Crash of a Boeing 727-22F in Kindu

Date & Time: Oct 31, 2005 at 1300 LT
Type of aircraft:
Registration:
9Q-CPJ
Flight Type:
Survivors:
Yes
MSN:
19088
YOM:
1967
Location:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was completing a cargo flight with various equipments on behalf of the Conader, the Commission Nationale de Désarmement et de Réinsertion. Following an uneventful flight, the crew started the approach in heavy rain falls. After landing on a wet runway, the aircraft was unable to stop within the remaining distance and overran. It lost its undercarriage and came to rest in marshy field. All three occupants escaped uninjured while the aircraft was damaged beyond repair. Aquaplaning suspected.

Crash of a Let L-410UVP-E19A in Bergamo: 3 killed

Date & Time: Oct 30, 2005 at 2204 LT
Type of aircraft:
Operator:
Registration:
9A-BTA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bergamo - Zagreb
MSN:
91 25 38
YOM:
1991
Flight number:
TDR729
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
7780
Captain / Total hours on type:
760.00
Copilot / Total flying hours:
1272
Copilot / Total hours on type:
200
Aircraft flight hours:
7185
Circumstances:
The twin engine aircraft departed Bergamo-Orio al Serio Airport on a night cargo service to Zagreb, carrying one passenger (the captain's wife), two pilots and a load of 1,600 kilos of small packages. After takeoff from runway 28, while climbing in foggy conditions, the aircraft entered a left turn then descended, collided with a powerline and crashed in an open field located one km north of the airfield. The aircraft disintegrated on impact and all three occupants were killed.
Probable cause:
As far as is established, documented and substantiated, the cause of the accident is due to a loss of control in flight of the aircraft. Although the cause of this loss of control could not be established with incontrovertible certainty, it can reasonably be assumed that it was caused by a deterioration in the situation awareness of the crew during the initial climb immediately after take-off. The loss of such situation awareness may have been contributed jointly or severally:
- The displacement or incorrect positioning of the load, which would have induced a moment of rotation on the longitudinal axis of the aircraft (roll) not immediately perceived and counteracted by the crew;
- Spatial disorientation, as a result of the possible optical illusion produced by the high speed "E" TWY lights, which, crossing the thick fog, could have induced the pilot to veer, thus causing the final loss of control of the aircraft. In addition, the limited flight experience of the co-pilot and the inadequate application of CRM techniques by the crew did not allow for a timely identification of the hazardous situation and the necessary actions to recover the aircraft.
Final Report:

Crash of a Learjet 25D in Sacramento

Date & Time: Oct 26, 2005 at 1825 LT
Type of aircraft:
Operator:
Registration:
N888DV
Flight Type:
Survivors:
Yes
Schedule:
Sacramento - Sacramento
MSN:
25-370
YOM:
1984
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17500
Captain / Total hours on type:
1100.00
Copilot / Total flying hours:
20000
Copilot / Total hours on type:
70
Circumstances:
The crew landed with the landing gear in the retracted position. While the airplane was on the base leg of the traffic pattern, the pilot heard a helicopter pilot make a transmission over the common radio frequency. As he completed the before landing checklist the pilot searched for the helicopter that he heard over the radio. During the landing flare he realized something was amiss and looked down at the instrument panel. He noticed that the landing gear lights were illuminated red. Just prior to contacting the runway surface he reached for the landing gear handle and manipulated it in the down position. The airplane made a smooth touchdown with the landing gear in the retracted position. The pilot stated that he did not make the proper check for the gear extension due to the timing of the helicopter distraction. The pilot reported no preimpact mechanical malfunctions or failures with the airplane or engine, stating that the accident was the result of pilot error.
Probable cause:
The pilot's failure to extend the landing gear and to verify they were in the down and locked position prior to touchdown. A related factor was his diverted attention.
Final Report:

Crash of a Boeing 737-4Q8 in Mumbai

Date & Time: Oct 9, 2005 at 1920 LT
Type of aircraft:
Operator:
Registration:
VT-SID
Survivors:
Yes
Schedule:
Calcutta - Mumbai
MSN:
24705
YOM:
1990
Flight number:
RSH117
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
111
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Calcutta, the aircraft landed at Mumbai-Chhatrapati Shivaji Airport runway 27. Unable to stop within the remaining distance, the aircraft overran and came to rest few dozen metres further. All 117 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a Casa 212 Aviocar 100 in Gerona

Date & Time: Oct 9, 2005
Type of aircraft:
Operator:
Registration:
T.12B-29
Flight Type:
Survivors:
Yes
MSN:
51
YOM:
1976
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Empuriabrava Airfield, the aircraft was too low, causing the undercarriage to collide with the perimeter fence. Decision was taken to divert to Gerona-Costa Brava Airport. The aircraft landed on a foamed runway and came to rest. There were no casualties but the aircraft was damaged beyond repair.

Crash of a Cessna 208B Super Cargomaster in Winnipeg: 1 killed

Date & Time: Oct 6, 2005 at 0543 LT
Type of aircraft:
Operator:
Registration:
C-FEXS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Winnipeg – Thunder Bay
MSN:
208B-0542
YOM:
1996
Flight number:
FDX8060
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4570
Captain / Total hours on type:
1500.00
Aircraft flight hours:
6724
Circumstances:
On the day before the occurrence, the accident aircraft arrived in Winnipeg, Manitoba, on a flight from Thunder Bay, Ontario. The aircraft was parked in a heated hangar overnight and was pulled outside at about 0410 central daylight time. The pilot reviewed the weather information and completed planning for the flight, which was estimated to take two hours and six minutes. The aircraft was refuelled and taxied to Apron V at the Winnipeg International Airport, where it was loaded with cargo. After loading was complete, the pilot obtained an instrument flight rules (IFR) clearance for the flight to Thunder Bay, taxied to Runway 36, received take-off clearance, and departed. The aircraft climbed on runway heading for about one minute to an altitude of 1300 feet above sea level (asl), 500 feet above ground level (agl). The flight was cleared to 9000 feet asl direct to Thunder Bay, and the pilot turned on course. The aircraft continued to climb, reaching a maximum altitude of 2400 feet asl about 2.5 minutes after take-off. The aircraft then started a gradual descent averaging about 400 feet per minute (fpm) until it descended below radar coverage. The accident occurred during hours of darkness at 0543. The Winnipeg Fire Paramedic Service were notified and responded from a nearby station.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The aircraft departed at a weight exceeding the maximum take-off weight and the maximum weight for operation in icing conditions.
2. After departure from Winnipeg, the aircraft encountered in-flight icing conditions in which the aircraftís performance deteriorated until the aircraft was unable to maintain altitude.
3. During the attempt to return to the Winnipeg International Airport, the pilot lost control of the aircraft, likely with little or no warning, at an altitude from which recovery was not possible.
Findings as to Risk:
1. Aviation weather forecasts incorporate generic icing forecasts that may not accurately predict the effects of icing conditions on particular aircraft. As a result, specific aircraft types may experience more significant detrimental effects from icing than forecasts indicate.
2. Bulk loading prevented determining the cargo weight in each zone, resulting in a risk that the individual zone weight limits could have been exceeded.
3. The aircraftís centre of gravity (CG) could not be accurately determined, and may have been in the extrapolated shaded warning area on the CG limit chart. Although it was determined that the CG was likely forward of the maximum allowable aft CG, bulk loading increased the risk that the CG could have exceeded the maximum allowable aft CG.
4. The incorrect tare weight on the Toronto cargo container presented a risk that other aircraft carrying cargo from that container could have been inadvertently overloaded.
Other Findings:
1. The pilotís weather information package was incomplete and had to be updated by a telephone briefing.
2. The operatorís pilots were not pressured to avoid using aircraft de-icing facilities or to depart with aircraft unserviceabilities.
3. The aircraft departed Winnipeg without significant contamination of its critical surfaces.
4. The biological material on board the aircraft was disposed of after the accident, with no indication that any of the material had been released into the ground or the atmosphere.
5. The fact that the aircraft was not equipped with flight data recorder or cockpit voice recorder equipment limited the information available for the occurrence investigation and the scope of the investigation.
Final Report:

Crash of an Antonov AN-12 in Aru: 2 killed

Date & Time: Oct 4, 2005
Type of aircraft:
Operator:
Registration:
9Q-CWC
Survivors:
Yes
Schedule:
Kisangani – Bunia
MSN:
2 40 09 01
YOM:
1962
Location:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
96
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The aircraft departed Kisangani on a flight to Bunia, carrying 96 soldiers and four crew members on behalf of the Congolese Army Forces. Upon landing at Aru Airstrip, the right main gear collapsed and the aircraft veered to the left and came to rest on the left side of the runway. Two soldiers were killed while walking into the still running propellers. Eleven people were injured.

Crash of a Pilatus PC-6/B2-H2 Turbo Porter in DeLand

Date & Time: Oct 3, 2005 at 1505 LT
Operator:
Registration:
N7895J
Flight Phase:
Survivors:
Yes
Schedule:
DeLand - DeLand
MSN:
767
YOM:
1976
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5233
Captain / Total hours on type:
43.00
Aircraft flight hours:
6517
Circumstances:
The airline transport certificated pilot with 10 skydiving passengers began a takeoff in a tailwheel-equipped and turboprop powered airplane on a CFR Part 91 skydiving flight. As the airplane started its climb, the pitch angle of the nose of the airplane increased until the airplane appeared to stall about 50 to 100 feet agl. It descended and impacted the runway in a left wing, nose low attitude. Several FAA inspectors responded to the accident site and documented the accident scene and the airplane systems. The inspectors reported that flight control continuity was established, and they noted that the stabilizer appeared to be in a nose up trim position. Measurement of the stabilizer trim position equated to a 56.5 percent nose up trim condition. The airplane's horizontal stabilizer trim system is electrical. An electric trim indicator, and a trim warning light were installed in the upper left portion of the instrument panel. The light will illuminate if "full-up" trim is set, and the engine is producing over 80 percent power. A placard stating, "Set Correct Trim for Takeoff," was installed on the lower instrument panel in front of the pilot position. The airplane's flight manual contains a "Before Takeoff" warning, which states, in part: "Warning - An extreme out-of-trim stabilizer can, in combination with loading, flaps position and power influence, result in an uncontrollable aircraft after the aircraft leaves the ground." In addition, a caution states, in part: "Caution - Failure to set correct trim settings will result in large control forces and/or unrequested pitching/yawing." Pilot actions listed in the "Before Takeoff" checklist include stabilizer trim settings. The airplane contained seat belts for all passengers, but the pilot's shoulder harness was not used, as it was folded and tie-wrapped near its upper attach point.
Probable cause:
The pilot's incorrect setting of the stabilizer trim and his failure to maintain adequate airspeed during takeoff initial climb, which resulted in a stall. A factor contributing to the accident was an inadvertent stall. A factor contributing to the severity of the pilot's injuries was his failure to utilize his shoulder harness.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Northrepps

