Crash of a Cessna 560 Citation V in Pueblo: 8 killed

Date & Time: Feb 16, 2005 at 0913 LT
Type of aircraft:
Operator:
Registration:
N500AT
Survivors:
No
Schedule:
Richmond – Columbia – Pueblo – Santa Ana
MSN:
560-0146
YOM:
1991
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
8577
Captain / Total hours on type:
2735.00
Copilot / Total flying hours:
2614
Copilot / Total hours on type:
334
Aircraft flight hours:
3657
Circumstances:
On February 16, 2005, about 0913 mountain standard time, a Cessna Citation 560, N500AT, operated by Martinair, Inc., for Circuit City Stores, Inc., crashed about 4 nautical miles east of Pueblo Memorial Airport, Pueblo, Colorado, while on an instrument landing system approach to runway 26R. The two pilots and six passengers on board were killed, and the airplane was destroyed by impact forces and post crash fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 91 on an instrument flight rules flight plan. Instrument meteorological conditions prevailed at the time of the accident.
Probable cause:
The flight crew's failure to effectively monitor and maintain airspeed and comply with procedures for deice boot activation on the approach, which caused an aerodynamic stall from which they did not recover. Contributing to the accident was the Federal Aviation Administration's failure to establish adequate certification requirements for flight into icing conditions, which led to the inadequate stall warning margin provided by the airplane's stall warning system.
Final Report:

Crash of a Grumman G-21A Goose in Penn Yan

Date & Time: Feb 15, 2005 at 0942 LT
Type of aircraft:
Registration:
N327
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Penn Yan - Penn Yan
MSN:
1051
YOM:
1939
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17573
Captain / Total hours on type:
46.00
Copilot / Total flying hours:
18347
Copilot / Total hours on type:
24
Aircraft flight hours:
8825
Circumstances:
The purpose of the flight was for the flight instructor to provide multiengine airplane training, in a late 1930's vintage amphibious airplane, to his brother, a single engine airplane rated private pilot. No published performance data was available for the airplane, and according to the flight instructor, much of what he knew about the performance of the airplane he learned from previous flights. Just after takeoff on the accident flight, and about 600 feet above ground level (agl), and as the pilot was retracting the landing gear and starting a left turn to the crosswind leg of the traffic pattern, the flight instructor retarded the right throttle in order to simulate a failure of the right engine. The pilot executed the procedures for an in-flight engine failure and the instructor looked out of the window to check for traffic in the airport traffic pattern. The flight instructor then heard the pilot state "I am at blue line but losing altitude." The flight instructor continued to scan for traffic and moved the right throttle forward to about the "half throttle" position. The pilot could not recall if he had adjusted either of the power controls after the initial application of power for takeoff. The airplane continued to descend, impacted the ground, and caught fire.
Probable cause:
The flight instructor's inadequate planning/decision and his remedial action to conduct or recover from a simulated emergency procedure.
Final Report:

Crash of a Hawker-Siddeley HS.780 Andover CC.2 in Old Fangak

Date & Time: Feb 15, 2005
Operator:
Registration:
9XR-AB
Flight Type:
Survivors:
Yes
Schedule:
Lokichogio - Old Fangak
MSN:
1564
YOM:
1965
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was damaged beyond repair following a landing accident. There were no casualties among the crew and the aircraft was damaged beyond repair. The accident occurred somewhere in February, exact date unknown.

Crash of a Dassault Falcon 20C in Oranjestad

Date & Time: Feb 13, 2005
Type of aircraft:
Operator:
Registration:
PR-SUL
Flight Type:
Survivors:
Yes
Schedule:
Porlamar - Oranjestad
MSN:
129
YOM:
1968
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful positioning flight from Porlamar, the aircraft landed at Oranjestad-Reina Beatrix Airport with its undercarriage retracted. The aircraft slid on ity belly for few dozen metres before coming to rest. Both pilots escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Canadair CL-600-1A11 Challenger in Teterboro

Date & Time: Feb 2, 2005 at 0718 LT
Type of aircraft:
Operator:
Registration:
N370V
Flight Phase:
Survivors:
Yes
Schedule:
Teterboro - Chicago
MSN:
1014
YOM:
1980
Crew on board:
3
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16374
Captain / Total hours on type:
3378.00
Copilot / Total flying hours:
5962
Copilot / Total hours on type:
82
Aircraft flight hours:
6901
Aircraft flight cycles:
4314
Circumstances:
On February 2, 2005, about 0718 eastern standard time, a Bombardier Challenger CL-600-1A11, N370V, ran off the departure end of runway 6 at Teterboro Airport (TEB), Teterboro, New Jersey, at a ground speed of about 110 knots; through an airport perimeter fence; across a six-lane highway (where it struck a vehicle); and into a parking lot before impacting a building. The two pilots were seriously injured, as were two occupants in the vehicle. The cabin aide, eight passengers, and one person in the building received minor injuries. The airplane was destroyed by impact forces and postimpact fire. The accident flight was an on-demand passenger charter flight from TEB to Chicago Midway Airport, Chicago, Illinois. The flight was subject to the provisions of 14 Code of Federal Regulations (CFR) Part 135 and operated by Platinum Jet Management, LLC (PJM), Fort Lauderdale, Florida, under the auspices of a charter management agreement with Darby Aviation (Darby), Muscle Shoals, Alabama. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan.
Probable cause:
The pilots' failure to ensure the airplane was loaded within weight and balance limits and their attempt to takeoff with the center of gravity well forward of the forward takeoff limit, which prevented the airplane from rotating at the intended rotation speed.
Contributing to the accident were:
1) PJM's conduct of charter flights (using PJM pilots and airplanes) without proper Federal Aviation Administration (FAA) certification and its failure to ensure that all for-hire flights were conducted in accordance with 14 CFR Part 135 requirements;
2) Darby Aviation's failure to maintain operational control over 14 CFR Part 135 flights being conducted under its certificate by PJM, which resulted in an environment conducive to the development of systemic patterns of flight crew performance deficiencies like those observed in this accident;
3) the failure of the Birmingham, Alabama, FAA Flight Standards District Office to provide adequate surveillance and oversight of operations conducted under Darby's Part 135 certificate; and
4) the FAA's tacit approval of arrangements such as that between Darby and PJM.
Final Report:

Crash of a Cessna 208B Super Cargomaster in Helsinki

Date & Time: Jan 31, 2005 at 1700 LT
Type of aircraft:
Operator:
Registration:
SE-KYH
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Helsinki-Örebro
MSN:
208B-0817
YOM:
2000
Flight number:
Helsinki – Örebro
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3886
Captain / Total hours on type:
3657.00
Aircraft flight hours:
6126
Circumstances:
The aircraft landed at Helsinki–Vantaa airport at around 02:47 on Monday, 31.1.2005. After landing, the pilot taxied to apron number four in the southeastern corner of the aerodrome and unloaded the cargo from Sweden. After having done that he left the airport and went to a suite the company reserves for the crew to rest before the return leg to Sweden, which was planned for the following afternoon. The pilot has worked for the company for approximately five years. As per standard policy, the company operates the aircraft with a two person crew. On the day in question the co-pilot had taken ill and the pilot had flown alone. The return leg to Sweden was also planned as a one-person crew flight. The following morning the aircraft was refuelled with 420 l of Jet A-1, in accordance with the pilot’s instructions. All in all ca. 725 kg of fuel was reserved for the return leg. According to his account, the pilot checked in for duty at the airport at around 14:30. After arriving, the pilot began to brush the accumulated snow and frozen snow melt off the upper surfaces of the aircraft. He said that there was a great deal of snow and ice on the aircraft. The cargo that was to go to Sweden did not arrive in time for him to fly it to Skavsta, his primary destination. Therefore, he phoned in a change to the flight plan, choosing Örebro instead as his destination. Örebro was a better choice regarding follow-on transport of the freight. The pilot had outdated meteorological information for the return leg and the operational flight plan form was inadequately filed in. The flight plan was inadvertently filed for another tail number. Information which should be included such as date, crew, prevailing upper winds, estimates to different waypoints, fuel calculations and pilot signatures were omitted from the flight plan. The pilot had not left a copy of the operational flight plan for the ground crew. No weight and balance calculation for the flight was to be found in the cockpit. It had been left in the ground handling service’s briefing room but had been correctly calculated. The pilot did not have access to the latest aeronautical information for the return leg. Printouts of aeronautical information for the inbound leg were found in the cockpit of the wreckage. At 16:52:45 the pilot acknowledged on Helsinki Control Tower (TWR) frequency 118.600 MHz that he was taxiing to takeoff position RWY 22L at intersection Y. At 16:54:40 TWR gave him takeoff clearance from that intersection and gave him the wind direction. The pilot later said that he executed a normal takeoff, using 10 degrees of flaps. The aircraft lifted off at the normal speed of 80-90 KT. At 16:56:05 the pilot called TWR on 118.600 MHz saying “TOWER” just once. As per the pilot’s account everything went well until he reached the height of 800-1000 ft (250-300 m) at which point he retracted the trailing edge flaps. Immediately after flap retraction, the pilot lost control of the aircraft, which began turning to the right. The pilot attempted to fly the aircraft to the end section of runway 22R for an emergency landing. Shortly before crashing to the right side of the extension of runway 22L the pilot managed to get the wings level. He lost consciousness in the crash.
Probable cause:
The chain of events can be regarded as having begun when the aeroplane stood overnight on the tarmac, exposed to the weather. Snowfall accumulated on the upper surfaces of the fuselage, wings and stabilizers during the night forming a thick coat of ice and snow as it partly melted during the day and refroze when the ambient temperature dropped towards the evening. The pilot noticed the impurities when he performed a walkaround check. However, he did not order a de-icing. Instead, he tried to remove the ice with a brush. It is only possible to remove dry and loose snow by brushing. In this case the frozen water that had trickled down remained stuck to surfaces. The pilot executed a takeoff with an aircraft whose aerodynamic properties were fundamentally degraded due to impurities. During the initial climb, immediately after flap retraction, airflow separated from the surface of the wing and the pilot did not manage to regain control of the aircraft. The pilot did not recognize the stall for what is was and did not act in the required manner to recover or, then again, it could be that he had not received sufficient training for these kinds of situations. Several factors are considered to have affected the pilot’s actions. He was either ignorant or negligent as to the effect of impurities on the aeroplane’s aerodynamic properties. Furthermore, the pressure of keeping to the schedule during the early preflight briefing activities may have affected his decision, even though a change in the flight plan eliminated the actual rush. It is the impression of the investigation commission that these factors were the principal ones that contributed to the omission of proper deicing. A probable contributing factor, albeit one difficult to verify, could have been the financial aspect. The company may have considered buying deicing services from an external service provider as an additional expense. Investigations showed that the operator in question had ordered aeroplane de-icing at Helsinki–Vantaa airport only once during the previous and ongoing winter season. The company regularly flew to this airport. Processes were in place for pre-flight briefing as well as for freight forwarding. However, the flight schedules with reference to the opening times of the company’s primary destination airport did not allow for long delays in ground operations. This may have partly put pressure on the pilot to complete the other pre-flight activities as soon as possible. As for the flap setting, the pilot’s takeoff technique was not proper for the existing circumstances. Moreover, when the aeroplane stalled, the pilot did not execute any effective corrective action to regain control of the aircraft. These would have been, among other things: having reset the flaps to the position prior to the stall as well as having taken advantage of the engine power reserve. As per his account, the pilot did not utilize all available engine power. Instead, he stuck to the maximum value prescribed for normal operations as specified in the aircraft operations manual. The fact that the said flight was flown, contrary to normal operations with only a one person crew, can be considered a contributing factor.
Final Report:

Crash of a Rockwell Grand Commander 690A in Courchevel

Date & Time: Jan 31, 2005
Operator:
Registration:
N67TC
Survivors:
Yes
MSN:
690-11233
YOM:
1975
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft stalled on approach to Courchevel Airport and touched down hard, causing substantial damage to the fuselage. There were no injuries but the aircraft was damaged beyond repair.

Crash of a Learjet 35A in Kansas City

Date & Time: Jan 28, 2005 at 2217 LT
Type of aircraft:
Operator:
Registration:
N911AE
Flight Type:
Survivors:
Yes
Schedule:
Salt Lake City - Kansas City
MSN:
35-109
YOM:
1977
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5127
Captain / Total hours on type:
1236.00
Copilot / Total flying hours:
4301
Copilot / Total hours on type:
482
Aircraft flight hours:
11138
Circumstances:
The Learjet 35A received substantial damage on impact with airport property and terrain during a landing overrun on runway 19 (7,002 feet by 150 feet, grooved asphalt) at Charles B. Wheeler Downtown Airport (MKC), Kansas City, Missouri. The airplane was operated by a commercial operator as a positioning flight to Kansas City International Airport (MCI), Kansas City, Missouri, with a filed alternate destination of Lincoln Airport (LNK), Lincoln, Nebraska. Night instrument meteorological conditions prevailed at the time of the accident. LNK was a certificated airport with a snow removal plan and was served by runway 17R (12,901 feet by 200 feet, grooved asphalt and concrete). The flight was en route to MCI to pick up passengers and continue on as an on-demand charter but diverted to MKC following the closure of MCI. MCI was closed due to a McDonnell Douglas MD83 sliding off a taxiway during an after landing taxi on contaminated runway/taxiway conditions. MKC held a limited airport certificate that did not have a snow removal plan and was served by runway 19. Following a precision approach and landing on runway 19 at MKC, the Learjet 35A slid off the departure end of the runway and impacted airport property and terrain. The Learjet 35A was operated with inoperative thrust reversers as per the airplane's minimum equipment list at the time of the accident. About 1:05 hours before the accident, runway 19 Tapley values were recorded as 21-22-22 with 1/2 inch of wet snow. About 17 minutes before the accident, MKC began snow removal operations. About 7 minutes before the accident, the MKC air traffic control tower (TWR) instructed the snow removal vehicles to clear the runway for inbound traffic. TWR was advised by airport personnel that runway 19 was plowed and surface conditions were 1/4 inch of snow of snow; friction values were not taken or reported. While inbound, the Learjet 35A requested any braking action reports from TWR. The first airplane to land was a Cessna 210 Centurion, and the pilot reported braking action to the TWR as "moderate", which was then transmitted by TWR as "fair" from a Centurion in response to the Learjet 35A's query. The Cessna 210 Centurion pilot did not use brakes during landing and did not indicate this to TWR during his braking action report. The Aeronautical Information Manual states that no correlation has been established between MU values and the descriptive terms "good," fair," and "nil" used in braking action reports. The Airport Winter Safety and Operations advisory circular (AC) states that "pilot braking action reports oftentimes have been found to vary significantly, even when reported on the same frozen contaminant surface conditions." The AC also states, "It is generally accepted that friction surveys will be reliable as long as the depth of snow does not exceed 1 inch (2.5 cm) and/or depth of wet snow/slush does not exceed 1/8 inch (3mm). The Learjet 35A flightcrew calculated a landing distance 5,400 feet. Two of the cockpit voice recording channels, which normally contain the pilot and copilot audio panel information, were blank.
Probable cause:
The contaminated runway conditions during landing. Contributing factors were the operation of the airplane without thrust reversers, flight to the planned alternate airport not performed by the flightcrew, and the insufficient runway information. Additional factors were the airport property and terrain that the airplane impacted.
Final Report:

Crash of a Let L-410UVP-E4 in Iaşi: 2 killed

Date & Time: Jan 27, 2005 at 1130 LT
Type of aircraft:
Operator:
Registration:
HA-LAR
Flight Type:
Survivors:
No
Schedule:
Budapest – Bucharest – Iaşi
MSN:
87 19 23
YOM:
1987
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was performing a mail flight from Bucharest-Băneasa Airport to Iaşi on behalf of the National Romanian Postal Service. On board were two pilots and a load of 310 kilos of mail. On approach to runway 15, the crew encountered poor visibility due to bad weather conditions and initiated a go-around procedure. During the second attempt to land, at an altitude of 2,700 feet, the crew informed ATC he would make a right turn outbound when the aircraft entered a left circuit and descended until it crashed in a wooded area located 300 metres west of the tower. The aircraft was totally destroyed and both pilots were killed.

Crash of a Dornier DO228-201 at Rothera Station

Date & Time: Jan 25, 2005 at 1433 LT
Type of aircraft:
Operator:
Registration:
D-CICE
Flight Type:
Survivors:
Yes
Schedule:
Halley - Rothera
MSN:
7073
YOM:
1985
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft christened 'Polar 4' was completing a flight from Halley to Rothera Station. Following a steep approach in marginal weather conditions with low clouds and snow falls, the aircraft landed hard and suffered substantial damages. There were no injuries but the aircraft was later transferred to Germany and declared damaged beyond repair in November 2005.