Crash of a Mitsubishi MU-300 Diamond 1A in Santos

Date & Time: Mar 23, 2003 at 1025 LT
Type of aircraft:
Registration:
PT-LNN
Survivors:
Yes
Schedule:
Rio de Janeiro – Santos
MSN:
0048
YOM:
1982
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12500
Captain / Total hours on type:
35.00
Copilot / Total flying hours:
4500
Copilot / Total hours on type:
19
Circumstances:
The aircraft departed Rio de Janeiro-Santos Dumont Airport on a flight to Santos, carrying one passenger and two pilots. Following an approach via the local NDB, the crew started the descent to Santos Airport but was forced to initiate a go-around procedure because he was not properly aligned. A second attempt to land was started to runway 35 with a tailwind component. Following an unstabilized approach, the aircraft landed 450 metres past the runway threshold (runway 35 is 1,390 metres long). Unable to stop within the remaining distance, the aircraft overran and came to rest in the Bertioga Canal. All three occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
Wrong approach configuration on part of the crew who continued the descent while the aircraft was unstable and moreover with a tailwind component. The aircraft landed at an excessive speed about 450 metres past the runway threshold, reducing the landing distance available. The tailwind component and the crew inexperience was contributing factors.
Final Report:

Crash of an Airbus A321-131 in Tainan

Date & Time: Mar 22, 2003 at 2235 LT
Type of aircraft:
Operator:
Registration:
B-22603
Survivors:
Yes
Schedule:
Taipei - Tainan
MSN:
602
YOM:
1996
Flight number:
GE543
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
169
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
13516
Aircraft flight cycles:
18580
Circumstances:
After landing on runway 36R at Tainan Airport, while decelerating, the aircraft struck construction vehicles parked beside the runway. The crew was able to stop the aircraft on the main runway and all 175 occupants evacuated safely. Two workers on the ground were injured. The aircraft was damaged beyond repair.
Probable cause:
Inadequate planning and implementation in airport construction safety procedures by both the CAA and the military authority, inadequacy in landing approval when exceeding the curfew hour, insufficient cooperation and coordination between the CAA and the military base authorities prior to construction work, lack of awareness to a lit runway when entering an active runway without acknowledging the tower controllers.

Crash of a Beechcraft 200 Super King Air in Badiraguato

Date & Time: Mar 20, 2003
Operator:
Registration:
XC-ADP
Flight Type:
Survivors:
Yes
Schedule:
Hermosillo – Badiraguato
MSN:
BB-156
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Badiraguato Airport, the twin engine aircraft went out of control and veered off runway. It collided with rocks, lost its tail and came to rest. All five occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Beechcraft E90 King Air in Kremmling

Date & Time: Mar 19, 2003 at 1930 LT
Type of aircraft:
Operator:
Registration:
N711TZ
Flight Type:
Survivors:
Yes
Schedule:
Grand Junction – Kremmling
MSN:
LW-226
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10564
Captain / Total hours on type:
212.00
Aircraft flight hours:
8040
Circumstances:
The pilot reported that he maneuvered for a left hand downwind leg for landing from the east to west. The pilot set up his downwind leg at 8,400 feet mean sea level putting him at what would have been 1,000 feet above the airport elevation of 7,411 feet. The pilot reported it was very dark and he could see the airport, but could not see the terrain. The pilot reported that suddenly he saw the ground. The airplane impacted the terrain and came to rest. The pilot reported that the airplane was experiencing no malfunctions prior to the accident. The airplane accident site was on the snow-covered edge of a mountain ridge at an elevation of 8,489 feet. An examination of the airplane's systems revealed no anomalies. Published terminal procedures for the runway indicated high terrain of 8,739 feet south-southeast of the airport. The published airport diagram for the airport directs right traffic for the pattern to runway 27.
Probable cause:
The pilot's improper in-flight planning and his failure to maintain safe clearance from the high terrain. Factors contributing to the accident were the high terrain and the dark night.
Final Report:

Crash of a PZL-Mielec AN-2R in Samedan

Date & Time: Mar 15, 2003 at 1725 LT
Type of aircraft:
Operator:
Registration:
LY-KAG
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Samedan - Samedan
MSN:
1G195-22
YOM:
1982
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3004
Captain / Total hours on type:
440.00
Aircraft flight hours:
4471
Circumstances:
The single engine aircraft departed Samedan Airport runway 03 for a local flight with two passengers and one pilot/instructor on board. While climbing to a height of 125 metres, the engine failed. The pilot initiated a 180° turn for an immediate landing on runway 21 when, at a speed of 140 km/h, the aircraft struck tree tops and crashed inverted to the right side of the runway. The wreckage was found 350 metres past the runway threshold and 20 metres to the right. All three occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The accident was caused by an engine failure in the climbing phase, in which the altitude of the aircraft was not sufficient for a 180° turn.
The following possibly contributed to the engine failure:
- Carburettor icing,
- Incorrect mixture regulation setting.
Final Report:

Crash of a Grumman C-2A Greyhound at Cherry Point MCAS

Date & Time: Mar 12, 2003
Type of aircraft:
Operator:
Registration:
162153
Survivors:
Yes
MSN:
33
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Cherry Point MCAS, the aircraft went out of control, lost its undercarriage and both wings and came to rest, bursting into flames. There were no casualties.

Crash of a Fokker F27 Friendship 500RF in Kinston

Date & Time: Mar 8, 2003 at 1027 LT
Type of aircraft:
Operator:
Registration:
N712FE
Flight Type:
Survivors:
Yes
Schedule:
Greensboro - New Bern
MSN:
10613
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8130
Captain / Total hours on type:
1450.00
Copilot / Total flying hours:
2911
Copilot / Total hours on type:
955
Aircraft flight hours:
26665
Aircraft flight cycles:
28285
Circumstances:
According to the pilot, an unsafe right gear indication was received during the approach, and the control tower controller confirmed the right gear was not fully extended. On landing roll the right main landing gear collapsed and the airplane slid off of the runway. Examination of the right main landing gear revealed the drag brace was fractured. The fracture was located at the lower side of a transition from a smaller internal diameter on the upper piece to a larger internal diameter on the lower piece. The region of the fracture surface was flat and perpendicular to the tube longitudinal axis. The region had a smooth, curving boundary, also consistent with fatigue. The fatigue features emanated from multiple origins at the inner surface of the tube. The Federal Aviation Administration (FAA) issued an Airworthiness Directive (AD) requiring an inspections of main landing gear drag stay units. The AD was prompted by the fracture of a drag stay tube from fatigue cracking that initiated from an improperly machined transition radius at the inner surface of the tube. According to Fokker ,the Fokker F27 Mark 500 airplanes (such as the incident airplane) were not equipped with drag stay units having part number 200261001, 200485001, or 200684001. One tube, part number 200259300, had a change in internal diameter (stepped bore), and the other tube, part number 200485300, had a straight internal bore. AD 97-04-08 required an ultrasonic inspection to determine if the installed tube had a straight or stepped bore. A review of maintenance records revealed that the failed drag stay tube had accumulated 28, 285 total cycles.
Probable cause:
The fatigue failure of the main drag stay tube. A factor is no inspection procedure required.
Final Report:

Crash of a Piper PA-46-500TP Malibu Meridian in Albuquerque: 3 killed

Date & Time: Mar 7, 2003 at 1918 LT
Registration:
N522RF
Flight Type:
Survivors:
No
Schedule:
Scottsdale – Albuquerque
MSN:
46-97119
YOM:
2001
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1200
Aircraft flight hours:
365
Circumstances:
The pilot was performing a night, VFR traffic pattern, to a full stop at a non-towered airport in a turboprop aircraft. He entered the traffic pattern (6,800 feet; 1,000 feet AGL) on an extended downwind; radar data indicated that his ground-speed was 205 knots. Over the next 3 nautical miles on down wind, radar data indicated that he slowed to a ground-speed of 171 knots, lost approximately 500 feet of altitude, and reduced his parallel distance from the runway from 4,775 feet to 2,775 feet. Witnesses said that his radio transmissions on CTAF appeared normal. The two witnesses observed a bright blue flash, followed by a loss of contact with the airplane. Rescue personnel found a broken and downed static wire from a system of three sets of power transmission wires. The dark night precluded ground rescue personnel from locating the downed aircraft; a police helicopter found the airplane approximately 2 hours after the accident. The pilot had recently completed his factory approved annual flight training. His flight instructor said that the pilot was taught to fly a VFR traffic pattern at 1,500 feet AGL (or 500 feet above piston powered aircraft), enter the downwind leg from a 45 degree leg, and fly parallel to the downwind approximately 1 to 1.5 nautical miles separation from it. His speed on downwind should have been 145 to 150 knots indicated, with 90 to 95 knots on final for a stabilized approach. The flight instructor said that the base turn should be at a maximum bank angle of 30 degrees. Radar data indicates that the pilot was in a maximum descent, while turning base to final, of 1,800 to 1,900 feet per minute with an airspeed on final of 145 to 150 knots. His maximum bank angle during this turn was calculated to have been more than 70 degrees. The separated static wire was located 8,266.5 feet from the runway threshold, and was approximately 30 feet higher than the threshold. Post-accident examinations of the airplane and its engine revealed no anomalies which would have precluded normal operations prior to impact.
Probable cause:
The pilot's unstabilized approach and his failure to maintain obstacle clearance. Contributing factors were the dark night light condition, and the static wires.
Final Report:

Ground accident of an ATR42-300 in Rome

Date & Time: Mar 6, 2003 at 2050 LT
Type of aircraft:
Operator:
Registration:
I-ATRF
Flight Phase:
Survivors:
Yes
Schedule:
Rome - Rimini
MSN:
034
YOM:
1986
Flight number:
MTC403
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
42
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7685
Captain / Total hours on type:
1159.00
Copilot / Total flying hours:
740
Copilot / Total hours on type:
232
Aircraft flight hours:
27472
Aircraft flight cycles:
28492
Circumstances:
Following a normal taxi procedure at Rome-Fiumicino Airport, the crew was at the holding point of runway 25, ready for departure. On board were 42 passengers and a crew of three. Both engines were turning at 70% torque. When the crew released the brakes, the swinging lever of the left main gear failed. The aircraft sank on its belly and stopped. All 45 occupants evacuated safely and there were no injuries. The aircraft was damaged beyond repair.
Probable cause:
Failure of the swinging lever of the left main gear due to the presence of fatigue cracks.
Final Report:

Crash of a Boeing 737-2T4 in Tamanrasset: 102 killed

Date & Time: Mar 6, 2003 at 1515 LT
Type of aircraft:
Operator:
Registration:
7T-VEZ
Flight Phase:
Survivors:
Yes
Schedule:
Tamanrasset - Ghardaia - Algiers
MSN:
22700
YOM:
1983
Flight number:
AH6289
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
97
Pax fatalities:
Other fatalities:
Total fatalities:
102
Captain / Total flying hours:
10760
Captain / Total hours on type:
1087.00
Copilot / Total flying hours:
5219
Copilot / Total hours on type:
1292
Aircraft flight hours:
41472
Aircraft flight cycles:
27184
Circumstances:
The aircraft was taking off from Tamanrasset to undertake, with a three-hour delay, scheduled flight DAH 6289 to Ghardaïa and Algiers. Six crew members (two flight crew and four cabin crew) and 97 passengers were on board. The co-pilot was pilot flying. No technical exemptions or deferred maintenance items applied to the airplane; on departure from Algiers it had been subject to routine maintenance for a minor technical problem, a hydraulic pump having been changed in the circuit B landing gear bay. The speeds decided on by the crew were V1 = 144 kt, VR = 146 kt, V2 = 150 kt. The EPR displayed was 2.18, that is to say nominal maximum thrust on take-off. At 14 h 01 min 37 s, the crew requested start-up clearance. At 14 h 08 min 36 s, the tower cleared the airplane to taxi, enter and taxi up runway 02. The wind was 330 at 12 kt. At 14 h 12 min 30 s, the co-pilot called out “we’re ready”. At 14 h 12 min 31 s, the tower cleared flight 6289 to line up and take off. At 14 h 13 min 36 s, flight DAH 6289 announced take-off. About five seconds after airplane rotation, at the moment when gear retraction was requested, a sharp thumping noise was recorded on the CVR. The airplane’s heading veered to the left, followed by a track correction. The Captain announced that he was taking over the controls. A short time later, the co-pilot told the control tower “we have a small problem”. The airplane continued to climb and reached a recorded height of about 400 ft. The speed dropped progressively from 160 kt during airplane lift-off to stall speed at the end of the recording. In fact, about ten seconds before, the noise of the stick shaker is heard on the CVR (which usually indicates that the airplane is 7% from its stall speed). The “Don’t Sink” aural warning, which normally indicates a loss of altitude during take-off when the airplane is below nine hundred feet, appeared about six seconds before the end of the recording. The airplane, with landing gear extended, struck the ground on its right side. A severe fire broke out immediately. The airplane slid along, losing various parts, struck and knocked over the airport perimeter fence then crossed a road before coming to a halt in flames. The control tower immediately sounded the alert.
Probable cause:
Probable causes:
The accident was caused by the loss of an engine during a critical phase of flight, the non-retraction of the landing gear after the engine failure, and the Captain, the PNF, taking over control of the airplane before having clearly identified the problem.
The following factors probably contributed to the accident:
• the perfunctory flight preparation, which meant that the crew were not equipped to face the situation that occurred at a critical moment of the flight;
• the coincidence between the moment the failure occurred and the request to retract the landing gear;
• the speed of the event that left the crew little time to recover the situation;
• maintaining an inappropriate rate of climb, taking into account the failure of one engine;
• the absence of any teamwork after the engine failure, which led to a failure to detect and correct parameters related to the conduct of the flight (speed, rate of climb, configuration, etc.);
• the takeoff weight being close to the maximum with a high aerodrome altitude and high temperature;
• the rocky environment around the aerodrome, unsuitable for an emergency landing.
Final Report: