Crash of a Swearingen SA226TC Metro II in Reus

Date & Time: Jan 31, 2004 at 1800 LT
Type of aircraft:
Operator:
Registration:
EC-HCU
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Reus - Barcelona
MSN:
TC-390
YOM:
1981
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3500
Captain / Total hours on type:
2700.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
360
Circumstances:
The crew was completing a positioning flight from Reus to Barcelona for maintenance purposes. During take off roll on runway 07, at a speed of 80 knots, the nose gear collapsed. The aircraft slid on its nose for few dozen metres before coming to rest on the runway. Both pilots escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The nose gear folded because the lever was in the gear up position. The lever was in that position either due to the failure of the crew to carry out the checklists in full, in the event that the aircraft was delivered to them with the gear lever in the gear retracted position, or inadvertent action on the gear lever at some point between the last check by the crew and the moment of the accident.
Final Report:

Crash of a Beechcraft 1900D in Ghardaïa: 1 killed

Date & Time: Jan 28, 2004 at 2101 LT
Type of aircraft:
Operator:
Registration:
7T-VIN
Survivors:
Yes
Schedule:
Hassi R’Mel – Ghardaïa
MSN:
UE-365
YOM:
1999
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
1742
Circumstances:
The aircraft departed Hassi R'Mel-Tilrhempt Airport at 2030LT on a 15-minutes charter flight to Ghardaïa, carrying three crew members and two employees of the Sonatrach (Société Nationale pour le Transport et la Commercialisation d’Hydrocarbures). At 2044LT, the crew was cleared for a right hand circuit in preparation for an approach to runway 30. At that moment a Boeing 727 inbound from Djanet was on long finals. The copilot stated that he intended to carry out an NDB/ILS approach to runway 30. The captain however preferred a visual approach. The copilot carried out the captain's course and descent instructions with hesitation. At 2057LT, the EGPWS alarm sounded. Power was added and a climb was initiated from a lowest altitude of 240 feet above ground level. The captain then took over control and assumed the role of Pilot Flying. The airplane manoeuvred south of the airport until 2101LT when the copilot saw the runway. The captain rolled left to -57° and pitched down to -18.9° in order to steer the airplane towards the runway. Again the EGPWS sounded but the descent continued until the airplane impacted the ground and broke up. All five occupants were injured and the aircraft was destroyed. A day later, the copilot died from his injuries.
Probable cause:
The Commission believes that the accident can be explained by a series of several causes which, taken separately, would not lead to an accident.
The causes are related to:
1 - the lack of rigor in the approach and landing phase evidenced by a failure to follow standard operating procedures, including the arrival checklist.
2 - the failure to strictly comply with the holding, approach and landing procedures in force for the aerodrome of Ghardaïa.
3 - the fact that the captain seemed occupied by the visual search maneuvers that put him temporarily out of the control loop. He was so focused on the visual search for the runway and abandoned the monitoring of parameters that are critical for the safety of the flight. This concentration completely disoriented him.
4 - the fact that the crew did not respond appropriately to different alarms that occurred, indicating a lack of control in the operation of the aircraft in that kind of situation. Lack of control was apparently due to his lack of training on this aircraft type.
5 - The activities in the southern part of Algeria may cause a certain routine that can promote the tendency to conduct visual approaches. It seems, indeed, that the crew is more experienced in visual flights.
6 - A lack of coordination and communication between the crew members flying together for the first time.

Crash of an Ilyushin II-18D in Luena

Date & Time: Jan 27, 2004 at 1440 LT
Type of aircraft:
Operator:
Registration:
ER-ICJ
Flight Phase:
Survivors:
Yes
Schedule:
Luena – Luanda
MSN:
186 0091 02
YOM:
1966
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll on runway 29, the aircraft did not accelerate as expected. The captain decided to abort the takeoff procedure but the aircraft could not be stopped within the remaining distance. It overran and collided with trees located 100 meters further. A crew member was injured and the aircraft was damaged beyond repair.

Crash of a Dassault Falcon 20C in Pueblo

Date & Time: Jan 21, 2004 at 0040 LT
Type of aircraft:
Operator:
Registration:
N200JE
Flight Type:
Survivors:
Yes
Schedule:
Saint Louis – Pueblo
MSN:
133
YOM:
1968
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3750
Captain / Total hours on type:
1900.00
Copilot / Total flying hours:
2850
Copilot / Total hours on type:
110
Aircraft flight hours:
8378
Circumstances:
The captain reported that he obtained weather briefings prior to and during the flight. The briefings did not include any NOTAMS indicating a contaminated runway at their destination airport. The captain obtained a report from the local fixed base operator that a Learjet had landed earlier and reported the runway as being okay. The tower was closed on their arrival, so they made a low pass over the airport to inspect the runways. Based on the runway and wind conditions, they decided their best choice for landing was on runway 08L. The captain said the landing was normal and the airplane initially decelerated with normal braking. As they encountered snow and ice patches, the captain said he elected to deploy the thrust reversers. The captain said that as the thrust reversers deployed, the airplane began to yaw to the left and differential braking failed to realign the airplane with the runway. The captain said the airplane departed the left side of the runway and rotated counter clockwise before coming to rest on a southwesterly heading. A witness on the airport said, "I watched them touch down. I heard the [thrust] reversers go on and then off, and then on again. As they came back on for the second time, that's when the plane started making full circles on the runway. This happened two, maybe three times before going off the side of the runway." The airplane's right main landing gear collapsed on departing the runway, causing substantial damage to the right wing, right main landing gear and aft pressure bulkhead. At the accident site, the right engine thrust reverser was partially deployed. The left engine thrust reverser was fully deployed with the blocker doors extended. An examination of the airplane revealed a stuck solenoid on the right engine thrust reverser. No other system anomalies were found. Approximately 33 minutes prior to the accident, the pilot requested from Denver Air Route Traffic Control Center, the weather for the airport. Denver Center reported the conditions as "winds calm, visibility 6 miles with light mist, 3,000 overcast, temperature zero degrees Centigrade (C) dew point -1 degree C, altimeter three zero 30.20, and there was at least a half inch of slush on all surfaces." The pilot acknowledged the information. The NOTAM log for the airport showed that at 2115, the airport issued a NOTAM stating there was "1/2 inch wet snow all surfaces." The airport operations manager reported that at the time of the accident the runway surface was covered with 3/4 inch of wet snow. The airport conducts a 24 hour, 7 days a week operation; however, operations support digresses to fire coverage only after 2300.
Probable cause:
The pilot's improper in-flight planning/decision to land on the contaminated runway, the stuck thrust reverser solenoid resulting in partial deployment of the right engine thrust reverser, and the pilot's inability to maintain directional control of the airplane due to the asymmetric thrust combined with a contaminated runway. Factors contributing to the accident were the wet, snow-covered runway, the airport's failure to remove the snow from the runway, and the pilot's failure to recognize the reported hazardous runway conditions by air traffic control.
Final Report:

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

Date & Time: Jan 19, 2004
Operator:
Registration:
PK-WAX
Flight Type:
Survivors:
Yes
Schedule:
Wamena – Mulia
MSN:
255
YOM:
1969
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Mulia Airport, during the last segment, the aircraft was caught by downdrafts and lost height, causing the nose gear to land first. The aircraft went out of control, ground looped and came to rest in a ditch. The pilot, sole on board, escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Yakovlev Yak-40 in Tashkent: 37 killed

Date & Time: Jan 13, 2004 at 1927 LT
Type of aircraft:
Operator:
Registration:
UK-87985
Survivors:
No
Schedule:
Termez - Tashkent
MSN:
9 54 08 44
YOM:
1975
Flight number:
UZB1154
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
37
Aircraft flight hours:
37000
Circumstances:
Following an uneventful flight from Termez, the crew started the descent to Tashkent-Yuzhny Airport by night and marginal weather conditions. The visibility was limited due to foggy conditions with an RVR between 600 and 900 metres for runway 08L. The captain continued the approach with an excessive rate of descent, causing the aircraft to pass below the MDA without any visual contact with the ground. At an altitude of 165-170 metres, the captain positioned the airplane in a flat attitude then continued the descent at a distance of 2 km from the runway threshold, but this time with an insufficient rate of descent. The aircraft passed over the runway threshold at a height of about 30-40 metres and flew over the runway for a distance of 3,3 km. The captain established a visual contact with the runway lights, elected to land but failed to realize he was in fact approaching the end of the runway which is 4 km long. He reduced both engines power to idle, activated the thrust reversers when he realized his mistake and attempted a go-around. The aircraft collided with a 2 metres high concrete wall located 260 metres past the runway end, lost its right wing and crashed in a drainage ditch located along the perimeter fence, bursting into flames. The aircraft was totally destroyed and all 37 occupants were killed, among them Richard Conroy, special UNO representative in Uzbekistan.
Probable cause:
The following factors were identified:
- The crew failed to maintain a correct approach pattern maybe following a wrong setting of the approach selector in SP mode instead of ILS mode,
- The crew decided to continue the approach without establishing any visual contact with the approach light and runway light system,
- The crew failed to comply with published procedures,
- The crew failed to initiate a go-around procedure.

Crash of a De Havilland DHC-6 Twin Otter in Sturt Island

Date & Time: Jan 5, 2004
Operator:
Registration:
P2-KSG
Flight Phase:
Survivors:
Yes
MSN:
509
YOM:
1976
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from a grassy runway (780 metres long), the pilot noted standing water on the ground. He attempted to take off prematurely to avoid these puddles but the aircraft stalled and crash landed. All three occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Rockwell Grand Commander 690A in Cortez: 1 killed

Date & Time: Jan 3, 2004 at 1212 LT
Operator:
Registration:
N700SR
Flight Type:
Survivors:
No
Schedule:
Mesa – Cortez
MSN:
690-11164
YOM:
1974
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1872
Captain / Total hours on type:
91.00
Aircraft flight hours:
7506
Circumstances:
The pilot executed the VOR approach to runway 21. He was heard to report passing the VORTAC outbound for the procedure turn, and crossing the VORTAC (final approach fix) inbound. Witnesses said they saw the airplane emerge from the overcast slightly high and fast. They said the airplane entered a steep left bank and turned about 90 degrees before disappearing in a snow shower northeast of the airport. They heard no unusual engine noises. Another witness near the accident site saw the airplane in a steep bank and at low altitude, "just above the power lines." Based on the witness location, the airplane had turned about 270 degrees. The witness said the wings "wobbled" and the nose "dipped," then the left wing dropped and the airplane descended to the ground "almost vertically." Members of the County Sheriff's Posse, who were at a gunnery range just north of the airport, reported hearing an airplane pass over at low altitude. One posse member said he heard "an engine pitch change." He did not see the airplane because it was "snowing heavily," nor did he hear the impact. An examination of the airplane revealed no anomalies. At the time of the accident, the weather at the destination airport was few clouds 300 feet, 900 feet broken, 3,200 feet overcast; visibility, 1/2 statute and snow; temperature, 32 degrees F.; dew point, 32 degrees F.; wind, 290 degrees at 10 knots, gusting to 15 knots; altimeter, 29.71 inches.
Probable cause:
The pilot's inadequate planned approach and his failure to maintain airspeed which resulted in a stall. Contributing factors were low altitude flight maneuvering in an attempt to lose excessive altitude and realign the airplane for landing, and his failure to perform a missed approach, and the snow fall.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Koyukuk

Date & Time: Jan 2, 2004 at 1630 LT
Operator:
Registration:
N45008
Flight Type:
Survivors:
Yes
Schedule:
Galena – Koyukuk
MSN:
31-8052167
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5283
Captain / Total hours on type:
1400.00
Aircraft flight hours:
12808
Circumstances:
The Title 14, CFR Part 135 cargo flight departed for a destination airport about 20 miles downriver. Although weather at the departure airport was VFR, no reports of the actual weather along the route of flight were available. Unable to locate the destination airport due to deteriorating weather conditions, the pilot attempted to return to the departure airport following the river for ground reference. The airplane entered fog and whiteout weather conditions, and collided in-flight with the frozen surface of the river.
Probable cause:
The pilot's continued flight into adverse weather conditions, and his failure to maintain clearance from terrain, which resulted in an in-flight collision with terrain. Factors associated with the accident were fog and whiteout weather conditions.
Final Report:

Crash of a Beechcraft A100 King Air in Terrace Bay

Date & Time: Jan 1, 2004
Type of aircraft:
Operator:
Registration:
C-GFKS
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Terrace Bay – Thunder Bay
MSN:
B-247
YOM:
1979
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On take off roll on runway 25 at dusk, left wing struck a snowbank on left side of the runway. Aircraft veered off runway and came to rest in snow with its nose gear sheared off and several damages to the fuselage. Both pilots were uninjured.
Probable cause:
A NOTAM stated that there were windrows four feet high, 10 feet inside the runway lights on both sides of the runway. This NOTAM also stated that the cleared portion of the runway was covered with ¼ inch of loose snow over 60 percent compacted snow and 40 percent ice patches and that braking action was fair to poor. The take-off was being conducted at dusk in conditions of poor lighting and contrast. Crosswind was not a factor.