Date & Time: Sep 30, 2005 at 1817 LT
Registration:
N421CA
Flight Type:
Survivors:
Yes
MSN:
421C-0153
YOM:
1976
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2475
Captain / Total hours on type:
255.00
Circumstances:
Northrepps Airfield has a single grass runway, orientated 18/36, and 1617 ft (493 m) long, with a down slope of 1.8% on Runway 18. On the day of the accident, the short grass was wet and an aftercast indicated that the wind at Northrepps was from approximately 210º at 10 to 13 kt. The pilot first flew an approach to Runway 18 and touched down close to the threshold; he subsequently reported that, looking at the slope of the runway ahead of him, he decided to go around and re‑position for a landing on Runway 36, to take advantage of the up-slope on that runway. The pilot stated that, during the approach to Runway 18, he had assessed that the braking effect of the wind would be insignificant in comparison to the braking effect that would be afforded by the uphill slope when landing on Runway 36. The pilot recalled seeing a “shortened” and “non‑standard” windsock mounted on a caravan adjacent to the Runway 18 threshold, but he did not believe that it could be relied upon for an accurate wind strength determination. He did not recall having seen the airfield’s other, larger, windsock. The approach for a short field landing on Runway 36 was normal and the pilot closed the throttles just before the threshold. The aircraft touched down close to the threshold, and the pilot immediately retracted the flaps. The pilot reported that he had lost two thirds of his touchdown speed by about the mid-point of the runway, and that the braking was within his expectations. He subsequently stated that he “seemed to get to a point… when I realised that I was effectively getting no braking at all from the wheels and the uphill slope had petered away”; he then experienced a sensation which he described as being similar to aquaplaning, with all braking authority seemingly lost. The aircraft continued along the runway, crossed the grassed overshoot area, ran over an earth bank beyond the end of the runway and came to rest on a public road just north of this bank. The pilot shut the aircraft down and all three occupants vacated the aircraft without difficulty.
Probable cause:
Prior to the flight, the pilot did not use the aircraft flight manual to calculate his landing performance. Given the wind and the surface conditions at Northrepps at the time of the intended operation, performance calculations showed that a landing could only be made safely if both the precise landing parameters and adequate braking were achieved. There was no evidence regarding the point of touchdown or the associated speed; it is therefore not possible to say with any certainty whether the failure to stop was the result of an imperfectly executed landing or the lack of braking effect on the short, wet grass.
Final Report:

Crash of a Mitsubishi MU-2B-36 Marquise in West Memphis: 1 killed

Date & Time: Sep 22, 2005 at 1958 LT
Type of aircraft:
Operator:
Registration:
N103RC
Flight Type:
Survivors:
No
Schedule:
West Memphis - Gainesville
MSN:
673
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12600
Captain / Total hours on type:
1900.00
Aircraft flight hours:
10892
Circumstances:
The twin-engine airplane was destroyed when it impacted an earthmoving scraper and terrain in a field about 2.5 miles north of the departure airport in night visual meteorological conditions. Witnesses reported that the pilot had aborted an earlier flight when he returned to the airport and told the mechanic that he had a right engine fire warning light. The discrepancy could not be duplicated during maintenance, and the airplane departed. About 23 minutes after departure, the pilot reported to air traffic control that he needed to return to the airport to have something checked out. The pilot did not report to anyone why he decided to return to the departure airport, and he flew over four airports when he returned to the departure airport. Radar track data indicated that the airplane flew over the departure end of runway 35 at an altitude of about 1,600 feet agl, and made a descending left turn. The airplane's altitude was about 800 feet agl when it crossed the final approach course for runway 35. The airplane continued the descending left turn, but instead of landing on runway 35, the airplane flew a course that paralleled the runway, about 0.8 nm to the right of runway 35. The airplane continued to fly a northerly heading and continued to descend. The radar track data indicated that the airplane's airspeed was decreasing from about 130 kts to about 110 kts during the last one minute and fifty seconds of flight. The last reinforced beacon return indicated that the airplane's altitude was about 200 feet agl, and the airspeed was about 107 kts. The airplane impacted terrain about 0.75 nm from the last radar contact on a 338-degree magnetic heading. A witness reported that the airplane was going slow and was "extremely low." He reported that the airplane disappeared, and then there was an explosion and a fireball that went up about 1,000 feet. Inspection of the airplane revealed that it impacted the earthmover in about a wings level attitude. The landing gear handle was found to be in the landing gear UP position. The inspection of the left engine and propeller revealed damage indicative of engine operation at the time of impact. Inspection of the right engine revealed damage indicative of the engine not operating at the time of impact, consistent with an engine shutdown and a feathered propeller. No pre-existing conditions were found in either engine that would have interfered with normal operation. The inspection of the right engine fire detection loop revealed that the connector had surface contamination. When tested, an intermittent signal was produced which could give a fire alarm indication to the pilot. After the surface contamination was removed, the fire warning detection loop operated normally.
Probable cause:
The pilot's improper in-flight decision not to land at the departure runway or other available airports during the emergency descent, and his failure to maintain clearance from a vehicle and terrain. Contributing factors were a false engine fire warning light, inadequate maintenance by company personnel, a contaminated fire warning detection loop, and night conditions.
Final Report: