Crash of a Partenavia P.68B in North Shore

Date & Time: Jul 20, 2001 at 0459 LT
Type of aircraft:
Operator:
Registration:
ZK-DMA
Flight Type:
Survivors:
Yes
Schedule:
Auckland-Whangarei
MSN:
68
YOM:
1976
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
706
Captain / Total hours on type:
200.00
Aircraft flight hours:
4773
Circumstances:
On Friday 20 July 2001, at around 0450, Partenavia P68B ZK-DMA was abeam North Shore Aerodrome at 5000 feet in darkness and enroute to Whangarei, when it suffered a double engine power loss. The pilot made an emergency landing on runway 21 at North Shore Aerodrome, but the aircraft overran the end of the runway, went through a fence, crossed a road and stopped in another fence. The pilot was the only person on board the aircraft and received face and ankle injuries. The aircraft encountered meteorological conditions conducive to engine intake icing, and ice, hail or sleet probably blocked the engine air intakes. The pilot had probably developed a mindset that dismissed icing as a cause, and consequently omitted to use alternate engine intake air, which should have restored engine power.
Probable cause:
The following findings were identified:
- The pilot was suitably qualified and authorised to conduct the flight.
- The aircraft was airworthy and its records indicated it had been maintained correctly.
- The aircraft encountered weather conditions conducive to the formation of engine intake icing.
- The engine air intakes probably became blocked by sleet, ice or hail, which caused both engines to lose power.
- The pilot probably developed a mindset that dismissed engine intake icing as a cause of the double engine power loss and omitted to apply the necessary corrective action.
- Had the pilot selected each engine’s alternate engine intake air on, engine power should have been restored.
- The Partenavia P68B flight manual warning concerning the use of alternate engine intake air should be amended to require the in-flight use of alternate air at ambient temperatures above freezing, in a high-humidity environment.
Final Report:

Crash of a Piper PA-46-310P Malibu in Stow

Date & Time: Jul 15, 2001 at 2107 LT
Registration:
N9133D
Survivors:
Yes
Schedule:
Columbia – Newburgh – Stow
MSN:
46-08110
YOM:
1988
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3500
Captain / Total hours on type:
2616.00
Aircraft flight hours:
2692
Circumstances:
Witnesses reported hearing an airplane engine at night, at high power for about 5 seconds followed by impact. They went to the scene and found the airplane on the left side of the approach end of runway 03, on fire. The pilot was removed and the fire was extinguished. The airplane had struck a runway threshold light located about 25 feet to the left side of the runway, and slid about 100 feet into trees, angling away from the runway on a heading of 360 degrees. The outboard 5 feet of the left wing was bent up about 20 degrees. Ground scars were found corresponding to the positions of the left, right, and nose landing gears, all of which had collapsed. The inboard section of the left wing came to rest on the nose of the airplane. The propeller blades were deformed with "S" bending and leading edge gouges. Flight control continuity was verified to the rudder and elevator. The aileron control cables had separated with puffed ends. All separations occurred at other than attach points. The pilot had received head injuries and has no memory of the accident.
Probable cause:
The pilot's failure to maintain airplane control during a go-around.
Final Report:

Crash of an Ilyushin II-76MD in Moscow: 10 killed

Date & Time: Jul 14, 2001 at 0853 LT
Type of aircraft:
Operator:
Registration:
RA-76588
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Moscow – Norilsk – Bratsk – Taiyuan
MSN:
00434 51530
YOM:
1984
Flight number:
RUR9633
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
10
Aircraft flight hours:
3523
Aircraft flight cycles:
1831
Circumstances:
The aircraft was engaged in a cargo flight from Moscow to Taiyuan, China, with intermediate stops in Norilsk and Bratsk, carrying two passengers, eight crew members and a load of 40,2 tons of construction materials. Due to foggy conditions, the horizontal visibility was reduced to 500-900 metres and the vertical visibility was estimated to be 70-80 metres. Following a takeoff roll of about 2,700 metres, the captain started the rotation at a speed of 290 km/h (about 25 km/h above the recommended speed). At a height of about 10 metres, the pilot-in-command started a turn to the right of 7° in order to compensate a deviation to the left during the takeoff roll. At a height of 23-24 metres, the stabilizers' position changed from -5,4° to -3,9° and the aircraft started to lose altitude. One second prior to impact, the elevator were in a 11-12° pitch angle and at a height of 20-21 metres, both right engines n°3 and 4 collided with trees at a distance of 930 metres from the runway end and 47 metres to the right of its extended centerline. Upon impact, both engines were torn off and the aircraft crashed in a wooded area located 1,460 metres past the runway end, bursting into flames. The aircraft was totally destroyed and all 10 occupants were killed.
Probable cause:
The following contributing factors were identified:
- A series of negligences was noted in the operations of the company and the maintenance of the airplane,
- The flight was not properly prepared and the total weight of the aircraft was well above the MTOW,
- Due to the combination of the following factors, the pilots did not take the corrective actions to maintain a good climb path:
- Lack of seriousness and lack of documentation control during cargo loading at Chkalovsky Airport,
- Lack of rigor and non-compliance with standard operating procedures regarding the pre-takeoff check of the cargo, which led the ground personnel to load cargo with a total weight in excess of 13,6 to 14 tons,
- At takeoff, the total weight of the aircraft was estimated to be 204 tons while it was certified for a maximum weight of 191.9 tons taking into account all factors at the time of the accident,
- All crew members were unable to identify in due time the successive errors made by the captain (pilot-in-command), among others the stabilizers that were prematurely positioned in an angle of -3.9 ° while the trailing edge flaps were retracted, causing the lift to be insufficient,
- The coordination within the flight crew was ineffective and the copilot and the navigator did not pay sufficient attention to the altitude of the aircraft through flight conditions in reduced visibility,
- Lack of visibility caused by foggy conditions which did not allow the flight crew to distinguish in time the obstacles located past the runway end,
- As a result of this accident, the operator certificate was revoked.

Crash of a PZL-Mielec AN-28 in Puerto Cabello: 13 killed

Date & Time: Jul 12, 2001 at 1246 LT
Type of aircraft:
Operator:
Registration:
YV-117CP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Puerto Cabello - Caracas
MSN:
AJE001-10
YOM:
1996
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
13
Circumstances:
Operated by Overtec, the aircraft was leased from a Polish company and was engaged in a demonstration flight from Puerto Cabello to Caracas on behalf of the Venezuelan National Guard. Shortly after takeoff from Puerto Cabello-General Bartolomé Salom Airport, while climbing, the twin engine aircraft encountered difficulties to gain height, stalled and crashed in an open field, bursting into flames. The aircraft was totally destroyed by a post crash fire and all 13 occupants were killed.
Probable cause:
Loss of control during initial climb following a loss of power on one engine for undetermined reasons.

Crash of a Cessna 402C in Boston

Date & Time: Jul 8, 2001 at 1214 LT
Type of aircraft:
Operator:
Registration:
N760EA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Boston – Nantucket
MSN:
402C-0056
YOM:
1979
Flight number:
9K065
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2539
Captain / Total hours on type:
476.00
Aircraft flight hours:
15140
Circumstances:
The pilot accepted an intersection departure and waived the wake turbulence holding time. A Boeing 737-300 departed ahead of him, and according to pilot, the Boeing's nosewheel lifted off the runway just as it passed him. The pilot also noted that the Boeing and its exhaust smoke drifted to the left of the runway's centerline. A wake turbulence advisory and takeoff clearance were issued by the tower controller and acknowledged by the pilot. The pilot initiated the takeoff, and after liftoff, the left wing dropped. It contacted the runway, and the airplane rolled inverted. The airplane then slid off the left side of the runway and a post-crash fire developed.
Probable cause:
The pilot's improper decision to waive the wake turbulence hold time, and his subsequent loss of control when wake vortex turbulence was encountered.
Final Report:

Serious incident with a Lockheed L-1011-385-1-14 TriStar 150 in Lyon

Date & Time: Jul 6, 2001 at 1856 LT
Type of aircraft:
Operator:
Registration:
C-FTNA
Flight Phase:
Survivors:
Yes
Schedule:
Lyon – Berlin
MSN:
1019
YOM:
1972
Flight number:
TS906
Country:
Region:
Crew on board:
14
Crew fatalities:
Pax on board:
197
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
22000
Captain / Total hours on type:
2600.00
Copilot / Total flying hours:
14300
Copilot / Total hours on type:
180
Aircraft flight hours:
66223
Aircraft flight cycles:
24979
Circumstances:
On 6 July 2001 at 18:46, a Lockheed TriStar operated by the Canadian airline Air Transat took off from runway 18R at Lyon Saint-Exupéry Airport (LYS), France for flight TSC906 to Berlin-Schönefeld Airport (SXF) with 14 crew members and 197 passengers. At 18:50 the crew contacted Marseilles and requested a heading of 350 degrees to avoid the area of active clouds that the crew had noticed on their weather radar. The controller cleared the flight to climb to FL160, at the requested course. The flight was cleared to climb further to FL190 and at 18:55 instructed to turn right to the MOREG reporting point. During the turn towards the reporting point, while the autopilot was connected, the crew saw that they were approaching an active cell. The captain, who was PNF, instructed the copilot to tighten the turn, which reached a 45° bank angle. At 18:56 Marseille transferred the flight to Geneva Control. It was during this first turn to MOREG that the first burst of hail hit the plane for a duration of one to two seconds. Then a second hailstorm struck the plane, with a duration of 10 to 15 seconds. At that moment the captain took control of the aircraft putting the airplane in a 60° bank angle. The plane lost 500 feet altitude. The crew did not declare an emergency but advised ATC of his intention to turn back to Lyon. The captain asked the flight engineer to depressurize the cabin, which was conducted during descent. There was no rapid depressurization. The windshield of the cockpit was badly damaged. The copilot had the best visibility and carried out the final approach and landing at Lyon-Saint Exupery. The plane landed safely at 1916LT and all 211 occupants evacuated safely.
Probable cause:
This accident occurred due to the flight of the aircraft in a very active cloud area whose color symbolism on the weather radar on board was not representative of the severity of the phenomena encountered. Although the crew chose to avoid the most active sector of this storm, it nevertheless flew through an area whose color representation on the board radar showed no real activity.
Final Report:

Crash of a Pilatus PC-6/B2-H2 Turbo Porter in Annemasse

Date & Time: Jun 26, 2001 at 1705 LT
Operator:
Registration:
F-GUAS
Survivors:
Yes
Schedule:
Annemasse - Annemasse
MSN:
557
YOM:
1963
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
919
Captain / Total hours on type:
520.00
Aircraft flight hours:
13000
Circumstances:
The pilot took off from Annemasse Airfield with nine skydivers on board. After dropping them at FL125, five to six seconds after initiating the descent, he felt strong vibrations. He reduced speed and saw the right out aileron separating from the wing. The pilot managed to maintain control of the aircraft by keeping the stick fully to the right and used the rudders to return to his departure aerodrome. He landed the airplane on the grass near the paved runway 30. During a hard landing, the right main landing gear broke off and damaged the fuselage. The pilot escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The accident was due to the loss of the right outboard aileron in flight. This loss was probably following the crack noticed by the pilot at the base of the right aileron balancing weight, which would have propagated in flight and would have then leads to tearing off the balancing weight. The accident resulted from the club pilots' decision to continue flying despite they have noticed the crack and that the manufacturer had advised them to stop flights.
Final Report:

Crash of an Embraer EMB-110P1 Bandeirante in Cootamundra

Date & Time: Jun 25, 2001 at 1021 LT
Operator:
Registration:
VH-OZG
Survivors:
Yes
Schedule:
Sydney – Griffith
MSN:
110-241
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6850
Captain / Total hours on type:
253.00
Circumstances:
The Embraer EMB-110P1 Bandeirante, VH-OZG, departed from Sydney Kingsford Smith international airport at 0855 on 25 June 2001, on a single-pilot instrument flight rules (IFR) charter flight to Griffith. The nine occupants on board the aircraft included the pilot and eight passengers. At about 0945, while maintaining an altitude of 10,000 ft, the master caution light illuminated. At the same time, the multiple alarm panel ‘GENERATOR 2’ (right generator) warning light also illuminated, indicating that the generator was no longer supplying power to the main electrical bus bar. After resetting the generator and monitoring its output, the pilot was satisfied that it was operating normally. A short time later, the master warning light illuminated again. A number of circuit breakers tripped, accompanied by multiple master alarm panel warnings. The red ‘FIRE’ warning light on the right engine fire extinguisher ‘T’ handle also illuminated, accompanied by the aural fire alarm warning. The pilot reported that after silencing the aural fire alarm, he carried out the engine fire emergency checklist actions. However, he was unable to select the fuel cut-off position with the right fuel condition lever, despite overriding the locking mechanism using his left thumb while attempting to operate the lever with his right hand. He also reported that the propeller lever did not remain in the feathered detent, but moved forward, as if spring-loaded, to an intermediate position. After unsuccessfully attempting to select fuel cut-off with the right fuel condition lever, or feather the right propeller with the propeller lever, the pilot pulled the right ‘T’ handle to discharge the fire bottle. The amber discharge light illuminated and a short time later the fire alarm sounded again. Passengers reported seeing lights illuminated on the multiple alarm panel and heard the sound of a continuous fire alarm in the cockpit. At 0956, the pilot notified air traffic services (ATS) that there was a ‘problem’ with the aircraft, but did not specify the nature of that problem. Almost immediately the pilot transmitted a PAN radio call and advised ATS that there was a fire on board the aircraft. The nearest aerodromes for an emergency landing were not available due to fog, and the pilot decided to divert to Young, which was about 35 NM to the south east of the aircraft’s position at that time. The pilot advised ATS that the fire was extinguished, and that he was diverting the aircraft to Young. Two minutes later, the pilot repeated his advice to ATS stating that a fire in the right engine had been extinguished, and requested emergency services for the aircraft’s arrival at Young. The pilot informed one of the passengers that there was an engine fire warning, and that they would be landing at Young. The passengers subsequently reported seeing flames in the right engine nacelle and white smoke streaming from under the wing. Smoke had also started to enter the cabin in the vicinity of the wing root. The pilot subsequently reported that he had selected the master switch on the air conditioning control panel to the ‘vent’ position, and that he had opened the left direct vision window in an attempt to eliminate smoke from the cabin. When that did not appear to have any effect he closed the direct vision window. The pilot of another aircraft reported to ATS that Young was clear, but there were fog patches to the north. On arrival at Young, however, the pilot of the Bandeirante was unable to land the aircraft because of fog, and advised ATS that he was proceeding to Cootamundra, 27 NM to the south southwest of Young. The crew of an overflying airliner informed ATS that Cootamundra was clear of fog. ATS confirmed that advice by telephoning an aircraft operator at Cootamundra aerodrome. At 1017 thick smoke entered the cabin and the pilot transmitted a MAYDAY. He reported that the aircraft was 9 NM from Cootamundra, and ATS informed him that the aerodrome was clear of fog. The pilot advised that he was flying in visual conditions and that there was a serious fire on board. No further radio transmissions were heard from the aircraft. At 1021, approximately 25 minutes after first reporting a fire, the pilot made an approach to land on runway 16 at Cootamundra. He reported that when he selected the landing gear down on late final there was no indication that the gear had extended. The pilot reported that he did not have sufficient time to extend the gear manually using the emergency procedure because he was anxious to get the aircraft on the ground as quickly as possible. Unaware that the right main landing gear had extended the pilot advised the passengers to prepare for a ‘belly’ landing. He lowered full flap, selected the propeller levers to the feathered position and the condition levers to fuel cut-off. The aircraft landed with only the right main landing gear extended. The right main wheel touched down about 260 m beyond the runway threshold, about one metre from the right edge of the runway. During the landing roll the aircraft settled on the nose and the left engine nacelle and skidded for approximately 450 m before veering left off the bitumen. The soft grass surface swung the aircraft sharply left, and it came to a stop on the grass flight strip east of the runway, almost on a reciprocal heading. The pilot and passengers were uninjured, and vacated the aircraft through the cabin door and left overwing emergency exit. Personnel from a maintenance organisation at the aerodrome extinguished the fire in the right engine nacelle using portable fire extinguishers.
Probable cause:
Significant factors:
1. Vibration from the worn armature shaft of the right starter generator resulted in a fractured fuel return line.
2. The armature shaft of the right engine starter generator failed in-flight.
3. Sparks or frictional heat generated by the failed starter generator ignited the combustible fuel/air mixture in the right engine accessory compartment.
4. Items on the engine fire emergency checklist were not completed, and the fire was not suppressed.
5. The operator’s CASA approved emergency checklist did not contain smoke evacuation procedures.
6. The pilot did not attempt to extend the landing gear using the emergency gear extension when he did not to get a positive indication that the gear was down and locked.
7. The aircraft landed on the right main landing gear and slid to a stop on the right main gear, left engine nacelle and nose.
Final Report:

Crash of an ATR42-320 in Tel Aviv

Date & Time: Jun 18, 2001
Type of aircraft:
Operator:
Registration:
4X-ATK
Survivors:
Yes
MSN:
073
YOM:
1987
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
39
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Tel Aviv-Ben Gurion Intl Airport, the right main gear remained stuck in its wheel well. The crew informed ATC about the situation and continued the approach. After touchdown, the aircraft slid for few dozen metres then veered off runway to the right and came to rest. All 42 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Transall C-160NG in Jayapura: 1 killed

Date & Time: Jun 16, 2001 at 1430 LT
Type of aircraft:
Operator:
Registration:
PK-VTP
Survivors:
Yes
Schedule:
Jayapura – Wamena
MSN:
F234
YOM:
1985
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
After takeoff from Jayapura-Sentani Airport, while climbing, the crew informed ATC about engine problems and was cleared for an immediate return. Following a 180 turn, the crew initiated an approach to runway 30. After touchdown, the crew started the braking procedure and reduced the engine power when a technical problem occurred on the right engine. The aircraft went out of control, veered off runway to the left, collided with a drainage ditch and came to rest against palm trees located 72 metres to the left of the runway centerline and 1,050 metres from the runway threshold. 18 occupants were injured and a passenger was killed. The aircraft was written off.
Probable cause:
A technical failure occurred on the right engine whose rotation could not be reduced below 14,200 rpm after touchdown, for reasons unknown.