Crash of a De Havilland Dash-8-103 in Båtsfjord

Date & Time: Jun 14, 2001 at 1608 LT
Operator:
Registration:
LN-WIS
Survivors:
Yes
Schedule:
Alta – Båtsfjord
MSN:
247
YOM:
1990
Flight number:
WF954
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
24
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
21890
Captain / Total hours on type:
321.00
Copilot / Total flying hours:
3400
Copilot / Total hours on type:
1000
Aircraft flight hours:
23935
Aircraft flight cycles:
29469
Circumstances:
The twin engine aircraft departed Alta Airport at 1522LT on a regular schedule service to Båtsfjord, carrying 24 passengers and a crew of three. Following an uneventful flight, the crew started a LOC/DME approach to runway 21. Shortly after passing the missed approach point, the pilot-in-command lost visual contact with the runway so the captain took over controls and continued the approach. The airplane became unstable and the crew encountered control problems due to difficulties to disengage the autopilot system. This caused the aircraft to lose height during the last segment and it landed hard, causing the right main gear to collapse upon impact. The aircraft slid for few dozen metres then veered off runway to the right and came to rest in a grassy area 23 metres to the right of the runway. All 27 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
The following factors were identified:
- The crew deviated from the prescribed procedure,
- The crew deviated from the company Standard Operating Procedure,
- The crew failed to comply with CRM requirements as described in the company Flight Operations Manual,
- The crew continued the approach after passing the minimum altitude without adequate visual reference with the runway,
- The crew did not consider 'go around' when passing Decision Point without adequate, visual references to the runway,
- The crew did not consider 'go around' during a landing with apparent flight control problems,
- The crew completed the landing despite the fact that the aircraft was not in a stabilised configuration,
- The non-stabilised landing with a high descent rate overloaded the right undercarriage fuse pin to a point at which it collapsed,
- The public address system did not function when used by the commander for evacuation.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Stockton

Date & Time: Jun 14, 2001 at 0923 LT
Operator:
Registration:
N70SL
Flight Type:
Survivors:
Yes
Schedule:
Stockton - Stockton
MSN:
46-22084
YOM:
1989
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8927
Captain / Total hours on type:
598.00
Copilot / Total flying hours:
746
Copilot / Total hours on type:
156
Aircraft flight hours:
1670
Circumstances:
During a forced landing the left wing struck a light standard pole, and the airplane came to rest inverted after colliding with a fence. The purpose of the flight was to conduct recurrent training to include emergency procedures. On the accident flight the certified flight instructor (CFI) initiated a simulated engine failure after takeoff during the initial climb out. The student advised the tower, and turned crosswind at 700 feet agl. The student set up for landing, which included lowering the landing gear and adding 10 degrees of flaps. On short final, descending through 400 feet agl, both the CFI and student realized they would not make the runway. Both pilot's advanced the throttle, to arrest the descent and perform a go-around. There was no corresponding response from the engine. During the final stages of the emergency descent, the pilot maneuvered the airplane to avoid a work crew at the airport boundary fence and the airplane collided with the light standard pole and a fence. An airframe and engine examination discovered no discrepancies with any system. Following documentation of the engine and related systems it was removed and installed in an instrumented engine test cell for a functional test. The engine started without hesitation and was operated for 44 minutes at various factory new engine acceptance test points. During acceleration response tests, technicians rapidly advanced the throttle to the full open position, and the engine accelerated with no hesitation. A second acceleration response test produced the same results. According to Textron Lycoming, there were no discrepancies that would have precluded the engine from being capable of producing power.
Probable cause:
A loss of engine power for undetermined reasons. Also causal was the inadequate supervision of the flight by the CFI for allowing a simulated emergency maneuver to continue below an altitude which would not allow for recovery contingencies.
Final Report:

Crash of a Beechcraft C90 King Air in Fort Lauderdale: 1 killed

Date & Time: Jun 13, 2001 at 2122 LT
Type of aircraft:
Operator:
Registration:
YV-2466P
Flight Type:
Survivors:
Yes
Schedule:
Charallave – Fort Lauderdale
MSN:
LJ-591
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3205
Captain / Total hours on type:
1800.00
Aircraft flight hours:
8279
Circumstances:
The Venezuelan registered Beech King Air C90 departed Caracas, Venezuela's Óscar Machado Zuloaga International Airport at 1516 eastern daylight time with a pilot and two passengers aboard, and flew to Fort Lauderdale-Hollywood International Airport, Florida. The route of flight filed with air traffic control was: after departure, direct to Maiquetia, thence Amber Route-315 to Bimini, thence Bahama Route 57V to Fort Lauderdale. The {planned} flight level was 220, and the pilot stated that 7 hours 15 minutes of fuel was aboard. Immigration/customs general declaration papers found aboard the wreckage stated the flight's intended destination was Nassau, and the pilot's daughter stated he always stopped at Nassau for fuel on many previous trips. After 6 hours 6 minutes, the aircraft crashed into a highway abutment about 1,700 feet short of his intended landing runway at Fort Lauderdale with total accountable onboard fuel of 3 to 4 gallons. One passenger received fatal injuries, one passenger received serious injuries, and the pilot received serious injuries. Engine factory service center disassembly examination revealed that the engines and their components exhibited no evidence of any condition that would have precluded normal operation, precrash. No precrash abnormalities with the propellers, their respective components, or any other aircraft system component were noted. Type certification data sheets for the C90 state that the unusable fuel aboard is 24 lbs., (3.6 gallons of Jet-A fuel).
Probable cause:
The pilot's failure to properly plan fuel consumption and to perform an en route refueling, resulting in a total loss of engine power due to fuel exhaustion while on downwind leg for landing at eventual destination, causing an emergency descent and collision with a highway embankment.
Final Report:

Crash of a Learjet 25D in Salina

Date & Time: Jun 12, 2001 at 1300 LT
Type of aircraft:
Operator:
Registration:
N333CG
Flight Type:
Survivors:
Yes
Schedule:
Newton - Salina
MSN:
25-262
YOM:
1978
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19000
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
5168
Copilot / Total hours on type:
470
Aircraft flight hours:
8419
Circumstances:
During a test flight, the airplane encountered an elevator system oscillation while in a high speed dive outside the normal operating envelope. The 17 second oscillation was recorded on the cockpit voice recorder and had an average frequency of 28 Hz. The aft elevator sector clevis (p/n 2331510-32) fractured due to reverse bending fatigue caused by vibration, resulting in a complete loss of elevator control. The flight crew reported that pitch control was established by using horizontal stabilizer pitch trim. The flightcrew stated that during final approach to runway 17 (13,337 feet by 200 feet, dry/asphalt) the aircraft's nose began to drop and that the flying pilot was unable to raise the nose using a combination of horizontal stabilizer trim and engine power. The aircraft landed short of the runway, striking an airport perimeter fence and a berm. The surface winds were from the south at 23 knots, gusting to 32 knots.
Probable cause:
The PIC's delayed remedial action during the elevator system oscillation, resulting in the failure of the aft elevator sector clevis due to reverse bending fatigue caused by vibration, and subsequent loss of elevator control. Factors contributing to the accident were high and gusting winds, the crosswind, the airport perimeter fence, and the berm.
Final Report:

Crash of a Learjet 24A in Victorville

Date & Time: Jun 7, 2001 at 1140 LT
Type of aircraft:
Operator:
Registration:
N805NA
Flight Type:
Survivors:
Yes
Schedule:
Victorville - Victorville
MSN:
24-102
YOM:
1966
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8550
Captain / Total hours on type:
40.00
Copilot / Total flying hours:
1800
Copilot / Total hours on type:
10
Aircraft flight hours:
10679
Circumstances:
The copilot inadvertently induced a lateral oscillation and lost control of the airplane while practicing touch-and-go landings. The pilot made the first touch-and-go. The copilot successfully made the second touch-and-go. The copilot attempted the third touch-and-go. At 50 feet, he disengaged the yaw damper and entered a pilot induced lateral oscillation. The airplane rapidly decelerated and developed a high sink rate. The airplane dragged the right tip fuel tank, which separated from the airplane, and the airplane bounced back into the air. The airplane landed hard, the main landing gear collapsed, and the airplane skidded to a stop off the right side of the runway. Both pilots and the passenger deplaned through the main entry door. The pilot-in-command had not demonstrated the handling characteristics of the airplane with the yaw damper off, and he felt he did not react quickly enough to prevent the accident.
Probable cause:
The copilot inadvertently induced a lateral oscillation resulting in an in-flight loss of control. The pilot-in-command failed to adequately supervise the copilot.
Final Report:

Crash of a Beechcraft 350C Super King Air in Santiago de Compostela

Date & Time: Jun 7, 2001 at 0213 LT
Registration:
F-GOAE
Flight Type:
Survivors:
Yes
Schedule:
Le Mans - Santiago de Compostela
MSN:
FM-1
YOM:
1990
Flight number:
OPE062
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3115
Captain / Total hours on type:
211.00
Copilot / Total flying hours:
791
Copilot / Total hours on type:
268
Aircraft flight hours:
5331
Aircraft flight cycles:
7451
Circumstances:
While on approach to Santiago de Compostela Airport, around 0000LT, meteorological conditions were reported to be good, and the crew requested a visual approach to runway 17, even though the active runway was 35. Once cleared to land, the aircraft encountered a fog patch and from this moment it began a high rate descent (2,000 to 3,000 feet per minute). A minute after entering an unexpected and unforeseen fog patch, at 00:13:02 of June 7, the aircraft struck some trees, in level flight and with an airspeed of 148 knots. The wings and engines detached from the fuselage, and they dragged along a scrubland area until they came to a stop. The crew suffered minor injuries and the aircraft was completely destroyed.
Probable cause:
The probable cause was the decision to start a visual approach without having the runway in sight and the continuance of the visual approach in spite of the loss of external visual references, as they unexpectedly entered a fog patch.
Final Report:

Crash of an Embraer EMB-820C Navajo in Curitiba

Date & Time: Jun 6, 2001 at 2010 LT
Operator:
Registration:
PT-EFU
Flight Type:
Survivors:
Yes
Schedule:
Guarapuava – Curitiba
MSN:
820-031
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2600
Captain / Total hours on type:
592.00
Circumstances:
Following an uneventful cargo flight from Guarapuava, the crew started the descent to Curitiba-Bacacheri Airport by night and adverse weather conditions. After touchdown on a wet runway surface, the twin engine aircraft went out of control, overran and collided with a concrete wall. All three occupants were injured, one of the pilot seriously.
Probable cause:
The decision of the crew to land at Curitiba-Bacacheri Airport was not appropriate due to poor weather conditions. The crew underestimated the weather conditions at destination and should take the decision to divert to a more suitable terrain.
Final Report:

Crash of a Piper PA-31-310 Navajo in Charlottetown: 3 killed

Date & Time: Jun 5, 2001 at 1621 LT
Type of aircraft:
Operator:
Registration:
C-GMTT
Flight Phase:
Survivors:
Yes
Schedule:
Gander – Charlottetown – Natuashish
MSN:
31-7712004
YOM:
1977
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2085
Captain / Total hours on type:
185.00
Circumstances:
The flight took off on Runway 22 at Gander, Newfoundland and Labrador, at 1428 Newfoundland daylight time with the pilot and four passengers on board. Their destination was Sango Bay, Newfoundland and Labrador, with an intermediate stop in Charlottetown, Newfoundland and Labrador, to drop off one of the passengers. Radar data show that, on departure from Gander, the aircraft climbed at about 500 feet per minute at 125 knots ground speed to 2500 feet, then descended and proceeded en route to Charlottetown at 1900 feet and 150 knots. The aircraft landed at Charlottetown at 1615. After a brief stop, the flight continued to Sango Bay. The pilot broadcast his intention to take off on Runway 10, taxied the aircraft to the threshold of the runway, and commenced the take-off roll. Part-way down the runway, the pilot aborted the take-off. He then broadcast his intention to take off on Runway 28. Both radio broadcasts were acknowledged by a local pilot who was approaching the airport to land. Upon reaching the threshold of Runway 28, the aircraft turned and accelerated, without stopping, on the take-off roll. The aircraft lifted off shortly before the runway end and remained near treetop height until disappearing from view. After lift-off, the stall warning horn sounded intermittently until impact. The aircraft was unable to climb above the hilly terrain and struck the road 1.5 nautical miles from the departure end of the runway. A passing motorist spotted the downed aircraft and notified firefighters and medical personnel who were then dispatched to the scene. The accident occurred at about 1621 during daylight hours, at 58°45' N, 55°66' W, at 440 feet above sea level.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The aircraft was over the maximum allowable take-off weight throughout its journey, reducing aircraft performance: the pilot apparently did not complete weight and balance calculations for
either of the flights.
2. The pilot did not use the proper short field take-off technique, and the aircraft was forced into the air before reaching sufficient flying speed.
3 The best angle of climb speed was not attained.
4. The unsecured cargo, some of which was found on top of the back of the rear passenger seat, most probably contributed to the severity of the injuries to the passenger in this seat.
Final Report:

Crash of a Piper PA-31-T2 Cheyenne II-XL in Jackson: 5 killed

Date & Time: Jun 3, 2001 at 1611 LT
Type of aircraft:
Registration:
N31XL
Survivors:
No
Schedule:
Malden – Atlanta
MSN:
31-8166003
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
9500
Captain / Total hours on type:
13.00
Aircraft flight hours:
6025
Circumstances:
About 20 minutes before the accident, the pilot reported to the air traffic controller that he had a problem with an engine and needed to shut the engine down. The flight had just leveled at 23,000 feet. The controller told the pilot that he was near Jackson, Tennessee, and that he could descend to 7,000 feet. About 10 minutes later, the pilot reported he was at 8,000 feet and requested radar vectors for the instrument landing system approach to runway 2 at the McKellar-Sipes Regional Airport, at Jackson. The pilot told the controller he had the left engine shut down. About 5 minutes later, the pilot reported he had a propeller runaway. About 1 minute later, the pilot reported he was in visual conditions and requested radar vectors direct to the airport. About 2 minutes later, the pilot reported he had a cloud layer under him and that he had the localizer frequency for runway 2 set. About 1 minute later, the pilot was told to contact the McKellar Airport control tower. The pilot acknowledged this instruction. No further transmissions were received from the flight. Examination of the left engine at the accident site showed the left propeller control was found disconnected at the point the propeller control extension bracket attaches to the propeller governor. The propeller control cable had also pulled loose from a swaged point at the control rod and was also separated further aft due to overstress. The housing for the propeller control rod was found securely attached to the engine and the control rod was securely attached to the extension bracket. The propeller governor control arm, which was disconnected from the propeller control cable and rod, was found spring loaded into the high RPM position. Examination of the fractured left propeller bracket assembly was performed by the NTSB Materials Laboratory, Washington, D.C. The bracket assembly was fractured in the area of the outermost eyehole, at the point a bolt passes through the bracket assembly and the propeller governor arm. The fracture surface contained small amounts of dirt, grease, and minor corrosion. The fracture surface features include flat areas that lie on multiple planes separated by ratchet marks, features typically left behind by the propagation of a fatigue crack. The fatigue crack emanated from multiple origins on opposite sides of the bracket. The total area of the fatigue crack occupied approximately 85 percent of the fracture surfaces. The fatigue fractures initiated on the outer edges of the surface and propagated inward toward the center. The remaining 15% of the fracture surface had features consistent with overstress separation. Near the middle of each fatigue region were microfissures suggesting that the crack propagated under high-stress conditions. The NTSB Materials Laboratory also examined the separation point between the left propeller control flexible cable and the rigid rod that connects to the bracket assembly. The cable and the swaged part of the rigid rod were in good condition with no fractures or damage. The Piper PA-31-T2 Pilot Operating Handbook, Section 3, Emergency Procedures, does not contain a procedure for loss of propeller control. Section 3 did contain a procedure for "Over speeding Propeller", which stated that if a propellers speed should exceed 1,976 rpm, to place the power lever of the engine with the over speeding propeller to idle, feather the propeller, place the engine condition lever in the stop position, and complete the engine shutdown procedures. Pilot logbook records show the pilot completed a simulator training course for the accident model airplane about 9 days before the accident and had about 13 flight hours in the Piper PA-31-T2.
Probable cause:
The pilot's shutting down the left engine following loss of control of the left propeller resulting in an in-flight loss of control of the airplane due to the windmilling propeller. Factors in the accident were the failure of the propeller control bracket assembly due to fatigue, the pilot's lack of experience in the type of airplane (turbo propeller) and the absence of a procedure for loss of propeller control in the airplane's flight manual.
Final Report:

Crash of a Fokker 100 in Dallas

Date & Time: May 23, 2001 at 1504 LT
Type of aircraft:
Operator:
Registration:
N1419D
Survivors:
Yes
Schedule:
Charlotte – Dallas
MSN:
11402
YOM:
1992
Flight number:
AA1107
Crew on board:
4
Crew fatalities:
Pax on board:
88
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14000
Captain / Total hours on type:
3600.00
Copilot / Total flying hours:
6700
Copilot / Total hours on type:
302
Aircraft flight hours:
21589
Circumstances:
During landing touchdown, following a stabilized approach, the right main landing gear failed. The airplane remained controllable by the pilots and came to a stop on the runway, resting on its right wing. The DFW Fire Department arrived at the accident site in 35 seconds and, following communication between the airplane's Captain and Fire Department's Incident Commander, it was decided that an emergency evacuation of the airplane was not necessary. Examination revealed that the right main gear's outer cylinder had fractured allowing the lower portion of the gear (including the wheel assembly) to separate from the airplane. Research, examination & testing of the cylinder revealed that a forging fold was introduced into the material during the first stage of its forging process. The first stage is a hand operation, therefore the quality is highly dependent on the person performing the hand operation. Following the first landing, the forging fold became a surface breaking crack, due to the normal loads imposed during landing. Although growth of the fatigue crack was suppressed by crack blunting, high load landings resulted in growth of the fatigue crack. Subsequently, the landing gear failed when the crack had reached a critical length. Additionally, the airplane's maintenance records were reviewed and no anomalies were found.
Probable cause:
A forging fold that was introduced during the manufacture of the right main landing, which resulted in a fatigue crack in the right main landing gear cylinder, and its subsequent failure during landing.
Final Report: