single machined casting, incorporating the P3 and bleed air bosses, is an improvement over the non-single casting boss plenum; however, cracks may still develop at bosses elsewhere on the plenum.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Tamarindo

Date & Time: Dec 16, 2005 at 1150 LT
Operator:
Registration:
TI-AZQ
Survivors:
Yes
Schedule:
San José - Tamarindo
MSN:
805
YOM:
1984
Flight number:
5C330
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5297
Circumstances:
Following an uneventful flight from San José-Tobías Bolaños Airport, the crew started the descent to Tamarindo Airport runway 07. On short final, at a height of about 500 feet, control was lost and the aircraft crashed in a wooded area located 2 km short of runway. All eight occupants were injured while the aircraft was destroyed.
Probable cause:
The accident was the consequence of a loss of control on short final following the combination of the following factors:
- An elevator cable probably broke away due to a progressive wear combined with a damaged pulley,
- The proximity of the terrain,
- The low speed of the aircraft,
- The lack of crew training in such situation,
- The loss of control of the aircraft occurred at a critical phase of the flight, initially caused by a mechanical failure and later to human factors.

Crash of a Douglas DC-9-32 in Port Harcourt: 108 killed

Date & Time: Dec 10, 2005 at 1408 LT
Type of aircraft:
Operator:
Registration:
5N-BFD
Survivors:
Yes
Schedule:
Abuja - Port Harcourt
MSN:
47562
YOM:
1972
Flight number:
SO1145
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
103
Pax fatalities:
Other fatalities:
Total fatalities:
108
Captain / Total flying hours:
10050
Captain / Total hours on type:
1900.00
Copilot / Total flying hours:
920
Copilot / Total hours on type:
670
Aircraft flight hours:
51051
Aircraft flight cycles:
60238
Circumstances:
The aircraft with call sign OSL 1 145 which departed Abuja at 1225 hrs UTC (1.25 pm local time) with endurance of 2 hours 40 minutes was on a scheduled passenger flight enroute Port Harcourt with 110 Persons on Board (103 Passengers and 7 Crew) and the flight continued normally. At 1241 hours UTC, the aircraft cruising at FL240 (24,000ft) Above Sea Level (ASL) got in contact with Port Harcourt Approach Control. The Approach control gave the OSL 1145 in - bound clearance to expect no delay on ILS Approach to runway 21, QNH of 1008 and temperature of 33° C. At about 1242 hours UTC (1.42pm local), the Approach controller passed the 1230 hours UTC weather report to the aircraft as follows: Wind - 260° /02kts Visibility - 12km Weather - Nil Cloud - BKN 420m, few CB (N-SE) at 690m QNH - 1008HPA Temperature - 33° C. About 1250 hours UTC (1.50 pm local), the aircraft, which was 90 nautical miles to the station, contacted Approach Control for initial descent clearance and was cleared down to FL 160. The aircraft continued its descent until about 1300 hours UTC (2.00 pm local) when the crew asked Approach Control whether it was raining over the station to which the controller reported negative rain but scattered CB and the crew acknowledged. At 1304 hours UTC, the crew reported established on the glide and the localizer at 8 nautical miles to touch down. Then the Approach controller informed the aircraft of precipitation approaching the station from the direction of runway 21 and passed the aircraft to Tower for landing instructions. At 1305 hours UTC, the aircraft contacted Tower and reported established on glide and localizer at 6 nautical miles to touch down. The controller then cleared the airplane to land on runway 21 but to exercise caution as the runway surface was slightly wet and the pilot acknowledged. At about 1308 hours UTC, the aircraft made impact with the grass strip between runway 21 and taxiway i.e. 70m to the left of the runway edge, and 540m from the runway 21 threshold. At about 60m from the first impact, the aircraft tail section impacted heavily with a concrete drainage culvert. The airplane then disintegrated and caught fire along its path spanning over 790m. The cockpit section and the forward fuselage were found at about 330m from the rest of the wreckage further down on the taxiway creating a total wreckage trail of 1 120m. Fire and rescue operations were carried out after which 7 survivors and 103 bodies were recovered. Five of the survivors died later in the hospital. The accident occurred in `Instrument Meteorological Conditions' (IMC) during the day.
Probable cause:
The probable cause of the accident was the crew's decision to continue the approach beyond the Decision Altitude without having the runway and/or airport in sight.
The contributory factors were:
- The crew's delayed decision to carry out a missed approach and the application of improper procedure while executing the go-around.
- The aircraft encountered adverse weather conditions with the ingredients of wind shear activity on approach.
- The reducing visibility in thunderstorm and rain as at the time the aircraft came in to land was also a contributory factor to the accident. And the fact the airfield lightings were not on may also have impaired the pilot from sighting the runway.
- Another contributory factor was the fact that the aircraft had an impact with the exposed drainage concrete culvert which led to its disintegration and subsequent tire outbreak.
Final Report: