Crash of a Boeing 707-323C in Lubumbashi

Date & Time: Sep 7, 2001
Type of aircraft:
Operator:
Registration:
TN-AGO
Flight Type:
Survivors:
Yes
Schedule:
Lubumbashi – Kinshasa
MSN:
19519
YOM:
1967
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Lubumbashi-Luano Airport, a deflector located on the right main gear failed. The crew continued the takeoff procedure and after liftoff, the right main gear could not be raised in its wheel well. Initially, the crew decided to continue to Kinshasa in a 'gear down' configuration but eventually decided to return to Lubumbashi for a safe landing. After touchdown, the aircraft deviated to the right of the runway centerline then veered off runway and came to rest in a ditch. All three crew members escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Piper PA-31-350 Navajo Chieftain in Reading: 1 killed

Date & Time: Sep 5, 2001 at 1313 LT
Operator:
Registration:
N8PK
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Reading – Montgomery
MSN:
31-8152141
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3230
Captain / Total hours on type:
20.00
Aircraft flight hours:
6204
Circumstances:
After takeoff, the pilot reported "an engine problem," but did not elaborate. A witness on the ground saw that the left engine was trailing smoke, but the engine was still operating, and did not sound like it was "missing". When asked by the tower controller if he required assistance, the pilot answered "no". The controller cleared the pilot for left traffic to a landing, and provided the current weather. There were no further transmissions from the pilot. Smoothed radar tracking data revealed that the airplane turned toward a left downwind, and leveled off at 1,400 feet msl (about 1,050 feet agl) and 156 knots. During the next 14 seconds, the airplane descended to 1,100 feet and increased airspeed to 173 knots. Then radar contact was lost. Witnesses observed the airplane variously in a right snap roll and a left wingover, followed by a sharp dive to the ground. The airplane had just undergone maintenance. During maintenance, unused oil was found in the left engine cowling, which the pilot admitted he had previously spilled. Following maintenance, the pilot was observed adding 3 additional quarts of oil to the left engine. The engine oil dipsticks were calibrated on both sides, with each side pertaining to the oil level in a specific engine. The side for the right engine was calibrated to read 1 3/4 quarts lower than the left engine. The airplane's wreckage was fragmented. No evidence of mechanical defect was found, nor was there any evidence of an extreme out-of-trim condition. There was also no evidence of engine failure, detonation, or pre-impact failure. The pilot held an airline transport pilot certificate. He reported 3,210 hours of flight time to the operator, and had recently been cleared to fly the airplane on 14 CFR Part 91 flights. The flight to the maintenance facility was the pilot's first solo flight in the airplane. An autopsy of the pilot revealed the presence of a prostate adenocarcinoma; however, according to his physician, the pilot was unaware of it.
Probable cause:
The pilot's loss of control for undetermined reasons, which resulted in a high speed dive to the ground.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Carcassonne

Date & Time: Aug 30, 2001 at 0804 LT
Operator:
Registration:
F-GAPR
Flight Phase:
Survivors:
Yes
MSN:
421B-0951
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from runway 28 at Carcassonne-Salvaza Airport, while in initial climb, the aircraft stalled and crashed to the right of the runway. All six occupants escaped with various injuries and the aircraft was destroyed.
Probable cause:
Loss of control during initial climb following a loss of power on the right engine.

Crash of a De Havilland DHC-4 Caribou in Port Alsworth

Date & Time: Aug 29, 2001 at 1900 LT
Type of aircraft:
Operator:
Registration:
N2225C
Flight Type:
Survivors:
Yes
Schedule:
Iliamna - Port Alsworth
MSN:
215
YOM:
1964
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6200
Captain / Total hours on type:
559.00
Copilot / Total flying hours:
10000
Circumstances:
The captain and the first officer were landing a short takeoff and landing (STOL) cargo airplane on a private, dirt and gravel surface runway. The airplane was configured for landing with 40 degrees of flaps. During the landing approach, variations in indicated airspeed and ground speed indicated windshear conditions. About 100 to 200 feet above the ground, the airplane encountered a downdraft and began to drift to the right of the runway centerline. The captain said she increased engine power and applied full left aileron and rudder, but could not gain directional or pitch control of the airplane. The right wing struck trees, short of the runway threshold, increasing the airplane's right yaw. The captain said that as the airplane neared the ground, she pulled the engine throttles off. The airplane struck the ground with the right main landing gear and right front portion of the fuselage. The airplane then pivoted to the right, 180 degrees from the approach heading. The owner of the airport reported that wind conditions from the east may produce downdrafts in the area of runway 05. He indicated that at the time of the accident, the wind was blowing from the east about 15 knots. The first officer reported the captain appeared to be attempting to maintain a stabilized approach angle by varying the pitch attitude of the airplane. A review of company training literature revealed that the airplane is especially sensitive to slight wind shear, and wind gusts as low as 5 knots when operating at low airspeeds. Pilots are cautioned that when flying the aircraft at low speeds, a large application of the aileron control may be required to maintain wings level. During gusty wind conditions, the threshold airspeed should be increased by one-half the gust factor, and any lateral displacement should be corrected rapidly. If a wing is allowed to drop beyond corrective action of full aileron, power should be increased immediately to regain level flight.
Probable cause:
The captain's failure to maintain the proper glidepath, and improper short field landing procedures. Factors in the accident were a downdraft, and the captain's inadequate evaluation of the weather conditions.
Final Report:

Crash of a Casa-Nurtanio CN-235-200 (IPTN) in Málaga: 4 killed

Date & Time: Aug 29, 2001 at 1016 LT
Operator:
Registration:
EC-FBC
Survivors:
Yes
Schedule:
Melilla – Málaga
MSN:
C-033
YOM:
1990
Flight number:
AX8261
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
44
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
7372
Captain / Total hours on type:
4166.00
Copilot / Total flying hours:
8485
Copilot / Total hours on type:
4885
Aircraft flight hours:
14577
Aircraft flight cycles:
20780
Circumstances:
Following an uneventful flight from Melilla, the crew was cleared to descend to Málaga-Pablo Ruiz Picasso Airport. On final approach to runway 32, the crew encountered an unexpected situation when the engine fire warning light came on in the cockpit panel, indicating a fire on the left engine. The copilot informed ATC and after he declared an emergency, was cleared to land on runway 32. On short final, both engines stopped. The aircraft stalled and crashed 538 metres short of runway threshold and came to rest against the embankment of a motorway. The captain and three passengers were killed while all other occupants were injured, some of them seriously. The aircraft was destroyed.
Probable cause:
It is considered that the cause of the accident was the incorrect execution, by the crew, of the emergency procedure of fire or serious damage to an engine contained in the Flight Operations Manual that was on board the aircraft, causing the consecutive shutdown of both engines with the consequent total loss of thrust, so that the progression of the flight was impeded. The activation of the emergency procedure occurred as a consequence of a left engine fire warning which turned out to be false. The appearance of the false fire warning could be caused by the presence of moisture and/or dirt in the connectors of the fire detector circuit. It is considered that a contributing factor to these circumstances could be the definition of maintenance tasks for that system in the Aircraft Maintenance Manual, which was not compliant to the methods recommended by the manufacturer of the fire detection system to avoid the existence of humidity in the installation. As factors that could have contributed to the incorrect performance of the crew during the application of the emergency procedure, the following are considered:
- A lack of coordination in the piloting tasks, carried out in the absence of 'Crew Resource Management" criteria.
- Insufficient training for the cockpit change received by the copilot, which did not include simulator training for the application of emergency procedures.
Final Report:

Crash of a Dassault Falcon 20C in Detroit

Date & Time: Aug 28, 2001 at 1805 LT
Type of aircraft:
Operator:
Registration:
N617GA
Flight Type:
Survivors:
Yes
Schedule:
Detroit – Rockford
MSN:
88
YOM:
1967
Flight number:
GAE617
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
24000
Captain / Total hours on type:
900.00
Copilot / Total flying hours:
5700
Copilot / Total hours on type:
200
Aircraft flight hours:
13282
Circumstances:
The airplane sustained substantial damage on impact with terrain and objects after traveling off the end of the runway during a main wheels up landing. The captain reported that prior to takeoff, he closed the cargo door and the copilot confirmed the door light was out. After takeoff at an altitude of about 600 feet, the cockpit door popped open and the crew noticed the cargo door was open. The captain elected to return to land. The captain reported he requested repeatedly for gear and flaps extension, but the copilot was late in doing so and it "caused us to overshoot the runway centerline." The copilot then began calling for a go around/missed approach at which time he raised the gear and the retracted some of the flaps. The copilot reported the captain continued to descend toward the runway and overshot the runway centerline to the right. The copilot reported that at this time he lowered the gear. The nose gear extended prior to touchdown, however the main gear did not. The airplane touched down approximately 1/2 way down the runway and traveled off the end. A witness reported noticing that the exterior door latch was not down as the airplane taxied to the runway.
Probable cause:
The wheels up landing performed by the flightcrew during the emergency landing and improper aircraft preflight by the pilot in command. Factors were the unsecured cargo door, the cemetery fence, and the lack of crew coordination during the flight.
Final Report:

Crash of a BAc 111-412EB in Libreville

Date & Time: Aug 28, 2001
Type of aircraft:
Registration:
5N-BDC
Survivors:
Yes
MSN:
111
YOM:
1967
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Libreville-Léon M'Ba Airport, the aircraft encountered difficulties to stop within the remaining distance. It overran, lost its nose gear and came to rest few dozen metres further. There were no casualties but the aircraft was damaged beyond repair.
Probable cause:
It was reported that both thrust reverser systems were inoperative.

Crash of a Cessna 402B in Marsh Harbour: 9 killed

Date & Time: Aug 25, 2001 at 1845 LT
Type of aircraft:
Registration:
N8097W
Flight Phase:
Survivors:
No
Schedule:
Marsh Harbour – Miami-Opa Locka
MSN:
402B-1014
YOM:
1975
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
The fatal aircraft, Registration N8097W was operated by Blackhawk International Airways and the listed owner was Skystream Inc; whose corporate address was the same as Mr. Gilbert Chacón’s Pembroke Pines, Florida home address. Blackhawk International Airways was owned by Gilbert Chacón and his son Erik, who founded the company in 1991. Blackhawk International Airways was authorized by the FAA as a part 135 Single Pilot Operation. Mr. Gilbert Chacon was the only pilot authorized by the FAA for Blackhawk International Airways. Once Morales acted as pilot- in-command of the Cessna 402B aircraft, this made Blackhawk International Airways a multi pilot operation. This was a clear violation of the FAA regulations. Mr. Morales was not signed off by the FAA to fly for Blackhawk International Airways, nor was Blackhawk International Airways signed off as a multi pilot operation. There were no FAA reports of any enforcement actions or service difficulty reports against the fatal aircraft. However, the FAA did report four administrative actions against Blackhawk International Airways, three for technical violations and the most recent for maintenance failures. The agency (FAA) issued a letter of correction on April 28, 2000, citing Blackhawk's failure to comply with manufacturer’s recommended maintenance programs and FAA programs for its aircraft's engines or other parts. Blackhawk failed to have a person in charge of maintenance with an appropriate certificate and used unsanctioned techniques and equipment for repairs. The Manager of the Palm Beach County Park Airport at Lantana, Florida stated that a last minute change resulted in the accident aircraft being dispatched to Marsh Harbour, Abaco, Bahamas. The Cessna 404 aircraft which was originally scheduled to conduct this flight, was fuelled, but subsequently changed to a Cessna 402B aircraft by the owner Mr. Gilbert Chacon. This charter flight from Lantana, Florida to the island of Marsh Harbour, Abaco, in the Bahamas, was operated under Visual Flight Rules (VFR).The accident occurred on August 25, 2001 shortly after the aircraft departed Marsh Harbour International Airport for the return trip to Opa Locka, Florida (USA). The flight number was not known. At the time of the accident, Blackhawk International Airways was not authorized by the Bahamas Aviation Authority to conduct commercial operations in the Bahamas. A determination could not be made as to whether or not the pilot filed a flight plan. No records existed to verify whether radio communications were established with Air Traffic Control (ATC) during the flight from Lantana, Florida to Marsh Harbour, Abaco, Bahamas. The flight was a 165 mile journey that was estimated to take one (1) hour to complete. The aircraft was not required to have a cockpit voice recorder. Witnesses reported the pilot and members of the group being transported, argued about the number of passengers and the amount of bags to be loaded on the aircraft. Witnesses also reported seeing eight (8) passengers board the aircraft. Two of the largest passengers (believed to be weighing approximately 300 pounds each,) were observed being seated in the rear of the aircraft. One witness reported that the pilot personally loaded the aircraft. Witnesses also reported that the pilot experienced problems starting the engines. Eye witness statements placed the time of departure of the flight for Opa Locka, Florida at approximately 1845 EDT. The aircraft became airborne from the 5,000 x 50 feet runway (Runway 27) between 2,500 to 2,800 feet. It climbed in a steep nose high attitude to approximately 40 feet above the runway, banked left, pitched nose down and impacted marshy terrain in a left wing, nose low attitude. The aircraft was destroyed and all nine occupants were killed, among them the US singer Aaliyah Dana Haughton.
Probable cause:
Findings and Probable Cause:
- Aircraft overweight. Pilot did not determine if the aircraft was within operating limitations. The aircraft’s weight was estimated to be 941 lbs over the maximum allowable takeoff weight. The weight of the un-recovered bag was not added to the weight and balance calculations. The center of gravity was estimated to be 4.4 inches aft of the maximum aft allowable center of gravity envelope).
- Pilot Unqualified. Pilot was not qualified under Part 135 for the aircraft in which he was flying.
- Documents Falsification. Pilot falsified logbook to reflect more flight time than he actually had accumulated. Review of pilot logbook revealed in several instances, pilot added as much as 1,000 hours to his total flight and multi engine times. Hundreds of day and night landings were falsified to meet qualification requirements. Pilot falsified aircraft information (types and registration numbers) reporting them to be Cessna C402 aircraft, when FAA database clearly lists the aircraft in question as aircraft other than Cessna C402. Pilot may not have completed a weight and balance report. (No evidence existed that showed he had completed a load manifest or weight and balance and performance calculations). Pilot failed to comply with prescribed Weight and Balance and Performance limitations in Pilot’s Operating Handbook. (The aircraft’s weight was estimated to be 941 lbs over the maximum allowable takeoff weight. The weight of the un-recovered bag was not added to the weight and balance calculations. The center of gravity was estimated to be 4.4 inches aft of the maximum aft allowable center of gravity envelope)). Pilot may not have followed “before takeoff” checklist in Pilot’s Operating Handbook.
- Fuel Selectors: “Left Engine – Left Main Tank, Right Engine – Right Main Tank”. Field investigation immediately following the accident revealed both fuel tank selectors were found selected to the right main tank. The left fuel valve was found in the left position, though the cable was separated from the valve. Impact damage may have changed the pre-impact settings, thereby rendering the observed positions as unreliable.
- Aircraft Flight Controls (secondary control surfaces – trim tabs) were found to be out of normal range required for takeoff. The aileron trim tab was found selected all the way to the right. The rudder trim tab was found selected to the left and the elevator trim tab was found in the full nose down position. Impact damage may have changed the pre-impact settings, thereby rendering the observed positions as unreliable.
- According to Pilot’s Operating Handbook (POH) normal takeoff is 0˚ flaps. (The flap selector handle was selected to 15˚with the indicator at approximately the 15˚position. The wing flap push rods were bent, indicating partial extension at impact).
- Blackhawk International Airways was not authorized to assign this pilot as a pilot in command because they did not have the authority to use a second pilot. Blackhawk International Airways was authorized as a single pilot operation with Mr. Gilbert Chacon as the only authorized pilot.
- Blackhawk International Airways reportedly hired Mr Morales two days prior to the fatal accident, although they did not have the authority to use a second pilot. Further, they did not exercise due diligence in ensuring pilot’s qualification prior to assigning duty as pilot in command.
- There were no FAA reports of any enforcement actions or service difficulty reports against the fatal aircraft. However, the FAA did report four administrative actions against Blackhawk, three for technical violations and the most recent for maintenance failures. The agency issued a correction letter April 28, 2000, citing Blackhawk's failure to comply with manufacturer recommended maintenance programs and FAA programs for its aircraft's engines or other parts, Blackhawk failed to have a person in charge of maintenance with an appropriate certificate and used unsanctioned techniques and equipment for repairs.
- Results of disassembly report confirms that no discrepancies existed that would have precluded normal operation of both left and right engines prior to impact.
- Forensic Report showed traces of benzoylegonine (a metabolite of cocaine) in the urine and traces of ethanol in the stomach contents of the pilot.
- On July 7, 2001, Morales was arrested by the Broward Sheriff's Office in an area of Pompano Beach known for drug sales. A deputy who pulled over Morales' 1993 Volkswagen Fox for running a stop sign said he found pieces of crack cocaine and other paraphernalia in the car. According to the deputy, Morales said he was in the area to buy powder cocaine for a friend.
- In November 2000, Morales was arrested by Fort Lauderdale police after he tried to "return'' $345 worth of stolen aviation parts to a local distributor. Instead of giving Morales cash, store employees called police, who were investigating a string of airplane burglaries. Mr. Morales was charged with dealing in stolen property after detectives found that a receipt in his bag belonged to the burglary victim who actually bought the parts. An additional charge of grand theft was tacked on when detectives recovered other stolen items.
Final Report:

Crash of a Beechcraft B200 Super King Air in Piqua: 1 killed

Date & Time: Aug 24, 2001 at 0640 LT
Registration:
N18260
Flight Type:
Survivors:
No
Schedule:
Dayton – Piqua
MSN:
BB-900
YOM:
1981
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7100
Captain / Total hours on type:
2400.00
Aircraft flight hours:
10821
Circumstances:
The airline transport rated pilot was attempting to land under visual flight rules for a scheduled passenger pick-up and subsequent charter flight. The pilot was communicating with a pilot at the airport, who was utilizing a hand held radio. The accident pilot reported he was not able to see the runway lights due to ground fog and continued to circle the airport for about 20 minutes. The pilot on the ground stated the airplane appeared to be about 1,500 feet above the ground when it circled, and then entered a downwind for runway 26. He was not able to hear or see the airplane as it flew away from the airport. He then began to hear the airplane during its final approach. The airplane's engines sounded normal. He then heard a "terrible sound of impact," followed by silence. When he arrived at the accident site, the airplane was fully engulfed in flames. The airplane impacted trees about 80-feet tall, located about 2,000 feet from, and on a 240 degree course to the approach end of runway 26. Several freshly broken tree limbs and trunks, up to 15-inches in diameter, were observed strewn along a debris path, which measured 370 feet. Examination of the wreckage did not reveal any pre-impact malfunctions. The weather reported at an airport about 19 miles south-southeast of the accident site, included a visibility of 1 3/4 miles, in mist, with clear skies and a temperature and dew point of 17 degrees Celsius. Witnesses in the area of the accident site generally described conditions of "thick fog" and a resident who lived across from the accident site stated visibility was "near zero" and he could barely see across the road.
Probable cause:
The pilot's improper decision to attempt a visual landing under instrument meteorological conditions and his failure to maintain adequate altitude/clearance, which resulted in an inflight collision with trees. A factor in this accident was the ground fog.
Final Report:

Crash of a Learjet 25 in Ithaca: 2 killed

Date & Time: Aug 24, 2001 at 0542 LT
Type of aircraft:
Operator:
Registration:
N153TW
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ithaca – Jackson
MSN:
25-053
YOM:
1970
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4826
Captain / Total hours on type:
760.00
Copilot / Total flying hours:
3634
Copilot / Total hours on type:
377
Aircraft flight hours:
12486
Circumstances:
While departing from the airport, with the second-in-command (SIC) at the controls, the airplane impacted a fence, and subsequently the ground about 1,000 feet beyond the departure end of the runway. A witness on the ramp area south of the runway, stated that he heard the engines spool up; however, due to the fog, he could only see the strobe lights on the airplane. He then observed the airplane rotate about 3,500 feet from the departure end of the runway and begin to climb at a steep angle, before losing sight of it when it was about 150 feet above ground level. The weather reported, at 0550 was, calm winds; 1/2 statute miles of visibility, fog; overcast cloud layer at 100 feet; temperature and dew point of 17 degrees Celsius. Excerpts of the cockpit voice recorder (CVR) transcript revealed that the flightcrew discussed the prevailing visibility at the airport on numerous occasions, and indicated that it appeared to be less than one mile. Examination of the wreckage revealed no anomalies with the airframe or engines. According to the FAA Instrument Flying Handbook, "Flying in instrument meteorological conditions (IMC) can result in sensations that are misleading to the body's sensory system...A rapid acceleration, such as experienced during takeoff, stimulates the otolith organs in the same way as tilting the head backwards. This action creates the somatogravic illusion of being in a nose-up attitude, especially in situations without good visual references. The disoriented pilot may push the aircraft into a nose-low or dive attitude."
Probable cause:
The pilot's failure to maintain a proper climb rate while taking off at night, which was a result of spatial disorientation. Factors in the accident were the low visibility and cloud conditions, and the dark night.
Final Report: