Crash of a BAe 125-800A in Las Potrancas: 3 killed

Date & Time: Oct 27, 2003 at 0808 LT
Type of aircraft:
Operator:
Registration:
XA-ISH
Flight Type:
Survivors:
No
Schedule:
Tampico - Las Potrancas
MSN:
258036
YOM:
1985
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Aircraft flight hours:
5717
Circumstances:
The aircraft departed Tampico-General Francisco Javier Mina Airport on a positioning flight to Las Potrancas Aerodrome located near Aldama, Tamaulipas. On approach to runway 02, the crew encountered marginal weather conditions with low clouds. As the aircraft was not properly aligned, the captain decided to initiate a go-around procedure and to make a left turn. At low height (about 800 feet), the aircraft struck a hill located to the left of the aerodrome and crashed. All three occupants were killed.
Probable cause:
It was determined that the accident was the consequence of a controlled flight into terrain after the crew continued the approach below MDA under VFR mode in IMC conditions until the aircraft impacted terrain at an altitude of 800 feet. The following contributing factors were identified:
- Poor crew resources management,
- The crew continued the approach in unfavorable weather conditions with low clouds,
- Approach to an airport without radio assistance support,
- The crew suffered a loss of situational awareness,
- Poor flight planning.
Final Report:

Crash of a Fairchild-Hiller FH-227B in Buenos Aires: 5 killed

Date & Time: Oct 26, 2003 at 0430 LT
Type of aircraft:
Operator:
Registration:
LV-MGV
Flight Type:
Survivors:
No
Schedule:
Buenos Aires - Corrientes
MSN:
567
YOM:
1967
Flight number:
CTZ760
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
5
Aircraft flight hours:
27650
Aircraft flight cycles:
21574
Circumstances:
Shortly after takeoff from Buenos Aires-Ezeiza-Ministro Pistarini Airport runway 17, while climbing by night, the crew reported technical problems. ATC cleared the crew for an immediate return and land. On final approach, the situation worsened and the crew apparently attempted an emergency landing on the Esperanza Golf Course when the aircraft struck a tree and crashed 5 km short of runway 35, bursting into flames. The aircraft was totally destroyed by impact forces and a post crash fire and all five occupants were killed.
Probable cause:
Failure of the left engine during initial climb for undetermined reasons. At the time of the accident, the aircraft was overload and operated over the MTOW. At impact, the left propeller was feathered while the right engine was running at full power.
Final Report:

Crash of a Fokker F27 Friendship 600 in Tarauacá

Date & Time: Oct 20, 2003 at 1132 LT
Type of aircraft:
Operator:
Registration:
PT-TVA
Survivors:
Yes
Schedule:
Cruzeiro do Sul – Tarauacá – Rio Branco
MSN:
10334
YOM:
1967
Flight number:
TVJ6167
Location:
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
3797.00
Copilot / Total hours on type:
2682
Aircraft flight hours:
55725
Aircraft flight cycles:
60270
Circumstances:
After landing at Tarauacá Airport, the crew started the braking procedure when control was lost. The aircraft veered off runway, collided with several obstacles and came to rest in a ditch. All 23 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Loss of control after landing after the crew selected the power levers on 'ground fine pitch', combined with the failure of the antiskid system due to poor maintenance. The operator was facing enormous financial difficulties which affected the motivation of the maintenance, flight and cabin crew, which was considered as a contributing factor.
Final Report:

Crash of a Cessna 340A in Scappoose: 2 killed

Date & Time: Oct 18, 2003 at 1413 LT
Type of aircraft:
Registration:
N340P
Flight Type:
Survivors:
No
Schedule:
Red Bluff – Scappoose
MSN:
340A-0507
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3850
Aircraft flight hours:
4041
Circumstances:
Witnesses first observed the aircraft on final approach for landing, with the engine(s) making a backfiring sound. While the aircraft was on short final, another aircraft pulled onto the runway and initiated its takeoff roll. The accident aircraft was observed to initiate a go-around, but did not appear to be gaining altitude and was at what the witnesses thought was a slow airspeed. About mid-field, the accident aircraft made an approximate 45 degree turn from runway heading. Within 1/4 mile from the runway, the aircraft lost altitude. The witness stated that the aircraft was about 80 feet agl when the aircraft stalled, rolled inverted (left wing down) and collided with the flat open terrain in a nose low attitude. A post-crash fire subsequently consumed the wreckage. During the post-crash inspection of the engines, it was found that both engines displayed signs of operating at a lean mixture setting. The left engine pistons and spark plugs displayed a more serious lean condition than the right side and displayed the early signs of detonation on the piston heads. No other mechanical failure or malfunction was noted to either the engines or airframe.
Probable cause:
The pilot's failure to maintain airspeed while maneuvering. An inadvertent stall, the pilot's failure to follow engine operation procedures and engine detonation were factors.
Final Report:

Crash of a Rockwell Grand Commander 680FL in Harrison

Date & Time: Oct 8, 2003 at 1825 LT
Registration:
N680WS
Flight Type:
Survivors:
Yes
Schedule:
Springdale – Harrison
MSN:
680-1413-63
YOM:
1964
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
725
Captain / Total hours on type:
86.00
Aircraft flight hours:
9362
Circumstances:
The twin-engine airplane was on the base leg to final turn, about 1-1 1/2 miles from the approach end of the runway when the left engine lost power. Instantly after, the right engine lost power and the pilot feathered both engines. The airplane then impacted a 70-foot high tree and collided with the ground about 1,000 feet short of the runway. The 700-hour pilot reported that he activated the electric fuel boost pumps and switched the fuel selectors from the auxiliary fuel tank positions to the main fuel tank positions, about 17 miles from the airport. He recalled that the fuel gauges indicated approximately 70 gallons of fuel in the main tank and about 10-15 gallons of fuel in the auxiliary tanks. The original installed fuel system was configured with a center tank and two outboard tanks. The center tank was composed of five, interconnected rubber cells, having a total capacity of 150 to 159 US gallons. Each outboard fuel tank was composed of two fuel cells with a combined capacity of 33.5 gallons. The total of the two outboard fuel tanks (four cells) was 67 gallons, providing a total usable capacity of 233 gallons. Each engine had its own fuel shutoff switch. Rotating a switch to the RIGHT OUTBOARD or LEFT OUTBOARD position allows fuel from the outboard tanks to flow to the respective engine and shuts off fuel from the center tank. Rotating a fuel shutoff switch to the CENTER position allows fuel to flow from the center tank to the respective engine, and shuts off flow from the respective outboard tank. Rotating the switch to the OFF position shuts off all fuel flow to the respective engine. There was no cross-feed configuration of the switches. Documentation was found in the historical records that indicated extended range fuel system modifications, however, the information was incomplete. After review of all available records and examination of the wreckage, it was determined that the fuel system configuration/capacity of the airplane at the time of the accident was: 156 gallons for the center tank system; 67 gallons for the outboard wing tanks; and a set of auxiliary tanks capable of holding 21 gallons (records of installation unknown). The total usable fuel capacity was estimated at 244 gallons. Cockpit fuel selector positions were: LEFT Fuel Shut Off Valve Selector-LEFT HAND OUTBOARD; LEFT Fuel Boost Pump-OFF; LEFT Engine Primer-OFF; LEFT Ignition Switch-RIGHT; RIGHT Fuel Shut Off Valve Selector-RIGHT HAND OUTBOARD; RIGHT Fuel Boost Pump-ON; RIGHT Engine Primer-OFF; RIGHT Ignition Switch-BOTH. Airframe fuel shutoff valves were found in the following positions (Each valve position corresponded to the cockpit selectors): Right Wing Auxiliary-OPEN; Right Wing Main-CLOSED; Left Wing Auxiliary-OPEN; Left Wing Main-CLOSED. A total of 37.5 gallons of usable fuel was drained from the uncompromised tanks (unknown amount had leaked at the accident site). Excerpts from the " Normal Procedures" section of the flight manual regarding fuel selector positions for take off and landing: "CAUTION; Burn center tank fuel first, when 100 gallons is shown on center tank gauge, switch to outboard tanks. Do not allow engine to be starved of fuel when outboard tanks run dry. Select center tanks at first indication of fuel pressure loss. Fuel boost pumps must be on when switching tanks." The "BEFORE LANDING CHECK" procedures in the aircraft flight manual state that the Fuel Selector Valves must be in the "CENTER TANK" position before the approach. The manufacturer stated that the simultaneous loss of power of both engines was likely a result of the outboard fuel tanks unporting. No mechanical anomalies were found during examination of the engines or airframe, and usable fuel was available in the center tank at the time of the accident.
Probable cause:
The loss of power to both engines due to fuel starvation as a result of the pilot's failure to complete the landing checklist while on final approach. A factor contributing to the accident was the lack of suitable terrain for the forced landing.
Final Report:

Crash of a Piper PA-31-310 Navajo in Gaspé: 3 killed

Date & Time: Sep 27, 2003 at 1857 LT
Type of aircraft:
Registration:
C-FARL
Survivors:
No
Schedule:
Le Havre-aux-Maisons - Gaspé
MSN:
31-306
YOM:
1968
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
5262
Captain / Total hours on type:
3000.00
Circumstances:
The PA-31-310, registration C-FARL, serial number 31306, operated by Les Ailes de Gaspé Inc., with one pilot and two passengers on board, was on a visual flight rules flight from Îles-de-la-Madeleine, Quebec to Gaspé, Quebec. While en route to Gaspé, the pilot was informed about weather conditions at his destination, which were a ceiling at 500 feet and visibility of ¾ mile in fog. The pilot requested clearance for an instrument approach, which he received at approximately 1857 eastern daylight time. A few seconds later the pilot switched on the aerodrome lights with his microphone button. That was the last radio transmission received from the aircraft. When the aircraft did not arrive at its destination, emergency procedures were initiated to find it. The wreckage was found the next day at 1028 eastern daylight time on a hilltop 1.2 nautical miles (nm) north-east of the airport. The aircraft was destroyed, but did not catch fire. The three occupants were fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot descended to the minimum descent altitude (MDA) without being established on the localizer track, thereby placing himself in a precarious situation with respect to the approach and to obstruction clearance.
2. On an instrument approach, the pilot continued his descent below the MDA without having the visual references required to continue the landing, and he was a victim of CFIT (controlled flight into terrain).
Findings as to Risk:
1. The aircraft was not, nor was it required to be, equipped with a ground proximity warning system (GPWS) or a radio altimeter, either of which would have allowed the pilot to realize how close the aircraft was to the ground.
2. The presence of a co-pilot would have allowed the pilots to share tasks, which undoubtedly would have facilitated identification of deviations from the approach profile.
3. The existing regulations do not provide adequate protection against the risk of ground impact when instrument approaches are conducted in reduced visibility conditions.
Other Findings:
1. The emergency locator transmitter (ELT) could not emit a distress signal because the battery disconnected on impact. Location of the aircraft was delayed until the day after the accident, which could have had serious consequences if there had been any survivors.
Final Report:

Crash of a Grumman G-64 Albatross in Fort Pierce: 2 killed

Date & Time: Sep 25, 2003 at 1126 LT
Type of aircraft:
Registration:
N70258
Flight Type:
Survivors:
Yes
Schedule:
Fort Pierce - Fort Pierce
MSN:
G-418
YOM:
1955
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
13000
Captain / Total hours on type:
450.00
Copilot / Total flying hours:
12800
Aircraft flight hours:
4276
Circumstances:
According to the pilot, during climb-out from runway 09 at an altitude of approximately 500 feet the right engine warning red magnetic chip detector light illuminated. The pilot decided to shut down the right engine and return to the airport. Shortly after making that decision the left engine began to lose power. The airplane was unable to maintain altitude, and the pilot prepared to make an off-airport emergency landing in a field. The airplane collided with the trees as the pilot maneuvered for the emergency landing. Examination of the airframe, and flight controls revealed no anomalies. Examination of the left and right engine revealed no mechanical anomalies. Examination of cockpit fuel selector controls revealed that the left engine fuel selector handle was in the off position and the right engine fuel selector handle was set in the left tank position. During the in-flight engine secure procedures the pilot is required to place the inoperative engine fuel selector in the off position.
Probable cause:
A loss of engine power due to the pilot placing the fuel selector in the off position which resulted in fuel starvation to the left engine, after the pilot intentionally shut down the right engine.
Final Report:

Crash of an Antonov AN-12BP in Wau

Date & Time: Sep 24, 2003
Type of aircraft:
Operator:
Registration:
ST-SAR
Flight Type:
Survivors:
Yes
MSN:
4 021 02
YOM:
1964
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing at Wau Airport, the left main gear collapsed. The aircraft veered off runway to the left and came to rest. All five crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Failure of the left main gear upon touchdown for unknown reasons.

Crash of a Cessna 402C in Nantucket: 1 killed

Date & Time: Sep 23, 2003 at 0523 LT
Type of aircraft:
Operator:
Registration:
N405BK
Flight Type:
Survivors:
Yes
Schedule:
Hyannis – Nantucket
MSN:
402C-0459
YOM:
1981
Flight number:
IS400
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
14000
Captain / Total hours on type:
4000.00
Aircraft flight hours:
9795
Circumstances:
The pilot was conducting an instrument landing system approach during night instrument meteorological conditions. The airplane was observed to descend toward the runway threshold to an altitude consistent with the approach decision height. A witness reported that he heard the airplane overhead, and assumed that the pilot had performed a missed approach. He described the engine noise as "cruise power" and did not hear any unusual sounds. Shortly thereafter, he received a call from airport operations stating that an airplane had crashed. The airplane impacted the ground about 1/4 mile to the left of the runway centerline, about 3,500 feet beyond the approach end of the runway. Examination of the airplane did not reveal any pre-impact mechanical malfunctions. A weather observation taken around the time of the accident, included a visibility 1/2 statue mile in fog, and an indefinite ceiling at 100 feet. The witness described the weather at the time of the accident as thick fog, and "pitch black."
Probable cause:
The pilot's failure to maintain aircraft control during a missed approach. Factors in this accident were fog and the night light conditions.
Final Report:

Crash of a Beechcraft A90 King Air in Summerville

Date & Time: Sep 21, 2003 at 2330 LT
Type of aircraft:
Operator:
Registration:
N34HA
Flight Type:
Survivors:
Yes
Schedule:
Barnwell – Summerville
MSN:
LJ-315
YOM:
1967
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9000
Captain / Total hours on type:
1000.00
Circumstances:
According to the pilot, prior to takeoff, he had the airplane fueled with 20 gallons of fuel in each wing for the short cross-country flight. After takeoff the airplane climbed to an altitude of 9500 feet. During the downwind to the arrival airport the right engine lost power. Shortly after the left engine lost power, the pilot made an emergency off-airport landing. Examination of the fuel system revealed that the fuel tanks were not beached, and there was a small amount of residual fuel in the fuel tanks. The exact amount of fuel onboard the airplane at the time of the departure was not determined.
Probable cause:
The pilot's inadequate preflight planning which resulted in fuel exhaustion and subsequent loss of engine power.
Final Report: