Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Hamilton

Date & Time: Dec 30, 2004 at 1300 LT
Registration:
N601DF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Hamilton – Stevensville
MSN:
61-0014
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13409
Captain / Total hours on type:
1000.00
Aircraft flight hours:
3289
Circumstances:
Immediately after taking off and raising the landing gear, the pilot noticed the left engine began to lose power. The airplane subsequently veered to the left before impacting up slopping terrain in a left wing low attitude, resulting in a fire breaking out which consumed the left side of the airplane. A postaccident examination revealed that the left engine had sustained thermal but no impact damage, and that the engine's right hand turbocharger had no thermal or impact damage. A further examination indicated that no restrictions were found in the center section of the turbocharger and there was no damage to the housing or the impeller; however, the impeller was frozen in the center section and would not turn. Indications of grooving and scraping from a lack of lubrication to the bearings and drive shaft was observed. No mechanical anomalies with the aircraft were noted by the pilot prior to takeoff which would have prevented normal operations.
Probable cause:
A partial loss of engine power due to the lack of lubrication and subsequent failure of the left engine's right turbocharger for undetermined reasons, and subsequent forced landing after takeoff. A factor was the unsuitable terrain for the forced landing.
Final Report:

Crash of an Ilyushin II-76TD in Dushanbe

Date & Time: Dec 30, 2004 at 0348 LT
Type of aircraft:
Operator:
Registration:
ER-IBM
Flight Type:
Survivors:
Yes
Schedule:
Billund – Baku – Kaboul
MSN:
00334 48390
YOM:
1983
Flight number:
RIN922
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Ilyushin 76 was chartered to fly a consignment of 28938 kg of humanitarian aid from Billund, Denmark to Kabul, Afghanistan. The airplane departed Billund at 18:00 and landed at Baku, Azerbaijan for a refueling stop. Visibility at Kabul was reported as 3000 m, and forecast worsening to 1200 m between 00:00 and 06:00 h due to snow and haze. Minima for Kabul airport however were a visibility of 5000 m and a cloud base at 450 m. The captain nevertheless departed Baku. While approaching Kabul the weather was reported to be: wind 340 degrees at 4 kts, visibility 2000 m, 1-2 octas clouds at 480 m, 5-7 octas clouds at 3000 m and a QNH of 1020 hPa. During the approach low clouds were moving in from the north. The visibility was limited to 500 m in fog and the wind direction changed. The crew of the Ilyushin were not informed of these changed values. The approach was continued and flaps and gear were selected down. At decision height the spoilers were extended and the descent was continued. The captain ordered the spoilers to be retracted, but this command was not carried out. At a height of 310 m, 4230 m short of the runway 29 threshold, the flaps were selected down to 43 degrees. The Il-76 was at that stage 365 m to the right of the extended centreline. The flight descended below the glideslope until it contacted the ground 910 m short of the runway threshold, at a speed of 230 km/h. The left undercarriage was destroyed and separated from the aircraft. The lower aft fuselage and cargo door were severely damaged and the pressure in the no. 1 and no. 2 hydraulic systems fell. The crew applied takeoff power, retracted the spoilers and selected flaps back to 30 degrees. The aircraft climbed away and the captain decided to head for Termez, Uzbekistan, but this airport was closed due to fog. It was decided to continue to Dushanbe, Tajikistan. The airplane made a low pass over the field so the air traffic controllers could observe the nature of the damage. A forced landing was then carried out.
Probable cause:
The following findings were identified:
- Disturbance in the work of the command-supervisory composition of the "Airline Transport Incorporation" company, that led to the failure to present the crew with AIP information of the Republic of Afghanistan about the Kabul Airport minima and the special features of the approach to this airport, as presented in the "Jeppesen", valid on 30.12.04;
- Decision making by crew and the decision to carry out an approach under below-minima conditions; unsatisfactory crew interaction during the final stage of the approach, which led to the loss of height, the failure to retract the spoilers, the descent below the established glide path, the collision of aircraft with a ground-based structure and the late spool-up of the engines to takeoff power;
- Deficiencies in the weather support of the flight, in that the crew were not given a visibility forecast, which did not allow crew to estimate the level of hazard of a change in the meteorological conditions.

Crash of a Piper PA-31P Pressurized Navajo in Gallup: 1 killed

Date & Time: Dec 29, 2004 at 1018 LT
Type of aircraft:
Registration:
N573B
Flight Type:
Survivors:
No
Schedule:
Glendale – Newton
MSN:
31-7530008
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
936
Captain / Total hours on type:
62.00
Aircraft flight hours:
6773
Circumstances:
While maneuvering during a precautionary landing with the right engine shutdown, the airplane entered a Vmc roll and an uncontrolled descent, and impacted wires, trees, and terrain. According to air traffic control communications, while en route the pilot experienced a rough running right engine and performed a precautionary shutdown of the engine. The pilot elected to divert to an airport and received vectors from air traffic control for a visual approach. Witnesses who were located at the airport reported the airplane was on a normal downwind for the runway. When the airplane reached the approach end of the runway, the pilot turned to the right which was away from the airport. A witness who was monitoring the UNICOM frequency informed the pilot he was turning away from the airport and the pilot responded, "Busy." The airplane continued the right turn subsequently entered a Vmc roll and a rapid descent toward the terrain. The airplane wreckage was located on hilly, rocky terrain approximately 3 miles south of the airport. The airplane was fragmented and destroyed during the impact sequence and post-impact fire. Examination of the airframe and propellers revealed no anomalies that would have precluded normal operations. Examination of the left engine revealed the forward gearbox was destroyed and mechanical continuity of the rotating components and internal mechanisms was established. Examination of the right engine revealed the forward gearbox was destroyed and mechanical continuity of the rotating components and internal mechanisms was established. The reason for the reported rough running engine was not determined. The lifters installed in both engines during the overhauls were not approved lifters for the accident engines.
Probable cause:
The pilot's failure to maintain minimum controllable airspeed which resulted in the loss of control, and impact with wires, a tree and terrain.
Final Report:

Crash of a Lockheed MC-130H Hercules at Qayyarah Airfield West AFB

Date & Time: Dec 29, 2004
Type of aircraft:
Operator:
Registration:
85-0012
Flight Type:
Survivors:
Yes
MSN:
5054
YOM:
1985
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The MC-130H Hercules plane was on a nighttime logistics transport mission in support of Operation Iraqi Freedom. US operated airfield in northern Iraq, reportedly Qayyarah Airfield West, a trench was being dug in the runway 33. The construction works, approx. 2700 feet from the southern end of the runway were not marked nor NOTAMed. On landing, at a speed of 80 knots, the Hercules plane ran into the construction works. The nose gear and forward undercarriage were sheared off and the left wing separated just outside the no. 2 engine. The aircraft then caught fire. The crew members egressed safely, but the four passengers required assistance from ground personnel and aircrew.
Probable cause:
The Board President determined the causes of the accident are:
1) A failure on the part of the mishap site Assistant S-3 (Battle Captain[s]) to disseminate timely Notices to Airmen (NOTAM) information via the appropriate channels,
2) the failure of the Army project manager for construction at the mishap site to ensure the construction was properly marked and
3) a failure of the NOTAM reporting system to include oversight and supervision of the NOTAM processes, within the area of responsibility (AOR).
Contributing factors in this mishap include:
1) a lack of training on the part of the U.S. Army to effectively prepare their personnel for combat zone airfield management and operations, and
2) the failure of the Garrison Commander at the mishap location to assume responsibility for ensuring safe flight operations at the airfield.
The Board President also determined there were numerous opportunities for airfield construction information to flow to the aircrew, but in each case the information was not properly disseminated prior to the aircrew departing for their scheduled mission.

Crash of a Beechcraft A90 King Air in Montpellier: 3 killed

Date & Time: Dec 24, 2004 at 0933 LT
Type of aircraft:
Operator:
Registration:
F-GVRM
Flight Type:
Survivors:
No
Schedule:
Montpellier - Montpellier
MSN:
LJ-121
YOM:
1966
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
12184
Captain / Total hours on type:
2610.00
Copilot / Total flying hours:
256
Copilot / Total hours on type:
6
Aircraft flight hours:
6872
Aircraft flight cycles:
6816
Circumstances:
The crew departed Montpellier-Méditerranée Airport at 0802LT for a local training flight with TRI, one TRE and one pilot under supervision. Following a touch and go on runway 31R, the instructor decided to reduce the power on the right engine and to perform a low pass over the runway. Then the aircraft turned to the left, lost height, rolled to the left and crashed in a pond located to the right of the runway. The aircraft was destroyed and all three occupants were killed.
Probable cause:
The accident was the result of the crew losing control of the aircraft after a go-around. It is likely that this was the result of inadequate management of the flight controls while performing a one engine go-around and a too late a reaction from the examiner (TRE). The examiner's recent lack of experience in instruction on BE90 and his right-front position may have contributed to the accident. No technical anomalies was found on the aircraft and the loss of control occurred at low altitude.
Final Report:

Crash of a Piper PA-61P Aerostar (Ted Smith 601) in Wheeling

Date & Time: Dec 18, 2004 at 2215 LT
Operator:
Registration:
N60CF
Flight Type:
Survivors:
Yes
MSN:
61-0415-149
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot attempted a night landing on a taxiway in front of the control tower, which was closed at the time. The airplane overran the end of the taxiway, rolled down an embankment and struck trees. The pilot, whose identity was not confirmed, was believed to have incurred minor injuries. He subsequently paid a passerby to take him to a local hotel, and after a night's rest, he left the area. Ownership of the airplane could not be determined due to a recent sale. Approximately 250 kilos of cocaine were found onboard the airplane. Further investigation was being conducted by federal authorities and local law enforcement.
Probable cause:
The pilot misjudged his distance/speed, and his intentional landing on an unsuitable taxiway
at night. A factor in the accident was the night light conditions.
Final Report:

Crash of a Cessna 421A Golden Eagle I in Denver: 3 killed

Date & Time: Dec 17, 2004 at 1522 LT
Type of aircraft:
Registration:
N421FR
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Denver - Denver
MSN:
421A-0069
YOM:
1968
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
12000
Copilot / Total flying hours:
414
Copilot / Total hours on type:
31
Aircraft flight hours:
2666
Circumstances:
The pilot's father had just purchased the airplane for his daughter, and she was receiving model-specific training from a contract flight instructor. Her former flight instructor was aboard as a passenger. The engines were started and they quit. They were restarted and they quit again. They were started a third time, and the airplane was taxied for takeoff. Shortly after starting the takeoff roll, the pilot reported an unspecified engine problem. The airplane drifted across the median and parallel runway, then rolled abruptly to the right, struck the ground, and cartwheeled. The landing gear was down. Neither propeller was feathered. Disassembly of the right engine and turbocharger revealed no anomalies. Disassembly and examination of the left engine and turbocharger revealed the mixture shaft and throttle valve in the throttle and fuel control assembly were jammed in the idle cutoff and idle rpm positions, respectively. Manifold valve and fuel injector line flow tests produced higher-than-normal pressures, indicative of a flow restriction. Disassembly of the manifold valve revealed the needle valve in the plunger assembly was stuck in the full open position, collapsing the needle valve spring. A scribe was used to free the needle valve, and the manifold valve and fuel injector lines were again flow tested. The result was a lower pressure. Plunger disassembly revealed the threads had been tapped inside the retainer and metal shavings were found between the retainer and spring. The Teledyne Continental Motor (TCM) retainer has no threads. GPS download showed that 2,698 feet had been covered between the start of the takeoff roll and the attainment of rotation speed. Maximum speed attained was 132 mph. Computations indicated distance to clear a 50-foot obstacle was 2,000 feet, distance to clear a 50-foot obstacle (single engine) was 2,600 feet, and accelerate-stop distance was 3,000 feet.
Probable cause:
Loss of engine power due to fuel starvation, and the instructor's failure to maintain aircraft control. Contributing factors were a partially blocked fuel line resulting in restricted fuel flow, the instructor's failure to perform critical emergency procedures, and his failure to abort the takeoff in a timely manner.
Final Report:

Crash of a Short 360-300 in Oshawa

Date & Time: Dec 16, 2004 at 2001 LT
Type of aircraft:
Operator:
Registration:
N748CC
Flight Type:
Survivors:
Yes
Schedule:
Toledo – Oshawa
MSN:
3748
YOM:
1988
Flight number:
SNC2917
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5300
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
800
Copilot / Total hours on type:
400
Circumstances:
Air Cargo Carriers, Inc. Flight SNC2917, a Short Brothers SD3-60 aircraft (registration N748CC, serial number SH3748), was on a charter cargo flight from Toledo, Ohio, USA, to Oshawa, Ontario, with two pilots on board. The crew conducted an instrument flight rules approach to Oshawa Municipal Airport in night instrument meteorological conditions. At approximately 2000 eastern standard time, the aircraft landed on Runway 30, which was snow-covered. During the landing roll, the pilot flying noted poor braking action and observed the runway end lights approaching. He rejected the landing and conducted a go-around procedure. The aircraft became airborne, but it started to descend as it flew over lower terrain, striking an airport boundary fence. It continued until it struck rising terrain and then a line of forestation, where it came to an abrupt stop. The flight crew exited the aircraft and waited for rescue personnel to render assistance. The aircraft was substantially damaged, and both pilots sustained serious injuries. There was no post-crash fire.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The crew planned and executed a landing on a runway that did not provide the required landing distance.
2. The flight crew most likely did not reference the Aircraft Flight Manual performance chart “Effect of a Slippery Surface on Landing Distance Required” to determine that landing the aircraft on the 4000-foot, snow-covered runway with flap-15 was inappropriate.
3. After landing long on the snow-covered runway and applying full reverse thrust, the captain attempted a go-around. He rotated the aircraft to a take-off attitude and the aircraft became airborne in ground effect at a slower-than-normal speed.
4. The aircraft had insufficient power and airspeed to climb and remained in ground effect until striking the airport perimeter fence, rising terrain, and a line of large cedar trees.
5. The flight crew conducted a flap-15 approach, based on company advice in accordance with an All Operator Message (AOM) issued by the aircraft manufacturer to not use flap-30. This AOM was superseded on 20 October 2004 by AOM No. SD006/04, which cancelled any potential flap-setting prohibition.
Other Finding:
1. The flight crew members were not advised that the potential Airworthiness Directive announced in the original AOM was not going into effect and that the use of flap-30 was acceptable, as relayed in the follow-up AOM.
Final Report:

Crash of a Rockwell Aero Commander 685 in Monterrey: 5 killed

Date & Time: Dec 14, 2004 at 1230 LT
Operator:
Registration:
XB-GSG
Survivors:
No
Schedule:
Monterrey – McAllen – Houston
MSN:
685-12058
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
On December 14, 2004 at 1230 central standard time, an Aero Commander AC-685 twin-engine airplane, Mexican registration XB-GSG, was destroyed upon impact with terrain following a loss of control while maneuvering near Apodaca, State of Nuevo Leon, in the Republic of Mexico. The two commercial pilots and 3 passengers were fatally injured. The airplane, serial number 12058, was registered to a private individual. The flight originated from the Monterrey Del Norte Airport, near Monterrey, State of Nuevo Leon, Mexico, approximately 1225 and was en route to the McAllen-Miller International Airport (MFE), near McAllen, Texas, with Houston, Texas, as its final destination. Visual meteorological conditions prevailed for the business flight for which an instrument flight rules (IFR) flight plan was filed. According to local authorities the airplane was attempting to return to the airport when the accident occurred. The wreckage of the airplane was located on the 350-degree radial from the Monterrey VOR (ADN), for 2.3 nautical miles. A post-impact fire destroyed the aircraft. A post-impact fire consumed the aircraft.

Crash of a Mitsubishi MU-2 Marquise in Denver: 2 killed

Date & Time: Dec 10, 2004 at 1940 LT
Type of aircraft:
Operator:
Registration:
N538EA
Flight Type:
Survivors:
No
Schedule:
Denver – Salt Lake City
MSN:
1538
YOM:
1981
Flight number:
ACT900
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2496
Captain / Total hours on type:
364.00
Copilot / Total flying hours:
857
Copilot / Total hours on type:
0
Aircraft flight hours:
12665
Circumstances:
Shortly after takeoff, the pilot reported to air traffic control he needed to return to the airport to land. The controller asked the pilot if he required any assistance, and the pilot responded, "negative for right now uh just need to get in as soon as possible." The controller then asked the pilot what the problem was, in which the pilot responded, "stand by one minute." Approximately 30 seconds later and while the airplane was on a left downwind to runway 35R, the pilot stated he was declaring an emergency and "...we've got an air an engine ta shut down uh please roll the equipment." The controller and other witnesses observed the airplane on the base leg and then overshoot the final approach to runway 35R. After observing the airplane overshoot the final approach, the controller then cleared the pilot to the next runway, runway 28, and there was no response from the pilot. The controller observed the airplane's landing lights turn down toward the terrain, and "the MU2 was gone." A witness observed the airplane make an "immediate sharp bank to the left and descend to the ground. The impact appeared to be just less than a 45 degree angle, nose first." A performance study revealed that while the airplane was on downwind, the airplane started to bank to the left. The bank angle indicated a constant left bank angle of about 24 degrees as the airplane turned to base leg. Twenty-three seconds later, the bank angle began to increase further as the airplane turned to final approach, overshooting the runway, while the angle of attack reached stall angle of about 17 degrees. The flight path angle then showed a decrease by 22 to 25 degrees, the calibrated airspeed showed a decrease by 40 to 70 knots, and the vertical speed indicated a 3,000 feet per minute descent rate just before impact. Examination of the airframe revealed the flaps were in the 20 degree position, and the landing gear was retracted. According to the airplane flight manual, during the base leg, the flaps should remain in the 5 degree position and the landing gear extended; and when landing is assured, the flaps then extended to 20 degrees and maintain 125 knots calibrated airspeed (KCAS) during final and 110 KCAS when over the runway. Minimum controllable airspeed (Vmc) for the airplane is 99 KCAS. Examination of the propellers revealed that at the time of impact, the left propeller was in the feathered position and the right propeller was in the normal operating range. Examination of the left engine revealed static witness marks on several internal engine components, and no anomalies were noted that would have precluded normal operation. The reason for the precautionary shutdown of the left engine was not determined. Examination of the right engine revealed rotational scorring and metal spray deposits on several internal engine components. Four vanes of the oil pump transfer tube were separated and missing. The gearbox oil-scavenge pump was not free to rotate and was disassembled. Disassembly of the oil-scavenge pump revealed one separated oil pump transfer tube vane was located in the pump. Pitting and wear damage was noted on all of the roller bearing elements and the outer bearing race of the propeller shaft roller bearing. No additional anomalies were noted.
Probable cause:
the pilot's failure to maintain minimum controllable airspeed during the night visual approach resulting in a loss of control and uncontrolled descent into terrain. A contributing factor was the precautionary shutdown of the left engine for undetermined reasons.
Final Report: