Crash of a Boeing 737-2M9 in Rio Branco

Date & Time: Jan 26, 2003 at 1415 LT
Type of aircraft:
Operator:
Registration:
PP-SPJ
Survivors:
Yes
Schedule:
Belém – Manaus – Rio Branco
MSN:
21236
YOM:
1976
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
89
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7120
Captain / Total hours on type:
5271.00
Copilot / Total flying hours:
1348
Copilot / Total hours on type:
310
Aircraft flight hours:
54989
Circumstances:
Following an uneventful flight from Manaus, the crew started the descent to Rio Branco-Presidente Médici Airport runway 06 in marginal weather conditions with limited visibility due to fog. After passing the MDA at 1,150 feet, the crew continued the approach with an excessive rate of descent of 1,222 feet per minute. At a height of 57 feet, the aircraft struck trees located 360 metres short of runway 06 threshold. The engines lost power, the aircraft lost speed and height then struck the ground about 100 metres short of runway. Upon impact, the undercarriage were torn off and the aircraft slid on a distance of 600 metres before coming to rest. All 95 occupants escaped uninjured while the aircraft was destroyed.
Probable cause:
Poor approach configuration on part of the flying crew who continued the approach after passing the MDA at 1,150 feet while the aircraft was not stabilized and the crew did not establish a visual contact with the obstacles on short final. The following contributing factors were identified:
- Following the first impact with trees, branches and pieces of wood entered the engines, causing a loss of power followed by a loss of speed and altitude,
- Complacency on the part of the crew,
- Pressure and stress,
- Visual perception issues,
- Violation of the standard operating procedures,
- Loss of situational awareness,
- Lack of crew resources management,
- Poor approach and landing planning,
- Poor weather conditions,
- Relative low experience of the copilot.
Final Report:

Crash of a Grumman G-159 Gulfstream I in Busia: 3 killed

Date & Time: Jan 24, 2003 at 1645 LT
Type of aircraft:
Operator:
Registration:
5Y-EMJ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Busia – Nairobi
MSN:
158
YOM:
1965
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine aircraft was returning from Busia to Nairobi, carrying a delegation of the Kenyan Government who made a local visit in Busia following the national elections. Shortly after takeoff from runway 13/31 which is 3,281 feet long, the aircraft encountered difficulties to gain height. It struck power cables and crashed onto a house. Both pilots and a passenger, the Labour Minister Ahmed Mohamed Khalif were killed while nine other occupants were seriously injured. The aircraft was destroyed. There were no casualties on the ground.
Probable cause:
The following findings were identified:
- Poor flight preparation on part of the crew,
- The total weight of the aircraft was estimated to be over 16 tons, well above the MTOW,
- Aircraft above 5,7 tons are not allowed to land at Busia Airport,
- According to circumstances, a minimum runway length of 3,900 feet was required,
- The captain's licences were not up to date,
- The aircraft documentation was not up to date and failed to comply with Kenyan regulations,
- The aircraft's maintenance was performed by technicians who did not have the proper licence and training,
- The aircraft already had in the past several accidents in Congo and Sudan,
- Following one accident in Sudan in 2000, the aircraft was considered as written off by the insurance and the owner, MIA International Ltd, purchased the hull from the insurers, repaired the aircraft and re-registered it, changing the registration from 5Y-MIA to 5Y-EMJ.

Crash of a Cessna 208B Super Cargomaster in San Angelo

Date & Time: Jan 24, 2003 at 1015 LT
Type of aircraft:
Operator:
Registration:
N944FE
Flight Type:
Survivors:
Yes
Schedule:
San Angelo - San Angelo
MSN:
208B-0044
YOM:
1987
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4356
Copilot / Total flying hours:
13884
Aircraft flight hours:
7503
Circumstances:
The airplane impacted a dirt field and a power line following a loss of control during a simulated engine failure while on a Part 135 proficiency check flight. Both pilots were seriously injured and could not recall any details of the flight after the simulated engine failure. Witnesses observed the airplane flying on a westerly heading at an altitude of 100 to 200 feet, and descending. They heard the sound of an engine “surging” and observed the airplane’s wings bank left and right. The airplane continued to descend and impacted the ground and power lines before becoming inverted. A pilot-rated witness reported that he observed about ¼ inch of clear and rime ice on the airplane’s protected surfaces (deice boots) and about ½ inch of ice on the airplane’s unprotected surfaces. An NTSB performance study of the accident flight based on radar data indicated that the airplane entered a descent rate of 1,300 feet per minute (fpm) about 1,100 feet above the ground. This rate of descent was associated with a decrease in airspeed from 130 knots to 92 knots over a span of 30 seconds. The airplane’s rate of descent leveled off at the 1,300 fpm rate for 45 seconds before increasing to a 2,000 fpm descent rate. The true airspeed fluctuated between a low of 88 knots to 102 knots during the last 45 seconds of flight. According to the aircraft manufacturer, the clean, wing flaps up stall speed was 78 knots. However, after a light rime encounter, the Pilot’s Operating Handbook (POH) instructed pilots to maintain additional airspeed (10 to 20 KIAS) on approach “to compensate for the increased pre-stall buffet associated with ice on the unprotected areas and the increased weight.” With flaps up, a minimum approach speed of 105 KIAS was recommended. The POH also stated that a significantly higher airspeed should be maintained if ½ inch of clear ice had accumulated on the wings.
Probable cause:
The flight crew's failure to cycle the deice boots prior to conducting a simulated forced landing and their failure to maintain adequate airspeed during the maneuver, which resulted in an inadvertent stall and subsequent loss of control. A contributing factor was the ice accumulation on the leading edges of the airfoils.
Final Report:

Crash of a Cessna 402C in Sacramento

Date & Time: Jan 23, 2003 at 2030 LT
Type of aircraft:
Operator:
Registration:
N6814A
Survivors:
Yes
Schedule:
Ukiah – Sacramento
MSN:
402C-0645
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3400
Captain / Total hours on type:
350.00
Aircraft flight hours:
13817
Circumstances:
The airplane collided with obstructions following a loss of power in one engine during a missed approach. Following the collision sequence the airplane came to rest upright about 500 feet from the approach end of the runway and was destroyed in a post-impact ground fire. The pilot told a responding sheriff's deputy and a Federal Aviation Administration (FAA) inspector that he made the ILS approach to land and initiated a missed approach. When he added power, the left engine sputtered and the airplane veered to the left. He activated the fuel boost pump, but the airplane contacted obstructions and crashed. The responding sheriff's deputy also observed the accident. He heard an engine of an airplane making unusual sounds. The engine "seemed to get quiet and then revved higher as if to climb." He looked in the direction of the sound and saw a series of blue flashes and then an orange fireball. The deputy reported that there was a dense fog in the area at the time. At the time of the accident, the airport's weather conditions were reported as 100 feet overcast and 1/4-mile visibility in fog. The landing minimums for the ILS approach are 200 feet and 1/2-mile. According to the operator's records, when the airplane departed from Ukiah, its gross takeoff weight was about 5,909 pounds. The pilot operating handbook (POH) for the airplane lists the following items in the single engine go around checklist: 1) Throttle full forward; 2) wing flaps up; 3) when positive climb rate achieved, gear up; 4) ensure the inoperative engine is feathered. For a gross weight of 5,900 pounds, and the existing atmospheric conditions, the single engine climb performance chart shows an expected positive rate of climb of 500 feet per minute if the airplane was configured correctly. The chart also lists the following subtractions from that performance for the listed condition: 1) -400 fpm for wind milling inoperative engine; 2) -350 feet for landing gear down; 3) -200 fpm for flaps extended to 15 degrees. Examination of the wreckage disclosed that neither engine's propeller was feathered, the landing gear was down and the flaps were extended to 10 degrees. Without the airplane configured correctly for the single engine missed approach, the net climb performance would be a negative 400 feet per minute. There were no discrepancies noted with the airframe examination. The engine examination revealed no mechanical anomalies with either engine that would have precluded normal operation. 14 CFR 135.224 states that a pilot cannot initiate an approach if the weather conditions are below landing minimums if the approach is started outside of the final approach fix. The pilot can continue the landing if they are already established on the approach and the airport goes below landing minimums. According to the operator's FAA approved operating specifications, the operator had not been approved for lower than standard landing minimums.
Probable cause:
Loss of engine power in the left engine for undetermined reasons. Also causal was the pilot's failure to correctly configure the airplane for a single engine missed approach, which resulted in a negative climb performance. A factor was the pilot's decision to initiate the approach when the weather conditions were below the published approach minimums.
Final Report:

Crash of a Cessna 207A Skywagon in Put-in-Bay

Date & Time: Jan 20, 2003 at 0945 LT
Operator:
Registration:
N9945M
Flight Phase:
Survivors:
Yes
Schedule:
Put-in-Bay – Port Clinton
MSN:
207-0153
YOM:
1970
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4500
Captain / Total hours on type:
405.00
Aircraft flight hours:
6283
Circumstances:
Shortly after takeoff, about 300 feet agl, the engine lost all power. The pilot activated the electric fuel pump, and moved the fuel selector several times. However, the engine did not regain power, and the pilot performed a forced landing into trees. After the accident, the pilot stated to a police officer that he might have departed with the fuel selector positioned to an empty tank. The pilot subsequently stated that both fuel gauges indicated "1/4" full, and he could not remember which tank was selected during the takeoff. Additionally, a passenger stated that he did not smell or observe fuel when he exited the airplane. The passenger added that in the past, the pilot had exhausted one fuel tank, then switched to the other tank and the engine re-started. Examination of the wreckage by an FAA inspector revealed that fuel selector was positioned to the right tank. The right fuel tank contained some fuel, and left fuel tank had ruptured. Following the accident, a successful engine test-run was performed.
Probable cause:
The pilot's inadequate fuel management, which resulted in fuel starvation and a total loss of engine power during the initial climb.
Final Report:

Crash of an Airbus A319 in New York

Date & Time: Jan 19, 2003 at 0715 LT
Type of aircraft:
Operator:
Registration:
N313NB
Flight Phase:
Survivors:
Yes
MSN:
1186
YOM:
2000
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Two maintenance technicians where on board Northwest Airlines' Airbus A319 N313NB which was taxied from a maintenance area to Gate 10. When they arrived in the vicinity of gate 10, the mechanic who was steering the plane, activated the parking brake and waited for ground personnel and a jetway operator to arrive. After the ground personnel arrived he released the parking brake. The airplane did not move and he advanced the throttles out of their idle detents "a couple of inches, about halfway." The airplane began to move at a "fairly decent speed," and he realized the throttles were still out of the idle detent position. He pulled the throttle back and applied brakes; however, the airplane did not slow and continued until it struck the concrete support column of the jetway, and the left wing contacted the right side of a Boeing 757-251 (N550NW, parked at gate 9). The nose gear sheared off the Airbus, and the right side of the Boeing sustained a 6-foot long, 2-foot wide gash, just aft of the R1 door. The mechanic estimated that the airplane was about halfway down the parking line when he pulled back the throttles. Initial review of the flight data recorder for the time period surrounding the accident revealed that about 10 seconds after the parking brake was released, the thrust lever angles for both engines were increased to about 17 degrees for about 8 seconds, before they were returned to the idle position. During that time, the engines N1 and N2 speeds increased to about 71, and 85 percent, respectively.
Probable cause:
Maintenance personnel failure to maintain aircraft control as a result of excessive throttle input.

Ground accident of an Embraer ERJ-135LR in Columbus

Date & Time: Jan 18, 2003
Type of aircraft:
Operator:
Registration:
N714BZ
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
145-260
YOM:
2000
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was under maintenance test at Columbus-John Glenn Airport (Port Columbus) and under the control of three technicians. While performing an engine run, the aircraft collided with a hangar and was damaged beyond repair. All three technicians escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
No investigations were conducted by the NTSB on this event.

Crash of a Fokker 50 in Mellila

Date & Time: Jan 17, 2003 at 1201 LT
Type of aircraft:
Operator:
Registration:
PH-FZE
Survivors:
Yes
Schedule:
Málaga – Melilla
MSN:
20182
YOM:
1990
Flight number:
YW8276
Location:
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12900
Captain / Total hours on type:
3500.00
Copilot / Total flying hours:
457
Copilot / Total hours on type:
64
Aircraft flight hours:
22534
Aircraft flight cycles:
25803
Circumstances:
After landing on runway 15 at Melilla Airport, the pilot-in-command noticed that he could not engage the ground idle/reverse of both propellers, and that the aircraft did not brake normally. The aircraft started to deviate to the left of the runway axis while both pilots were applying brakes. After tyre n°3 burst, the deviation continued until the aircraft left the paved surface of the runway and finally fell through an embankment with around 15 metres of height located at the end of runway 15. The aircraft was destroyed and the pilot-in-command and other nine people suffered minor injuries. There was no fire.
Probable cause:
It is considered that the accident probably happened because of a combination of three factors:
1. An unstable approach that resulted in a higher than normal touchdown speed.
2. The inability to select propeller reverse due to the probable tripping of the circuit breaker FLIGHT IDLE SOLENOID 1 & 2 before or at touchdown.
3. The cross connection of the wheel speed transducer wire harness of wheels 3 and 4, which, due to heavy braking, produced a flat spot in wheel 3 and reduced the braking capability of wheel 4.
Final Report:

Crash of a Fokker F28 Fellowship 4000 in Quito

Date & Time: Jan 17, 2003 at 0940 LT
Type of aircraft:
Operator:
Registration:
HC-BMD
Flight Phase:
Survivors:
Yes
Schedule:
Quito – Tulcán – Cali
MSN:
11220
YOM:
1984
Flight number:
EQ120
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
72
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7085
Captain / Total hours on type:
4103.00
Copilot / Total flying hours:
1666
Copilot / Total hours on type:
124
Aircraft flight hours:
21547
Aircraft flight cycles:
40084
Circumstances:
During the takeoff roll on runway 35, at a speed of 125 knots, after a course of 2,110 metres, both tyres on the left main gear burst. The crew rejected the takeoff procedure but the aircraft was unable to stop within the remaining distance (runway 35 is 3,120 metres long). It overran, causing the nose gear to collapse, and came to rest 81 metres further. All 77 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Lack of a positive actions and reaction on part of the crew following the bursting of both tires on the left main gear, causing the aircraft to overrun the runway.
Final Report:

Crash of a BAe 3101 Jetstream 31 in Yacuiba

Date & Time: Jan 17, 2003 at 0900 LT
Type of aircraft:
Operator:
Registration:
CP-2404
Survivors:
Yes
Schedule:
Yacuiba - Santa Cruz
MSN:
680
YOM:
1985
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8194
Copilot / Total flying hours:
832
Circumstances:
During the takeoff roll at Yacuiba Airport, at V2 speed, the right engine lost power. The captain decided to continue the takeoff procedure. During initial climb, decision was taken to return for an emergency landing and the crew shut down the right engine and feathered its propeller. After touchdown on runway 20, the aircraft was unable to stop within the remaining distance, overran, lost its nose gear and collided with bushes and small trees, coming to rest about 50 metres past the runway end. All 21 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The accident was the consequence of the combination of the following factors:
- Excessive speed upon landing,
- Delayed application of the brake systems,
- The runway length available was limited according to the conditions in force,
- The total weight of the aircraft upon landing,
- The aircraft configuration,
- The direction and intensity of the wind,
- An inadequate crew training.
Additionally, the exact cause of the loss of power on the right engine was not clearly determined at the time the final report was published.
Final Report: