Crash of a Convair CV-580 in Cincinnati: 1 killed

Date & Time: Aug 13, 2004 at 0049 LT
Type of aircraft:
Operator:
Registration:
N586P
Flight Type:
Survivors:
Yes
Schedule:
Memphis - Cincinnati
MSN:
68
YOM:
1953
Flight number:
HMA185
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2500
Captain / Total hours on type:
1337.00
Copilot / Total flying hours:
924
Copilot / Total hours on type:
145
Aircraft flight hours:
67886
Circumstances:
On August 13, 2004, about 0049 eastern daylight time, Air Tahoma, Inc., flight 185, a Convair 580, N586P, crashed about 1 mile south of Cincinnati/Northern Kentucky International Airport (CVG), Covington, Kentucky, while on approach to runway 36R. The first officer was killed, and the captain received minor injuries. The airplane was destroyed by impact forces. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 as a cargo flight for DHL Express from Memphis International Airport (MEM), Memphis, Tennessee, to CVG. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The flight crew was scheduled to fly the accident airplane on a roundtrip sequence from MEM to CVG. Flight 185 departed MEM about 2329. The first officer was the flying pilot, and the captain performed the non flying pilot duties. During postaccident interviews, the captain stated that the takeoff and climb portions of the flight were normal. According to the cockpit voice recorder (CVR) transcript, at 0017:49, the captain stated that he was just going to “balance out the fuel here.” The first officer acknowledged. From 0026:30 to 0027:08, the CVR recorded the captain discussing the airplane’s weight and balance with the first officer. Specifically, the captain stated, “couldn’t figure out why on the landing I was out and I was okay on the takeoff.” The captain added, “the momentum is one six six seven and I…put one zero six seven and I couldn’t work it.” He then stated, “so…we were okay all along.” At 0030:40, the first officer stated, “weird.” At 0032:31, the captain stated, “okay just let me finish this [the weight and balance paperwork] off and…I’m happy,” and, about 2 minutes later, he stated, “okay, back with you here.” At 0037:08, the captain contacted Cincinnati Terminal Radar Approach Control (TRACON) and reported an altitude of 11,000 feet mean sea level. About 1 minute later, the first officer stated, “something’s messed up with this thing,” and, at 0039:07, he asked “why is this thing?” At 0041:21, the first officer stated that the control wheel felt “funny.” He added, “feels like I need a lot of force. it is pushing to the right for some reason. I don’t know why…I don’t know what’s going on.” The first officer then repeated twice that it felt like he needed “a lot of force.” The CVR did not record the captain responding to any of these comments. At 0043:53, when the airplane was at an altitude of about 4,000 feet, the captain reported to Cincinnati TRACON that he had the runway in sight. The approach controller cleared flight 185 for a visual approach to runway 36R and added, “keep your speed up.” The captain acknowledged the clearance and the instruction. The first officer then stated, “what in the world is going on with this plane? sucker is acting so funny.” The captain replied, “we’ll do a full control check on the ground.” At 0044:43, the approach controller again told the captain to “keep your speed up” and instructed him to contact the CVG Air Traffic Control Tower (ATCT). At 0045:11, the captain contacted the CVG ATCT and requested clearance to land on runway 36R, and the local control west controller issued the landing clearance. Flight data recorder (FDR) data indicated that, shortly afterward, the airplane passed through about 3,200 feet, and its airspeed began to decrease from about 240 knots indicated airspeed. At 0045:37, when the airplane was at an altitude of about 3,000 feet, the captain started the in-range checklist, stating, “bypass is down. hydraulic pressure. quantity checks. AC [alternating current] pump is on. green light. fuel panel. boost pumps on.” About 0046, the first officer stated, “I’m telling you, what is wrong with this plane? it is really funny. I got something all messed up here.” The captain replied, “yeah.” The first officer then asked, “can you feel it? it’s like swinging back and forth.” The captain replied, “we’ve got an imbalance on this…crossfeed I left open.” The first officer responded, “oh, is that what it is?” A few seconds later, the first officer stated, “we’re gonna flame out.” The captain responded, “I got the crossfeed open. just keep power on.” At 0046:45, the CVR recorded a sound similar to decreasing engine rpm. Immediately thereafter, the first officer stated, “we’re losing power.” At 0046:52, the first officer stated, “we’ve lost both of them. did we?” The captain responded, “nope.” FDR data showed that, about 1 second later, a momentary electrical power interruption occurred when the airplane was at an altitude of about 2,400 feet. At 0046:55, the CVR stopped recording. Airplane performance calculations indicated that, shortly after the power interruption, the airplane’s descent rate was about 900 feet per minute (fpm). According to air traffic control (ATC) transcripts, at 0047:12, the captain reported to the CVG ATCT that the airplane was “having engine problems.” The local control west controller asked, “you’re having engine problems?” The captain replied, “affirmative.” At 0047:28, the controller asked the captain if he needed emergency equipment, and the captain replied, “negative.’” This was the last transmission received by ATC from the accident flight crew. The FDR continued recording until about 0049. The wreckage was located about 1.2 miles short of runway 36R.
Probable cause:
Fuel starvation resulting from the captain’s decision not to follow approved fuel crossfeed procedures. Contributing to the accident were the captain's inadequate preflight planning, his subsequent distraction during the flight, and his late initiation of the in-range checklist. Further contributing to the accident was the flight crew’s failure to monitor the fuel gauges and to recognize that the airplane’s changing handling characteristics were caused by a fuel imbalance.
Final Report:

Crash of a Douglas A-26C-45-DT Invader in Rainbow Lake

Date & Time: Aug 12, 2004
Type of aircraft:
Operator:
Registration:
C-FCBK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Rainbow Lake - High Level
MSN:
28940
YOM:
1944
Flight number:
Tanker 11
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot, sole on board, was engaged in a fire fighting mission and was supposed to leave Rainbow Lake for High Level. During the takeoff roll, at a speed of 90 knots, one of the engine lost power. The pilot rejected takeoff and released the load of fire retardant. Unable to stop within the remaining distance, the aircraft overran, rolled for about 1,200 feet then struck a drainage ditch and came to rest. The pilot was seriously injured and the aircraft was damaged beyond repair.

Crash of a Boeing 737-205 in Freetown

Date & Time: Aug 11, 2004 at 1423 LT
Type of aircraft:
Operator:
Registration:
3X-GCM
Flight Phase:
Survivors:
Yes
Schedule:
Freetown - Conakry - Banjul
MSN:
23469
YOM:
1986
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
119
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Due to poor weather conditions in Freetown, the flight was delayed for hours. Finally, the crew was cleared for takeoff from runway 12/30 which is 3,200 metres long. During the takeoff roll, the captain decided to abort for unknown reasons. Unable to stop within the remaining distance, the aircraft overran, lost its right main gear and right engine before coming to rest in a grassy area located 100 metres past the runway end. All 127 occupants were rescued, among them 50 passengers were injured. The aircraft was damaged beyond repair.
Probable cause:
The accident was the consequence of the non-application by the crew of the checklist prior to takeoff and the lack of coordination between the copilot, who was the pilot flying, and the captain.

Crash of a Casa 212 Aviocar 200 in San Carlos de Rio Negro

Date & Time: Aug 5, 2004 at 1648 LT
Type of aircraft:
Operator:
Registration:
ARBV-0206
Flight Type:
Survivors:
Yes
Schedule:
Puerto Ayacucho - San Carlos de Rio Negro
MSN:
183
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The approach to San Carlos de Rio Negro Airport was completed in stormy weather. After touchdown, the twin engine aircraft failed to stop within the remaining distance. It overran, went down an embankment, collided with a fence and came to rest along a dirt road. A passenger was slightly injured while 11 other occupants escaped unhurt. The aircraft was damaged beyond repair.

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Lakeway: 6 killed

Date & Time: Aug 3, 2004 at 1159 LT
Registration:
N601BV
Flight Phase:
Survivors:
No
Schedule:
Lakeway – Oklahoma City
MSN:
61-0272-058
YOM:
1976
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
3500
Aircraft flight hours:
4483
Circumstances:
The commercial pilot, who managed the airplane and jointly owned it with one of the passengers, departed from a 3,930-foot-long, asphalt runway on a warm day. Weight and balance calculations, which investigators derived from estimated weights for total fuel, passengers, and cargo loads, determined that the airplane was likely within center of gravity limitations and about 208 pounds below its maximum gross weight. One witness stated that the airplane became airborne near the end of the runway before it began a shallow climb and clipped small branches on the tops of trees that were about 30 feet tall. That witness and others observed that the airplane continued past the trees, made a steep bank to the left, rolled inverted, and nose-dived to the ground. The witnesses' descriptions of the airplane's flightpath and the examination of the debris path and wreckage at the accident site are consistent with an impact following an aerodynamic stall. According to calculations performed using the airplane's published performance data chart, for the airplane's configuration and estimated weight and the density altitude conditions at the time of the accident, the airplane would have required about 3,800 feet on a paved, level runway to clear a 50-foot obstacle with the pilot using the short-field takeoff technique. Although the chart does not make any allowances for an upsloping runway or provide data for a 30-foot obstacle, the runway slope is slight (a 27-foot rise over the entire length) and likely did not significantly increase the airplane's takeoff roll, and interpolation of the data revealed no significant distance differences for the shorter obstacle. However, according to the chart, the 3,800-foot distance is contingent upon the pilot holding the airplane's brakes, applying full engine power with the brakes set, and then releasing the brakes to initiate the takeoff roll. In addition, the airplane's ability to achieve its published performance parameters (which are derived from test flights in new airplanes) can be degraded by a number of factors, such as pilot deviations from the published procedures, reduced engine performance, or increased aerodynamic drag associated with minor damage and wear of the airframe. It could not be determined where on the runway the pilot initiated the takeoff roll or at what point full engine power was applied. However, because the runway was only 130 feet longer than the airplane required (according to its published performance data), there was little margin for any deviations from the published takeoff procedure. Although examination of the engines, propellers, and related systems revealed no evidence of precrash anomalies, postaccident damage precluded engine performance testing to determine whether the engines were capable of producing their full-rated power. Therefore, the significance of maintenance issues with the airplane (in particular, a mechanic's assessment that the turbochargers needed to be replaced and that the airplane's required annual inspection was not completed) could not be determined with respect to any possible effect on the airplane's ability to perform as published. A review of Federal Aviation Administration (FAA) and insurance records revealed evidence that the pilot may have been deficient with regard to his ability to safely operate a PA 60-601P. For example, according to FAA records, as a result of an April 2004 incident in which the pilot landed the accident airplane on a wet grassy runway with a tailwind, resulting in the airplane going off the runway and striking a fence, the FAA issued the pilot a letter of reexamination to reexamine his airman competency. However, the pilot initially refused delivery of the letter; he subsequently accepted delivery of a second letter (which gave the pilot 10 days to respond before the FAA would suspend his certificate pending compliance) and contacted the FAA regarding the matter on Monday, August 2, 2004 (the day before the accident), telling an FAA inspector to "talk to his lawyer." In addition, as a result of the same April 2004 incident, the pilot's insurance company placed a limitation on his policy that required him to either attend a certified PA-60-601P flight-training program before he could act as pilot-in-command of the accident airplane or have a current and properly certificated pilot in the airplane with him during all flights until he completed such training. There was no evidence that the pilot adhered to either of the insurance policy requirements. In addition, the FAA had a previous open enforcement action (a proposed 240-day suspension of the pilot's commercial certificate) pending against the pilot for allegedly operating an airplane in an unsafe manner in September 2003; that case was pending a hearing with an NTSB aviation law judge at the time of the accident. Although the FAA's final rule for Part 91, Subpart K, "Fractional Ownership Operations," became effective on November 17, 2003, the regulations apply to fractional ownership programs that include two or more airworthy aircraft. There was no evidence that the pilot had a management agreement involving any other airplane; therefore, the rules of Part 91, Subpart K, which provide a level of safety for fractional ownership programs that are equivalent to certain regulations that apply to on-demand operators, did not apply to the accident flight. In the year before the accident, the FAA had conducted a ramp check of the pilot and the accident airplane and also conducted an investigation that determined there was not sufficient evidence that the pilot was conducting any illegal for-hire operations.
Probable cause:
The pilot's failure to successfully perform a short-field takeoff and his subsequent failure to maintain adequate airspeed during climbout, which resulted in an aerodynamic stall.
Final Report:

Crash of a PZL-Mielec AN-28 in Beni

Date & Time: Jul 29, 2004
Type of aircraft:
Registration:
ES-ELI
Flight Type:
Survivors:
Yes
MSN:
1AJ002-06
YOM:
1985
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft crashed upon landing, lost its right and came to rest. There were apparently no casualties.

Crash of a Rockwell Sabreliner 60 in Mexicali

Date & Time: Jul 28, 2004 at 1330 LT
Type of aircraft:
Operator:
Registration:
XC-PFN
Flight Type:
Survivors:
Yes
Schedule:
Tijuana – Mexicali
MSN:
306-111
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Tijuana, the aircraft landed too far down the runway 28 at Mexicali-General Rodolfo Sanchez Taboada Airport. Unable to stop within the remaining distance, it overran, rolled for about 750 metres, collided with an embankment and came to rest in a sandy area. All six occupants escaped uninjured while the aircraft was damaged beyond repair. The aircraft had the dual registration XC-PFN (civil) and PF-213 (military).

Crash of a Beechcraft 350 Super King Air in Punto Fijo

Date & Time: Jul 24, 2004
Operator:
Registration:
YV-910CP
Flight Type:
Survivors:
Yes
Schedule:
La Carlota - Calabozo - Punto Fijo
MSN:
FL-206
YOM:
1998
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft completed a charter flight from La Carlota to Calabozo with four passengers and two pilots. At Calabozo Airport, the four passengers brandished guns and took over the airplane on an illegal flight to Punto Fijo. Upon arrival, the aircraft crashed under unknown circumstances. There were no casualties and the aircraft was destroyed.

Crash of a Basler BT-67 in El Jaguey

Date & Time: Jul 23, 2004 at 0930 LT
Type of aircraft:
Operator:
Registration:
FAS117
Flight Type:
Survivors:
Yes
MSN:
24509
YOM:
1944
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
22
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown at El Jaguey Airstrip, the aircraft suffered a hydraulic failure and became uncontrollable. It veered off runway, lost its undercarriage and came to rest few dozen metres further. All 24 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a Douglas DC-9-14 in Mexico City

Date & Time: Jul 21, 2004 at 1933 LT
Type of aircraft:
Operator:
Registration:
XA-BCS
Flight Phase:
Survivors:
Yes
Schedule:
Mexico City – Durango – Torreón
MSN:
47043
YOM:
1967
Flight number:
JR706
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
52
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
96300
Aircraft flight cycles:
102000
Circumstances:
Shortly after takeoff from runway 05L at Mexico City-Benito Juarez Airport, while in initial climb, the aircraft encountered windshear. It lost height and crash landed on the runway. Upon impact, the landing gear were torn off. Out of control, the aircraft veered off runway, lost its right wing and came to rest. All 56 occupants evacuated safely and the aircraft was destroyed.
Probable cause:
Loss of control upon takeoff due to windshear.