Crash of a Let L-410UVP-E3 in Cap Haïtien: 21 killed

Date & Time: Aug 24, 2003 at 0457 LT
Type of aircraft:
Operator:
Registration:
HH-PRV
Flight Phase:
Survivors:
No
Schedule:
Cap Haïtien - Port-de-Paix
MSN:
87 20 01
YOM:
1987
Flight number:
TBG1301
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
21
Captain / Total flying hours:
8863
Captain / Total hours on type:
701.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
275
Aircraft flight hours:
2982
Aircraft flight cycles:
4154
Circumstances:
Shortly after a night takeoff from runway 05 at Cap Haïtien Airport, while in initial climb, the crew reported technical problems, declared an emergency and was cleared to return. While on base leg, the aircraft lost height and crashed in a sugar cane field located 2 km from the airport, bursting into flames. All 21 occupants were killed. It was later reported that the door of the forward baggage hold opened during takeoff.
Probable cause:
The accident was the consequence of a stall during approach while on the downwind leg base due to a loss of VMC at low altitude.
The following contributing factors were identified:
- Failure of the crew to manage the approach procedure (poor CRM),
- Use of maximum flaps (42°),
- Insufficient altitude,
- Lack of coordination between crew members,
- A possible state of fatigue of the captain,
- A possible overweight aircraft,
- The opening of the forward baggage hold door during takeoff.
Final Report:

Crash of a Cessna 208B Grand Caravan in Old Fangak

Date & Time: Aug 19, 2003
Type of aircraft:
Operator:
Registration:
5Y-TWI
Flight Phase:
Survivors:
Yes
MSN:
208B-0606
YOM:
1997
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While taking off from Old Fangak Airstrip, the single engine aircraft hit trees located past the runway end, nosed down and crashed in a marsh. All six occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Beechcraft T-1A Jayhawk in Biloxi

Date & Time: Aug 16, 2003 at 2221 LT
Type of aircraft:
Operator:
Registration:
91-0093
Flight Type:
Survivors:
Yes
Schedule:
Del Rio - Biloxi
MSN:
TT-34
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Mishap Student pilot (MSP) was flying an Instrument Landing System (ILS) approach to runway 21 at Keesler AFB. They were in Visual Meteorological Conditions (VMC) at night and the runway was wet. After some deviations on the approach, they arrived over the threshold on a normal glide slope and faster (about 114 kts) than the computed approach speed of 108 kts. The aircraft touched down approximately 1500 feet down the runway. The Mishap Instructor Pilot (MIP) actuated the speed brakes/spoilers switch and the student began to immediately apply brake pressure. After 4-5 seconds, the instructor recognized that the aircraft was not decelerating and declared that she was taking control of the aircraft. The instructor immediately applied maximum braking with no perceived deceleration. She then grabbed the glare shield in an attempt to gain additional leverage on the brakes and again felt no perceived deceleration. At this point, the aircraft was rapidly running out of available runway. The instructor selected the emergency brakes just prior to arriving at the departure end threshold and the brakes locked resulting in a hydroplane skid. The aircraft departed the prepared surface and came to a halt 190 feet later. As a result of the runway departure, the right main and nose gear collapsed, and the forward fuselage and both wings were heavily damaged.
Probable cause:
Based on clear and convincing evidence, the Board President determined that this mishap was caused by a combination of several factors during the landing sequence. First, the Mishap Student Pilot (MSP) flew faster than the computed approach and landing speeds. Additionally she maintained higher than idle thrust for the first few seconds after touchdown. Because of these factors, the aircraft did not settle completely on the runway after touchdown-as the struts were not completely compressed. This put the aircraft systems in the "AIR" mode meaning that the speed brakes/spoilers could not deploy. Finally, the runway was wet; and the crew was inexperienced and thus did not recognize the anti-skid cycling at high speeds on the wet runway.

Crash of a Learjet 35A in Cancún

Date & Time: Aug 14, 2003 at 2222 LT
Type of aircraft:
Registration:
N403FW
Flight Type:
Survivors:
Yes
Schedule:
Fort Lauderdale - Cancún
MSN:
35-403
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
7950
Circumstances:
On August 14, 2003, about 2222 central daylight time, a Gates LearJet Corporation 35A, N403FW, registered to Aircraft Holdings LLC, operated by Air America Flight Services, Inc., was landed with the landing gear retracted at the Cancun International Airport, Cancun, Mexico. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed for the 14 CFR Part 91 positioning flight. The airplane was substantially damaged and there were no injuries to the airline transport rated pilot and copilot, nor to the three medical personnel on board the airplane. The flight originated about 2145 eastern daylight time from the Fort Lauderdale Executive Airport, Fort Lauderdale, Florida. According to the director of operations for the operator, the airplane was cleared for a visual approach to runway 12, and the flightcrew advised him they did read the landing checklist. The landing gear was down and locked as indicated by the three green lights; though they didn't recall if the landing gear was extended as evidenced by the landing lights. They also advised him of feeling fuselage to runway surface contact; the airplane slid approximately 4,000 feet before coming to rest upright. Following the occurrence, the nose of the airplane was raised and the nose landing gear was observed to be inside the wheel well. Emergency extension of the landing gear was initiated and the nose landing gear extended and locked; the main landing gear did not extend as fuselage to runway contact prevented extension of the main landing gears. The airplane was dragged from the runway where approximately 2 days later, a crane raised the airplane. At that time, the main landing gears which were in the wheel wells, extended and locked into position.

Crash of a Let L-410UVP in Rumbek

Date & Time: Aug 13, 2003
Type of aircraft:
Operator:
Registration:
9XR-JT
Survivors:
Yes
Schedule:
Lokichogio - Rumbek
MSN:
81 07 07
YOM:
1981
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft departed Lokichogio on a charter flight to Rumbek on behalf of a humanitarian agency. On final approach, the captain saw an animal crossing the runway and decided to delay the landing. The aircraft landed too far down the runway and was unable to stop within the remaining distance. It overran and came to rest few dozen meters further. All five occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Cessna 404 Titan II in Jandakot: 2 killed

Date & Time: Aug 11, 2003 at 1537 LT
Type of aircraft:
Operator:
Registration:
VH-ANV
Flight Phase:
Survivors:
Yes
Schedule:
Jandakot - Jandakot
MSN:
404-0820
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
16722
Captain / Total hours on type:
12345.00
Aircraft flight hours:
16819
Circumstances:
The aircraft took off from runway 24 right (24R) at Jandakot Airport, WA. One pilot and five passengers were on board the aircraft. The flight was being conducted in the aerial work category, under the instrument flight rules. Shortly after the aircraft became airborne, while still over the runway, the pilot recognized symptoms that he associated with a failure of the right engine and elected to continue the takeoff. The pilot retracted the landing gear, selected the wing flaps to the up position and feathered the propeller of the right engine. The pilot later reported that he was concerned about clearing a residential area and obstructions along the flight path ahead, including high-voltage powerlines crossing the aircraft’s flight path 2,400 m beyond the runway. The aircraft was approximately 450 m beyond the upwind threshold of runway 24R when the pilot initiated a series of left turns. Analysis of radar records indicated that during the turns, the airspeed of the aircraft reduced significantly below the airspeed required for optimum single-engine performance. The pilot transmitted to the aerodrome controller that he was returning for a landing and indicated an intention to land on runway 30. However, the airspeed decayed during the subsequent manoeuvring such that he was unable to safely complete the approach to that runway. The pilot was unable to maintain altitude and the aircraft descended into an area of scrub-type terrain, moderately populated with trees. During the impact sequence at about 1537, the outboard portion of the left wing collided with a tree trunk and was sheared off. A significant quantity of fuel was spilled from the wing’s fuel tank and ignited. An intense postimpact fire broke out in the vicinity of the wreckage and destroyed the aircraft. Four passengers and the pilot vacated the aircraft, but sustained serious burns in the process. One of those passengers died from those injuries 85 days after the accident. A fifth passenger did not survive the post-impact fire.
Probable cause:
Significant factors:
1. The material specification contained in the engineering order for replacing the pump bushing of the engine driven fuel pump (EDFP) fitted to the right engine was not appropriate.
2. High torsional loads between the EDFP’s spindle shaft and the sleeve bearing sheared the pump’s drive shaft during a critical phase of flight.
3. The reduction in fuel pressure was insufficient to sustain operation of the engine at the take-off power setting.
4. The loss of engine power occurred close to the decision speed with the landing gear extended while the aircraft was over the runway.
5. The pilot elected to continue the takeoff.
6. The aircraft was manoeuvred, including turns and banks, at low altitude resulting in a decrease in airspeed below that required to maximise one-engine inoperative performance.
7. The pilot was unable to maintain the aircraft’s altitude over terrain that was unsuitable for an emergency landing.
Final Report:

Crash of a Cessna 340A in Bishop: 1 killed

Date & Time: Aug 8, 2003 at 2132 LT
Type of aircraft:
Operator:
Registration:
N340DC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bishop - Upland
MSN:
340A-0968
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1302
Captain / Total hours on type:
1.00
Aircraft flight hours:
1123
Circumstances:
During a nighttime takeoff initial climb, the airplane collided with terrain near the airport. Witnesses reported watching the airplane accelerate on runway 12, rotate, and climb to 200 to 300 feet above ground level. The climb rate decreased and the airplane appeared to initiate a left turn, with the roll continuing to a wings vertical attitude. At this point the airplane descended into the terrain. One witness north of the accident site described the landing lights going from horizontal to vertical followed by a decrease in engine sound just before impact. According to the airplane owner, the pilot had never flown the accident airplane before the first leg to the accident location to drop off the owner and another passenger. Examination of the pilot records failed to locate any previous flight time in Cessna 300 or 400 series airplanes. In the last 30 days he had given instruction in a smaller light twin engine airplane. Post accident examination of the wreckage revealed the landing gear to be in the down position at the time of impact. The retractable landing lights were extended and the nose gear taxi light was destroyed. Both propellers exhibited symmetrical power signatures. No preimpact mechanical malfunctions or failures were identified. The impact site was east of the airport about 0.68 nautical miles. The departure direction is towards a mountain range with sparse population and few ground reference lights. The moon's disk was 25 degrees above the southeastern horizon and was 89 percent illuminated. The FAA AC61-23C Pilot's Handbook of Aeronautical Knowledge addresses the environmental factors and potential in-flight visual illusions, which could affect pilot performance. The reference material describes Somatogravic Illusion as, "a rapid acceleration during takeoff can create the illusion of being in a nose up attitude. The disoriented pilot will push the airplane into a nose low, or dive attitude. A rapid deceleration by a quick reduction of the throttles can have the opposite effect, with the disoriented pilot pulling the airplane into a nose up, or stall attitude."
Probable cause:
The pilot's in-flight loss of control due to a Somatogravic illusion and/or spatial disorientation. Factors in the accident were the dark lighting conditions and the pilot's lack of familiarity with the airplane.
Final Report:

Crash of a Cessna 208B Grand Caravan in Tocomita: 1 killed

Date & Time: Aug 8, 2003 at 0932 LT
Type of aircraft:
Operator:
Registration:
YV-1069C
Survivors:
Yes
Schedule:
Porlamar - Canaima
MSN:
208B-0713
YOM:
1998
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
En route from Porlamar to Canaima, the crew informed ATC about engine problems and was cleared to divert to Tocomita for an emergency landing. On final approach, the aircraft stalled and crashed into trees 100 meters short of runway. A passenger was killed while 15 other occupants were injured. The aircraft was destroyed.

Crash of a Learjet 35A in Groton: 2 killed

Date & Time: Aug 4, 2003 at 0639 LT
Type of aircraft:
Registration:
N135PT
Flight Type:
Survivors:
No
Schedule:
Farmingdale - Groton
MSN:
35-509
YOM:
1983
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4300
Copilot / Total flying hours:
9000
Aircraft flight hours:
9287
Circumstances:
About 5 miles west of the airport, the flightcrew advised the approach controller that they had visual contact with the airport, canceled their IFR clearance, and proceeded under visual flight rules. A witness heard the airplane approach from the east, and observed the airplane at a height consistent with the approach minimums for the VOR approach. The airplane continued over the runway, and entered a "tight" downwind. The witness lost visual contact with the airplane due to it "skimming" into or behind clouds. The airplane reappeared from the clouds at an altitude of about 200 feet above the ground on a base leg. As it overshot the extended centerline for the runway, the bank angle increased to about 90-degrees. The airplane then descended out of view. The witness described the weather to the north and northeast of the airport, as poor visibility with "scuddy" clouds. According to CVR and FDR data, about 1.5 miles from the runway with the first officer at the controls, and south of the extended runway centerline, the airplane turned left, and then back toward the right. During that portion of the flight, the first officer stated, "what happens if we break out, pray tell." The captain replied, "uh, I don't see it on the left side it's gonna be a problem." When the airplane was about 1/8- mile south of the runway threshold, the first officer relinquished the controls to the captain. The captain then made an approximate 60-degree heading change to the right back toward the runway. The airplane crossed over the runway at an altitude of 200 feet, and began a left turn towards the center of the airport. During the turn, the first officer set the flaps to 20 degrees. The airplane reentered a left downwind, about 1,100 feet south of the runway, at an altitude of 400 feet. As the airplane turned onto the base leg, the captain called for "flaps twenty," and the first officer replied, "flaps twenty coming in." The CVR recorded the sound of a click, followed by the sound of a trim-in-motion clicker. The trim-in-motion audio clicker system would not sound if the flaps were positioned beyond 3 degrees. About 31 seconds later, the CVR recorded a sound similar to a stick pusher stall warning tone. The airplane impacted a rooftop of a residential home about 1/4-mile northeast of the approach end of the runway, struck trees, a second residential home, a second line of trees, a third residential home, and came to rest in a river. Examination of the wreckage revealed the captain's airspeed indicator reference bug was set to 144 knots, and the first officer's was set to 124 knots. The flap selector switch was observed in the "UP" position. A review of the Airplane Flight Manual revealed the stall speeds for flap positions of 0 and 8 degrees, and a bank angle of 60 degrees, were 164 and 148 knots respectfully. There were no charts available to calculate stall speeds for level coordinated turns in excess of 60 degrees. The flightcrew was trained to apply procedures set forth by the airplane's Technical Manual, which stated, "…The PF (Pilot Flying) will call for flap and gear extension and retraction. The PNF (Pilot not flying) will normally actuate the landing gear. The PNF will respond by checking appropriate airspeed, repeating the flap or gear setting called for, and placing the lever in the requested position... The PNF should always verify that the requested setting is reasonable and appropriate for the phase of flighty and speed/weight combination."
Probable cause:
The first officer's inadvertent retraction of the flaps during the low altitude maneuvering, which resulted in the inadvertent stall and subsequent in-flight collision with a residential home. Factors in the accident were the captain's decision to perform a low altitude maneuver using excessive bank angle, the flight crews inadequate coordination, and low clouds surrounding the airport.
Final Report:

Crash of a Douglas C-54G-10-DO Skymaster in Ulu

Date & Time: Aug 2, 2003 at 0800 LT
Type of aircraft:
Operator:
Registration:
C-GBSK
Flight Type:
Survivors:
Yes
MSN:
36049
YOM:
1945
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The four engine aircraft was completing a cargo flight to Ulu, carrying four crew members and a load consisting of 45 oil drums. On final approach, the crew realized his speed was too high so he reduced engine power and selected full flaps. The aircraft lost height so power was added. But the aircraft continued to descent and struck the ground short of runway threshold. Upon impact, the undercarriage were torn off. The aircraft slid on its belly, lost its both wings and came to rest few hundred feet further. All four crew members escaped with minor injuries and the aircraft was damaged beyond repair.