Crash of a Learjet 36A in Astoria

Date & Time: Dec 3, 2002 at 0612 LT
Type of aircraft:
Operator:
Registration:
N546PA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Astoria - Astoria
MSN:
36-045
YOM:
1980
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3350
Captain / Total hours on type:
2350.00
Copilot / Total flying hours:
1170
Copilot / Total hours on type:
920
Aircraft flight hours:
12335
Circumstances:
The pilot (PIC) reported that during acceleration for takeoff (approximately V1 [takeoff decision speed]) the airplane collided with an elk. The PIC reported that after the collision, he applied wheel brakes and deployed the airplane's drag chute, however, the airplane continued off the departure end of the runway. The airplane came to rest in a marshy bog approximately 50 feet beyond the departure threshold. Currently, approximately 15,000 feet of the airport's perimeter is bordered with animal control fence. The airport recently received a FAA Aviation Improvement Program (AIP) Grant that will provide funding for an additional 9,000-feet of fence. Airport officials stated that the fencing project should be completed by summer of 2003. At the completion of the project, game control fencing will encompass the entire airport perimeter. The U.S. Government Airport/Facilities Directory (A/FD) contains the following remarks for the Astoria Regional Airport: "Herds of elk on and in the vicinity of airport..."
Probable cause:
Collision with an elk during the takeoff roll. Factors include dark night VFR conditions.
Final Report:

Crash of a Cessna 500 Citation I in Marília

Date & Time: Dec 1, 2002 at 2310 LT
Type of aircraft:
Registration:
PT-LIY
Survivors:
Yes
Schedule:
Goiânia – Marília
MSN:
500-0219
YOM:
1975
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2200
Captain / Total hours on type:
1200.00
Copilot / Total flying hours:
1300
Copilot / Total hours on type:
200
Circumstances:
Following an uneventful flight from Goiânia-Santa Genoveva Airport, the crew started the descent to Marília Airport by night. Poor weather conditions at destination forced the crew to make a direct approach to runway 03. After landing, the aircraft was unable to stop within the remaining distance, overran, lost its undercarriage and came to rest in bushes 143 metres past the runway end. All seven occupants were rescued, among them four were injured. The aircraft was damaged beyond repair.
Probable cause:
Poor approach configuration on part of the crew who landed the aircraft 750 metres past the runway threshold, reducing the landing distance available. The following contributing factors were identified:
- The crew completed an unstabilized approach,
- Poor approach planning,
- Limited visibility due to the night and poor weather conditions,
- The braking action was low because the runway surface was wet,
- The crew failed to initiate a go-around procedure.
Final Report:

Crash of a Let L-410UVP-E20 in Olkiombo: 1 killed

Date & Time: Nov 28, 2002 at 1330 LT
Type of aircraft:
Registration:
5Y-ONT
Survivors:
Yes
Schedule:
Musiara – Mombasa
MSN:
87 18 12
YOM:
1987
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
After takeoff from Musiara Airport, during initial climb, the crew raised the landing gear and flaps. About 45 seconds after liftoff, the left engine failed. The crew elected to restart it but without success and decided to divert to Olkiombo Airport located 18 km from their position. On approach to runway 09, the aircraft stalled and crashed in an open field. The copilot was killed while 19 other occupants were injured, some seriously. The aircraft was destroyed.
Probable cause:
Failure of the left engine during initial climb for unknown reasons.

Crash of a Cessna 550 Citation II in Sandspit

Date & Time: Nov 12, 2002 at 2052 LT
Type of aircraft:
Operator:
Registration:
C-GYCJ
Flight Type:
Survivors:
Yes
Schedule:
Vancouver - Sandspit
MSN:
550-0561
YOM:
1987
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4550
Captain / Total hours on type:
1450.00
Copilot / Total flying hours:
3300
Copilot / Total hours on type:
850
Circumstances:
The aircraft departed Vancouver International Airport, British Columbia, on a medical evacuation flight to the Sandspit Airport in the Queen Charlotte Islands, British Columbia. On board the aircraft were two pilots and a team of two Advanced Life Support Paramedics. When the aircraft arrived at Sandspit, the surface wind was strong, gusty, and across the runway. The crew conducted an instrument approach to Runway 30, and just before touchdown the aircraft's nose pitched down; the captain believed that the nosewheel, and then the main gear, collapsed as the aircraft slid on its belly. The crew carried out an evacuation and proceeded to the airport terminal building. When they returned to the aircraft to retrieve their belongings, the crew discovered that the gear was in the up position, as was the landing gear selector. The accident occurred at 2052 Pacific standard time. There were no injuries. The aircraft was substantially damaged.
Probable cause:
Findings as to causes and contributing factors:
1. The crew did not complete the before-landing checks, ignored aural warnings, and did not lower the landing gear, which resulted in a gear-up landing.
Findings as to risk:
1. The aircraft was not equipped with a GPWS, which could have prevented this accident.
2. The before-landing checklist in use did not reflect the AFM requirement that the speed brakes should be retracted prior to 50 feet.
Final Report:

Crash of an IAI 1124A Westwind II in Taos: 2 killed

Date & Time: Nov 8, 2002 at 1457 LT
Type of aircraft:
Operator:
Registration:
N61RS
Flight Type:
Survivors:
No
Schedule:
Las Vegas - Taos
MSN:
384
YOM:
1983
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5251
Captain / Total hours on type:
877.00
Copilot / Total flying hours:
14234
Copilot / Total hours on type:
682
Aircraft flight hours:
3428
Circumstances:
After passing the initial approach fix, during an instrument approach to the destination airport, radar and radio contact were lost with the business jet. One witness reported hearing "distressed engine noises overhead," and looked up and saw what appeared to be a small private jet flying overhead. The engine seemed to be "cutting in and out." The witness further reported observing the airplane in a left descending turn until his view was blocked by a ridge. The witness then heard an explosion and saw a big cloud of smoke rising over the ridge. A second witness heard a loud noise and looked up and saw a small white airplane with two engines. The witness stated that the airplane started to turn left with the nose of the airplane slightly pointing toward the ground. The airplane appeared to be trying to land on a road. A third witness heard the roar of the airplane's engines, and looked toward the noise and observed the airplane in a vertical descent (nose dive) impact the ground. The witness "heard the engines all the way to the ground." Examination of the airframe and engines did not disclose any structural or mechanical anomalies that would have prevented normal operation. The National Weather Service had issued a SIGMET for severe turbulence and mountain wave activity. Satellite images depicted bands of altocumulus undulates and/or rotor clouds over the accident site.
Probable cause:
The pilot's inadvertent flight into mountain wave weather conditions while IMC, resulting in a loss of aircraft control.
Final Report:

Crash of a Cessna 207 Skywagon in Cradle Mountain

Date & Time: Nov 7, 2002 at 1404 LT
Registration:
VH-EHL
Flight Type:
Survivors:
Yes
Schedule:
Cradle Mountain - Cradle Mountain
MSN:
207-0141
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
730
Captain / Total hours on type:
180.00
Circumstances:
The Cessna 207 aircraft (C207) was engaged on a sightseeing flight from Cradle Mountain, to Lake St. Clair and return. On board were the pilot and 4 passengers. The flight departed Cradle Mountain at approximately 1310 ESuT and tracked direct to Lake St Clair at 7000 ft due to turbulence. The aircraft then returned to Cradle Mountain. At approximately 1404, as the aircraft was approaching the airfield, the pilot configured the aircraft for a straight in approach to strip 02. The pilot had selected two stages of flap, and had reduced power to approximately 19 inches of manifold pressure. He reported that at approximately half a mile from the airfield the engine stopped without any prior warning. After completing trouble checks, the pilot became aware that the aircraft would not reach the airfield. He then manoeuvred the aircraft towards an open area on his right while broadcasting a MAYDAY call. Melbourne air traffic control acknowledged this call. The pilot then completed additional trouble checks and changed the fuel tank selection, but the engine failed to respond. The aircraft touched down heavily on the main wheels and slid approximately 40 metres before coming to a stop. During the touchdown and subsequent ground slide, the nose wheel detached from the aircraft, the propeller was damaged and the right wing was partially separated from the airframe. After the aircraft stopped the pilot checked the passengers and discovered that two of them had suffered serious injuries.
Probable cause:
The pilot reported that he had completed a daily inspection of the aircraft earlier in the morning. That inspection included assessing the fuel quantity on board the aircraft and completing a fuel drain and water check. Both of these checks did not reveal any problem with the fuel. The pilot estimated that there was approximately 185 litres of fuel on board the aircraft, 90 litres in the right tank and 95 litres in the left tank. The aircraft had last been refuelled the day previously from drum stock. The aircraft had completed two flights since that refuelling with no problems being reported. The engineers that recovered the aircraft reported that there was approximately 30 litres of fuel in the left tank and approximately 100 litres of fuel in the right tank. The C207 aircraft has a fuel selector in the cockpit that allows the pilot to supply fuel to the engine from either the right tank or the left tank, but not from both tanks simultaneously. The pilot reported that he conducted the flight with the fuel selector switched to the left tank. He also reported that he did not move the selector during the flight and only moved it to the right tank as part of his trouble checks when the engine failed. The pilot reported that he did not complete flight or fuel plans for the flight, but operated on previous knowledge from other flights. A post occurrence analysis of the weather indicated that the winds at 7000 feet were as forecast. Post flight analysis of the flight revealed that the aircraft would have required 57 litres of fuel to complete the flight, which included allowances for taxi and climb. The engine was sent by the owner to an engine overhaul facility for testing. The ATSB did not attend the testing of the engine. The engine was fitted to the test cell in the condition as removed from the aircraft. The engine was started and test run in accordance with the engine manufacturer's overhaul manual. The engine ran normally and all temperature and pressure limits were within normal ranges. The investigation was unable to determine why the engine failed to operate normally in the latter stages of the flight.
Final Report:

Crash of an Antonov AN-12BK in Kome

Date & Time: Nov 7, 2002 at 1130 LT
Type of aircraft:
Operator:
Registration:
4K-AZ21
Flight Type:
Survivors:
Yes
Schedule:
Bergen - Ostende - N'Djamena - Kome
MSN:
8 3 456 09
YOM:
1968
Flight number:
AZQ4132
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The four engine aircraft departed Bergen on a cargo flight to Kome with intermediate stops in Ostend and N'Djamena, carrying six crew members and a load of various goods. For unknown reasons, the aircraft landed 800 metres past the runway threshold (Kome's runway is 1,800 metres long). Unable to stop within the remaining distance, the aircraft overran, lost its undercarriage and came to rest in a field. All six occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Britten-Norman BN-2A-21 Islander in Tarakan: 7 killed

Date & Time: Nov 7, 2002 at 1027 LT
Type of aircraft:
Operator:
Registration:
PK-VIZ
Survivors:
Yes
Schedule:
Tarakan - Long Bawan
MSN:
697
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
Shortly after takeoff from Tarakan Airport, en route to Long Bawan, the pilot encountered engine problems and decided to return. On approach, the aircraft stalled and crashed on the top of a hill located 1,500 metres short of runway. Three passengers were injured while seven other occupants were killed.
Probable cause:
Engine failure for unknown reasons.

Crash of a Fokker 50 in Luxembourg: 20 killed

Date & Time: Nov 6, 2002 at 1006 LT
Type of aircraft:
Operator:
Registration:
LX-LGB
Survivors:
Yes
Schedule:
Berlin – Luxembourg
MSN:
20221
YOM:
1991
Flight number:
LG9642
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
20
Captain / Total flying hours:
4242
Captain / Total hours on type:
2864.00
Copilot / Total flying hours:
1156
Copilot / Total hours on type:
443
Aircraft flight hours:
21836
Aircraft flight cycles:
24068
Circumstances:
The Fokker 27 Mk050 registered LX-LGB and operated by Luxair left Berlin on 6 November 2002 at 07h 40min on flight LG 9642/LH 2420 with destination Luxembourg. Cruising level was at FL180. At 08h 50min, Frankfurt Control asked the crew to stop descent at FL 90, direct to Diekirch and at 08h 52min the flight was transferred to Luxembourg Approach. They were instructed to enter the Diekirch hold at FL90, to expect later on vectors for an ILS 24 and were given the latest RVR readings. At 08h 59min, well before reaching the Diekirch hold, the aircraft was recleared to 3000ft QNH and to turn left heading one three zero. At this time the aircraft flew in the clear sky above a fog layer. RVR was two hundred seventy five meters. The crew evoked a go-around if the RVR was not three hundred meters whilst passing ELU (it’s minima for a category II approach). At 09h04 min 36s, the aircraft passed overhead ELU maintaining 3000ft QNH. At 09h04 min 57s, the ATC controller transmitted an RVR of three hundred meters. Power was further reduced, flaps 10 were selected and the landing gear was lowered. Immediately after the landing gear was lowered, the pitch angle of the two propellers simultaneously reached a value that is lower than the minimum values for flight. This propeller pitch setting involves a rapid decrease of speed and altitude. During the following seconds, the left engine stopped and then the right engine stopped. The flight data recorders, no longer powered ceased functioning. At 09h05 min 42s (radar time base), the aircraft disappeared from the radar screen. It was immediately found in a field seven hundred meters to the north of runway centreline 24 and three point five kilometres to the east of the threshold. Six people were critically injured while 16 others were killed. Within the following hours, four of the survivors died from their injuries. The only two survivors were a passenger, a French citizen, and the captain.
Probable cause:
The initial cause of the accident is the crew’s acceptance of the approach clearance although they were not prepared to it, namely the absence of preparation of a go-around. It led the crew to perform a series of improvised actions that ended in the prohibited override of the primary stop on the power levers and leading to an irreversible loss of control.
Contributory factors can be listed as follows:
1. A lack of preparation for the landing, initiated by unnecessary occupations resulting from an obtained RVR value, which was below their company approved minima, created a disorganisation in the cockpit, leading to uncoordinated actions by each crewmember.
2. Some procedures as laid down in the operations manual were not followed at some stage of the approach. All this did not directly cause the accident, but created an environment whereby individual actions were initiated to make a landing possible.
3. Routine and the will to arrive at destination may have put the crew in a psychological state of mind, which could have been the origin of the deviations from standard procedures as noticed.
4. The priority in the approach sequence given to the crew by ATC, which facilitated the traffic handling for the controller who was not aware of the operational consequences.
5. The low reliability of the installed secondary stop safety device that was favoured by the non-application of service bulletin ABSC SB Fo50-32-4. Also the mode of distribution of the safety information (Fokker Aircraft B.V. – Service letter 137) to the operator as well as the operator’s internal distribution to the crews, that did not guarantee that the crews were aware of the potential loss of secondary stop on propeller pitch control.
6. Latent shortcomings in the Authority and the organisational structure of the operator, in combination with poor application of SOPs by the crew.
Final Report:

Crash of a PZL-Mielec AN-2TP in Sovetskiy

Date & Time: Nov 6, 2002
Type of aircraft:
Registration:
RA-70140
Flight Phase:
Survivors:
Yes
Schedule:
Sovetsky – Svetly
MSN:
1G137-14
YOM:
1972
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Some passengers were late and the crew apparently hurried the departure to avoid a night flight to Svetly. Doing so, the crew failed to prepare the flight properly and did not proceed to any engine runup prior to taxi and takeoff. During the taxi manoeuvre, the aircraft suffered controllability problems so the crew selected the propeller lever to the fine pitch position. The takeoff procedure was initiated without checks and the crew forgot that the propeller lever was not in the takeoff position. After liftoff, at a height of 3-5 metres, the aircraft encountered difficulties to gain height and speed. The crew attempted an emergency landing when the aircraft collided with trees and crashed in a wooded area. All 15 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Poor flight preparation on part of the crew who failed to follow the pre taxi and the pre takeoff checklist. The aircraft was unable to gain sufficient speed and height after takeoff because the propeller lever was not in the correct position.