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

Date & Time: Jul 31, 2003
Operator:
Registration:
ARC-511
Flight Type:
Survivors:
Yes
MSN:
31-7405151
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances while on approach to Corozal-Las Brujas Airport. All three occupants were injured and the aircraft was destroyed.

Crash of a Cessna 551 Citation II/SP in Sorocaba: 1 killed

Date & Time: Jul 23, 2003 at 0840 LT
Type of aircraft:
Operator:
Registration:
PT-LME
Flight Type:
Survivors:
Yes
Schedule:
Lins - Sorocaba
MSN:
551-0023
YOM:
1980
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3920
Captain / Total hours on type:
1300.00
Copilot / Total flying hours:
1000
Copilot / Total hours on type:
90
Aircraft flight hours:
8761
Circumstances:
The aircraft departed Lins Airport on a ferry flight to Sorocaba with two pilots on one passenger (the owner) on board. The aircraft was transferred to Sorocaba Airport for maintenance purposes. While descending, the crew was informed that runway 36 was in use and that three small aircraft were completing local training in the circuit. In good weather conditions, the captain decided to complete a straight-in approach to runway 18. After touchdown, the aircraft was unable to stop within the remaining distance. It overran, crossed a road and came to rest into a ravine. The passenger escaped uninjured, the copilot was seriously injured and the captain was killed. The aircraft was destroyed.
Probable cause:
Wrong approach configuration on part of the crew who completed an unstabilized approach and landed too far down the runway (about a half way down) at an excessive speed. In such conditions, the aircraft could not be stopped within the remaining distance. The following contributing factors were identified:
- The crew did not make any approach briefing,
- The crew failed to follow the approach checklist,
- The aircraft had deficiencies in maintenance, particularly with regard to the brakes systems,
- The techlogs were out of date,
- Maintenance was periodic but insufficient,
- Although the runway 36 was in use, the captain preferred to land on runway 18,
- The aircraft was unstable on short final and landed too far down the runway, reducing the landing distance available,
- The aircraft' speed upon landing was excessive, preventing the reverse thrust systems to be activated,
- The captain took over control and activated the reverse thrust system on the right engine only,
- Poor crew coordination,
- The crew was operating in a conflict environment after touchdown,
- Poor judgment of the situation,
- Poor flight planning,
- Lack of crew discipline.
Final Report:

Crash of a Boeing 707-3J6C in Dhaka

Date & Time: Jul 11, 2003 at 0638 LT
Type of aircraft:
Operator:
Registration:
5X-AMW
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Dhaka - Amman
MSN:
20723
YOM:
1974
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from runway 14 at Dhaka-Zia Ul-Haq Airport, the crew encountered an unexpected situation and the captain decided to abandon the takeoff procedure. Unable to stop within the remaining distance (runway 14 is 3,200 metres long), the aircraft overran, lost its undercarriage and came to rest 450 metres further. All five crew members escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Casa 2.111 in Cheyenne: 2 killed

Date & Time: Jul 10, 2003 at 1310 LT
Type of aircraft:
Operator:
Registration:
N72615
Survivors:
No
Schedule:
Midland – Cheyenne – Missoula
MSN:
124
YOM:
1952
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
21000
Copilot / Total flying hours:
15000
Aircraft flight hours:
1895
Circumstances:
The airplane was en route to an air show and was making a refueling stop. The tower controller cleared the pilot to land. The airplane was observed on a 3-mile straight-in final approach when it began a left turn. The controller asked the pilot what his intentions were. The pilot replied, "We just lost our left engine." The pilot then reported that he wasn't going to make it to the airport. Witnesses observed the airplane flying "low to the ground and under-speed for [a] good 4 minutes." The right propeller was turning, but the left propeller was not turning. There was no fire or smoke coming from the left engine. The pilot was "obviously trying to pull up." The airplane "dipped hard left," then struck the ground left wing first. It slid through a chain link fence, struck a parked automobile, and collided with a school bus wash barn. The ensuing fire destroyed the airplane, parked car, and wash barn. Disassembly and examination of both engines disclosed no anomalies that would have been causal or contributory to the accident. According to the Airplane Flight Manual, "Maximum power will probably be required to maintain flight with one engine inoperative. Maximum power at slow air speed may cause loss of directional control."
Probable cause:
A loss of engine power for reasons undetermined, and the pilot's failure to maintain aircraft control. Contributing factors were the unsuitable terrain on which to make a forced landing, low airspeed, the fence, automobile, and the school bus wash barn.
Final Report:

Crash of a Boeing 737-2J8C in Port Sudan: 116 killed

Date & Time: Jul 8, 2003 at 0417 LT
Type of aircraft:
Operator:
Registration:
ST-AFK
Survivors:
Yes
Schedule:
Port Sudan - Khartoum
MSN:
21169
YOM:
1975
Flight number:
SD139
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
106
Pax fatalities:
Other fatalities:
Total fatalities:
116
Circumstances:
The aircraft departed Port Sudan Airport at 0407LT on a schedule service to Khartoum with 105 passengers and 11 crew members on board. During climbout, the crew informed ATC about technical problems and was cleared to return for an emergency landing on runway 33. On final approach in limited visibility, the aircraft struck the ground and crashed about 5 km from the runway threshold. The aircraft was totally destroyed by impact forces. A boy aged two was injured while 116 other occupants were killed, among them eight EU citizens and one high ranking officer of the Sudan Army.
Probable cause:
Failure of one engine during initial climb for unknown reasons.

Crash of a Mitsubishi MU-2B-35 Marquise in Belém: 4 killed

Date & Time: Jul 1, 2003 at 1957 LT
Type of aircraft:
Operator:
Registration:
PT-LFX
Survivors:
No
Schedule:
São Luis – Belém
MSN:
650
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
11236
Captain / Total hours on type:
4886.00
Copilot / Total flying hours:
1015
Copilot / Total hours on type:
359
Circumstances:
The twin engine aircraft was completing a taxi flight from São Luis to Belém, carrying two passengers, two pilots and a load of briefcases with bank documents. On approach to Belém-Val de Cans Airport by night, the crew encountered poor weather conditions with limited visibility, CB's, rain falls and severe turbulences. On final approach, the aircraft went out of control and crashed on the Ilha das Onças Island, about 5,5 km west of runway 06 threshold. The aircraft was destroyed and all four occupants were killed.
Probable cause:
It was determined that both engines were running normally at impact and no technical anomalies were found on the aircraft and its equipments. Both pilots were properly licenced and experienced on this type of aircraft. At the time of the accident, weather conditions were poor with CB's, rains falls, severe turbulences, strong winds and probable windshear that may have been a contributing factor.
Final Report:

Crash of a Let L-410UVP in Moscow

Date & Time: Jun 30, 2003
Type of aircraft:
Operator:
Registration:
FLARF-01192
Flight Phase:
Survivors:
Yes
Schedule:
Moscow - Moscow
MSN:
810718
YOM:
1981
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While flying in the vicinity of Moscow-Myachkovo Airport, the aircraft suffered a double engine failure. The pilot completed an emergency landing in a field near the airport. While all occupants were uninjured, the aircraft was damaged beyond repair. The exact date of the mishap remains unknown, somewhere in June 2003.
Probable cause:
Double engine failure for unknown reasons.

Crash of a Cessna 414 Chancellor in Fort Myers: 2 killed

Date & Time: Jun 26, 2003 at 1251 LT
Type of aircraft:
Registration:
N749AA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
West Palm Beach – Fort Myers
MSN:
414-0049
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
972
Captain / Total hours on type:
1.00
Aircraft flight hours:
1710
Circumstances:
The pilot reported visually checking the main fuel tanks during his preflight inspection of the airplane and later reported there was enough fuel for the intended flight which would be less than 1 hour, plus a 45-minute reserve amount of fuel. He estimated the fuel level in the main fuel tanks was 2-3 inches from the top. He also reported that before the accident flight he had never flown the accident make and model airplane, and that he had not had any flight training in the airplane. The passengers were boarded, the flight departed and climbed to between 4,500 and 6,500 feet msl. He leaned the mixture during cruise, and the flight continued. He began descending when the flight was 12 miles from the destination airport, and he performed the pre landing checks when the flight was 3 miles from the destination airport. The flight entered left downwind where he lowered the landing gear and turned on the fuel pumps. When abeam the landing point he reduced power, lowered the flaps 10 degrees, and turned onto base leg. During the base leg while rolling out of the turn and flying at 600 feet, "the right engine suddenly came to a stop...." He banked to the left to maintain zero sideslip, pushed the mixture, propeller, and throttle controls full forward, and identified the right engine had failed. He reportedly pulled the right propeller control to the feather position but during the postaccident investigation, the right propeller blades were not in the feather position and there was no evidence of preimpact failure or malfunction of the propeller. The pilot further reported that while pulling the right propeller control to the feather position, the airplane, "began to yaw right and simultaneously bank right...." He moved the left throttle control to idle, and they were on the ground in a span of 6 seconds from the time the right engine quit. No fuel leakage was noted at the scene, and no fuel contamination was noted in a nearby pond. Additionally, only residual fuel was noted in the fuel lines in each engine compartment. A total of 4.0 and 1.5 gallons of fuel were drained from the left and right auxiliary fuel tanks, respectively. No evidence of preimpact flight control failure or malfunction was noted. Neither propeller was at or near the feather range at the time of impact. Both engines were removed from the airplane, placed on a test stand with a "club" propeller, and both engines were noted to operate normally during the engine run. Examination of the right seat in the third row of the airplane revealed the seat frame was bent down on the left side, and all seat feet were in position but distorted; no fracture of the seat feet were noted. Examination of the seat of the passenger who sustained minor injuries (left seat in the third row) revealed the seatpan was compressed down, and the lapbelt was unbuckled. The inboard arm rest was bent inward, and the outboard arm rest was bent outward. The seat frame indicated displacement to the left. The seat back was twisted counter clockwise, and the left forward seat foot was in place. The seat and attach structure was certificated for a maximum forward g loading of 9 g's, and a maximum sideward g loading of 1.5 g's. This does not include a 1.33 margin of safety factor. The seat and attach structure was tested to ultimate loads in a combined forward, sideward, and upward directions in accordance with CAR 3.390-2. The same loads were also applied in a downward direction by itself. The empennage was separated just aft of the aft pressure bulkhead but remained secured by flight control cables. According to personnel from the airplane manufacturer, the tested load (150 percent limit) for the empennage in negative shear translates to 14.0 g loading. Based on Cessna Engineering rough calculations, they believe the empennage is capable of sustaining an additional 30 percent beyond what it was tested to, or an estimated 18.2 g's in negative shear loading.
Probable cause:
The failure of the pilot to maintain airspeed (Vs) following a total loss of engine power from the right engine due to fuel starvation, resulting in an inadvertent stall, uncontrolled descent, and in-flight collision with trees and terrain. Factors in the accident was the failure pilot to feather the right propeller following the total loss of engine power, and his lack of total experience in the accident make/model of aircraft.
Final Report:

Crash of a Tupolev TU-134SKh in Nyagan

Date & Time: Jun 24, 2003
Type of aircraft:
Operator:
Registration:
RA-65929
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nyagan – Salekhard
MSN:
66495
YOM:
1987
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was subject to major maintenance during the last two months, especially with the rudder actuators that were replaced. As there were still problems with the actuators during the last flight, decision was taken to make the appropriate adjustments followed by a flight to Salekhard. During the takeoff roll on runway 16/34, at a speed of 150 km/h, the aircraft deviated to the left and the captain decided to counter this deviation by using the nosewheel steering system. This caused the right front tyre to burst. At a speed of 250 km/h, the takeoff procedure was abandoned but this decision was taken too late. Unable to stop within the remaining distance (the runway 16/34 is 2,530 metres long), the aircraft overran, lost its nose gear and rolled for 577 metres before coming to rest. All 11 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The following findings were identified:
- Poor quality of work from the engineering personnel of Voronezh Avia during the replacement and adjustment of the hydraulic amplifier GU-108D,
- Unsatisfactory flying and technical operation of the aircraft after the completion of the replacement of the hydraulic amplifier, during which the incorrectly installed rudder actuator was not discovered,
- The decision taken by the crew to continue the takeoff procedure despite significant efforts needed for the deflection of the right rudder pedal already noted during the preflight checks,
- The late rejection of the takeoff procedure.

Crash of a Canadair RegionalJet CRJ-100ER in Brest: 1 killed

Date & Time: Jun 22, 2003 at 2351 LT
Operator:
Registration:
F-GRJS
Survivors:
Yes
Schedule:
Nantes - Brest
MSN:
7377
YOM:
2000
Flight number:
AF5672
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
16000
Captain / Total hours on type:
5300.00
Copilot / Total flying hours:
4800
Copilot / Total hours on type:
650
Aircraft flight hours:
6649
Aircraft flight cycles:
6552
Circumstances:
On Sunday 22 June 2003, the CRJ-100 registered F-GRJS was operating as scheduled flight AF 5672 between Nantes Atlantique and Brest-Guipavas aerodromes (France) under an IFR flight plan. The flight represented the last leg of a Brest – Nantes – Strasbourg – Nantes – Brest rotation. The aeroplane was operated by Brit Air on behalf of Air France. The Captain was pilot flying (PF). The crew also included another pilot (the co-pilot), and one cabin crew. The aeroplane took off at 21 h 16 (2) with twenty-one passengers. The flight was approximately fifty minutes late, due to a delay in the first flight of the day that had affected the subsequent flights. During the flight, with the authorisation of the control centre, the crew passed northeast of the planned track in order to avoid cumulonimbus formations. At Brest Guipavas, the 21 h 00 ATIS indicated visibility of eight hundred meters with some fog and a cloud base at two hundred feet with the presence of cumulonimbus. The runway in use was 26 Left with an ILS approach. Runway use was temporarily restricted to Cat I due to presence of works. At 21 h 36 min 27 s, the flight (radio call sign BZ 672 EC) was cleared by the enroute controller to descend to Flight Level 150 then, at 21 h 39 min 10 s, to Flight Level 70. At 21 h 39 min 23 s, the crew announced that they were descending to Flight Level 70 towards BODIL, the initial approach fix, avoiding storms. At 21 h 39 min 31 s, the Brest approach controller transmitted "Descend four thousand feet QNH one thousand and eight, number two on approach, plan a holding pattern at Golf Uniform". At 21 h 44 min 21 s, the controller cleared descent to three thousand feet and added "and perform a holding pattern". The aeroplane was approximately 20 NM DME from BG. At 21 h 47 min 40 s, that is, approximately one-and-a-half-minutes before the planned start of the hold, the controller cleared descent to two thousand feet QNH. At 21 h 48 min 01 s, the controller announced "Echo Charlie, preceding aeroplane has landed, continue the approach, report at Outer Marker". Four seconds later, at 9.4 NM DME, the autopilot "Heading" and "Vertical Speed" modes became active and the aeroplane adopted a heading of 257°. The Brest ILS frequency was displayed on the VOR 1 and the VOR navigation source was selected. At 21 h 48 min 21 s, the controller called back "Are you ready for the approach?". The crew confirmed and the controller asked "Report at Outer Marker". The Copilot read this back. At the Captain’s request, the Co-pilot extended the flaps to 20° then the landing gear. The aeroplane stabilized at two thousand feet QNH on autopilot, still in Heading mode, at about 7 NM DME. Simultaneously, the wind, which had started to veer northwest during the descent, caused the aeroplane to drift towards the left. The flight crew did not notice this drift. At 21 h 49 min, the co-pilot extended the flaps to 30° then to 45° and the crew performed the pre-landing checklist. At 21 h 49 min 35 s, the controller cleared the landing for runway 26 Left and indicated a cloud base of less than one hundred feet. At 21 h 49 min 40 s, the aeroplane, in level flight, passed under then above the glide slope. At 21 h 50 min, the aeroplane passed the GU beacon, slightly to the left, with a track deviating to the left in relation to the localizer centreline. At that moment, the wind calculated by the Flight Management System (FMS) was 300° / 20 kt. A short time later, the aeroplane began its descent. The aeroplane continued to drift to the left of the localizer centreline. At 21 h 50 min 45 s the aeroplane again passed through the glide slope, and the Captain said "Approach selected, LOC and Glide"; the Co-pilot confirmed. The autopilot "heading" and "vertical speed" modes remained active. The aeroplane thereafter remained below the glide slope for the remainder of the flight. Between 21 h 50 min 58 s and 21 h 51 min 02 s, the GPWS announced, successively, "Five hundred", "Glide slope" then "Sink rate". At 21 h 51 min 01 s, the aeroplane began a turn to the right. By this time, the aeroplane was 4.68 points to the left of the localizer centreline. At 21 h 51 min 04 s, the Captain disengaged the autopilot. At 21 h 51 min 05 s, the GPWS announced "Three hundred". Between 21 h 51 min 07 s and 21 h 51 min 14 s, seven "Glide slope" alarms sounded. During this time, the Co-pilot said "come right" on two occasions and the aeroplane attitude changed from - 5° to 0°. At 21 h 51 min 15 s, the GPWS announced "One hundred". At 21 h 51 min 16 s, with the aeroplane at 529 feet QNH and 93 feet on the radio altimeter, the Co-pilot said "I’ve got nothing in front", then the Captain said "Go around". Simultaneously, the engine thrust increased significantly. The aeroplane attitude returned to - 5 in four seconds. At 21 h 51 min 19 s, the Co-pilot said "Go around". At 21 h 51 min 20 s, the GPWS announced "Sink rate" then "Pull up". The Co-pilot said "Go around" again at 21 h 51 min 22. The first sounds of the impact were recorded by the CVR at 21 h 51 min 22 s, and the recording stopped at 21 h 51 min 24. s. The aeroplane, which touched the ground without any great force, rolled, struck several obstacles and ended up 450 meters left of the extended runway centreline, 2,150 meters from the runway threshold. The Captain was killed. The rest of the crew and the passengers managed to evacuate the aeroplane, which was destroyed by fire.
Probable cause:
The causes of the accident are as follows:
• neglecting to select the APPR mode at the start of the approach, which led to non-capture of the localizer then of the glide slope;
• partial detection of flight path deviations, due to the crew’s focusing on vertical navigation then on horizontal navigation;
• continuing a non-stabilised approach down to the decision altitude.
Lack of communication and coordination in the cockpit, and a change of strategy on the part of the Controller in managing the flight were contributing factors.
Final Report: