Crash of a PZL-Mielec AN-2T in Kobyay

Date & Time: Apr 23, 2001 at 1745 LT
Type of aircraft:
Operator:
Registration:
RA-01122
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Pokrovsk – Magan – Kobyay – Sangar
MSN:
1G238-04
YOM:
1990
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
2135
Aircraft flight cycles:
3112
Circumstances:
The aircraft departed Pokrovsk on an ambulance flight to Sangar with intermediate stops in Magan and Kobyay. On approach to Kobyay Airport, the aircraft was too high and its speed was excessive. Rather than initiating a go-around procedure, the captain continued the approach and landed 375 metres pas the runway threshold (the runway length is 600 metres). Unable to stop within the remaining distance, the aircraft overran, collided with various obstacles and came to rest 50 metres further. The crew did not report the incident to the company and decided to take off few minutes later. After liftoff, the aircraft was unable to gain sufficient speed and height. It struck trees and crashed in a snow covered terrain, bursting into flames. All 13 occupants were injured, among them five seriously. The aircraft was destroyed by fire.
Probable cause:
It was determined that the captain was intoxicated at the time of the accident and that he started the mission from Pokrovsk already drunk. He took the decision to take off from Kobyay Airstrip despite the propeller blades have been damaged during the previous overrun.

Crash of an Ilyushin II-76MD in Ostend

Date & Time: Apr 18, 2001
Type of aircraft:
Operator:
Registration:
UR-78821
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Ostend - Algiers - Conakry
MSN:
00934 96914
YOM:
1989
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The four engine aircraft was engaged in a cargo flight from Ostend to Conakry with an intermediate stop in Algiers, carrying eight crew members and a load consisting of 32 tons of paint and medical supplies for the Guinean market. During the takeoff roll on runway 26 at Ostend Airport, an engine fire warning light came on in the cockpit panel. The captain decided to abandon the takeoff procedure and initiated an emergency braking maneuver. Unable to stop within the remaining distance, the aircraft overran for about 40 metres then lost its nose gear and came to rest on its left wing, damaging both left engine nacelles and the wingtip as well as the fuselage that was bent upward the cockpit area. All eight crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
No technical anomalies were found on the aircraft and the engine fire warning light came on by error.

Crash of a Mitsubishi MU-2B-36 Marquise in Caucasia: 1 killed

Date & Time: Apr 15, 2001
Type of aircraft:
Operator:
Registration:
HK-2245P
Flight Type:
Survivors:
No
Schedule:
Bogotá – Caucasia
MSN:
684
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
While on final approach to Caucasia Airport, the twin engine aircraft crashed in unknown circumstances 3 km short of runway. The aircraft was destroyed and the pilot, sole on board, was killed.

Crash of a Cessna 208B Grand Caravan in Tembo

Date & Time: Apr 14, 2001
Type of aircraft:
Operator:
Registration:
ZS-OCZ
Flight Phase:
Survivors:
Yes
MSN:
208B-0617
YOM:
1997
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Tembo Airstrip, while in initial climb, the pilot encountered problems to gain sufficient height as the engine lost power. He attempted an emergency landing when the aircraft crash landed in an open field located about one km from the airfield, bursting into flames. All nine occupants escaped uninjured while the aircraft was destroyed by fire.

Crash of an Antonov AN-12BK in Nouadhibou

Date & Time: Apr 10, 2001
Type of aircraft:
Registration:
3C-AWU
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nouakchott – Nouadhibou – Lisbon
MSN:
8 34 58 04
YOM:
1968
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Nouadhibou Airport, while in initiale climb, one of the engine caught fire. The crew reduced his altitude and attempted an emergency landing in a beach located 6 km from the airport. The aircraft crash landed and came to rest, bursting into flames. All six occupants escaped uninjured while the aircraft was destroyed by fire.
Probable cause:
Engine fire during initial climb for unknown reasons.

Crash of a Piper PA-46-500TP Malibu Meridian in Vero Beach: 2 killed

Date & Time: Apr 9, 2001 at 1208 LT
Registration:
N262MM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Vero Beach - Daytona Beach
MSN:
46-97040
YOM:
2001
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1514
Captain / Total hours on type:
33.00
Copilot / Total flying hours:
378
Aircraft flight hours:
45
Circumstances:
Witnesses observed N262MM taxi to runway 29 left and the pilot perform what appeared to be a normal engine runup. The airplane then taxied onto runway 29 left for takeoff. The wind was from the east, making the takeoff with a tail wind. During the takeoff, the engine seemed to operate at a steady level, but appeared to be low on power. The flight lifted off about halfway down the runway and the landing gear was retracted. The airplane climbed slowly and turned slowly to the left. The airplane then entered a 60-80 degree left bank followed by the airplane rolling level and the wings rocking back and forth. The airplane was now on a southerly heading and the nose dropped. The airplane then collided with trees about 15-20 feet above the ground, fell to the ground, and burst into flames. Witnesses stated they saw no smoke or flames coming from the airplane prior to impact with the trees. At the time of the accident the landing gear was retracted and the engine was running. Transcripts of recorded communications show that at 1205:40, the local controller instructed the flight to taxi into position and hold on runway 29 left. At 1206:43, N262MM was cleared for takeoff and a north bound departure was approved. At 1208:03, the passenger transmitted "we need to land we have to turn around". The local controller cleared the flight to return to the airport when able. At 1208:20, the passenger transmitted "two mike mike we're going down we're going down", followed by "over the golf (unintelligible)". The local controller responded "copy over the golf course". No further transmissions were received from the flight. Analysis of background noise contained on the ATC recordings show that at the time the passenger on N262MM transmitted to controllers that they were ready for takeoff and when he acknowledged the takeoff clearance, the propeller was rotating at 1,261 and 1,255 respectively. When the passenger transmitted to controllers after takeoff, that they needed to land, the propeller was rotating at 1,980 rpm. When the passenger transmitted we have to turn around, shortly after the above transmission, the propeller was rotating at 2,017 rpm. When the passenger made his last transmission stating they were going down, the propeller rpm was 1,965. The maximum propeller speed at takeoff is 2,000 rpm. Additional evidence was found indicating electrical arcing and progressive fatigue cracking in the engine’s P3 line, which could result in a rapid rollback of engine power. Simulator testing showed that a P3 line failure would result in the engine decelerating from full takeoff power (2,000 propeller rpm) and stabilizing at an idle power setting in less than 9 seconds. However, the sound spectrum analysis of the first radio transmission indicated the propeller rpm was 1,980, and two subsequent radio transmissions, the last of which was made 17 seconds after the initial transmission, detected the propeller rpm at near takeoff speed. Thus, there was no evidence of dramatic rpm loss, making the P3 line failure an unlikely cause of the accident. Postcrash examination of the aircraft structure, flight controls, engine, and propeller, showed no evidence of failure or malfunction. Witnesses indicated the flight used about 3,650 feet of runway for takeoff or about half of the 7,296 foot long runway. Charts contained in the Piper PA-46-500TP, Pilot's Operating Handbook, indicated that for the conditions at the time of the accident, the airplane should have used about 2,000 feet of runway for the ground roll during the takeoff with no wing flaps extended. The charts also show that the airplane indicated stall speed at 60 degrees of bank angle with the landing gear and wing flaps retracted is 111 knots.
Probable cause:
The pilot's excessive bank angle and his failure to maintain airspeed while returning to the airport after takeoff due to an unspecified problem resulting in the airplane stalling and colliding with trees during the resultant uncontrolled descent.
Final Report:

Crash of a Beechcraft A100 King Air in Grande Prairie

Date & Time: Apr 7, 2001 at 0512 LT
Type of aircraft:
Operator:
Registration:
C-FWPN
Survivors:
Yes
Schedule:
Fort Saint John – Grande Prairie
MSN:
B-51
YOM:
1970
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Fort Saint John, the crew started a night approach to Grande Prairie Airport. The aircraft landed slightly to the left of the runway centerline. After touchdown on a snow covered runway (about two inches of snow), the left wing struck a windrow of snow. Out of control, the aircraft veered off runway and came to rest in snow. All five occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Boeing 737-2E1F in Saint John's

Date & Time: Apr 4, 2001 at 0615 LT
Type of aircraft:
Operator:
Registration:
C-GDCC
Flight Type:
Survivors:
Yes
Schedule:
Hamilton – Montréal – Halifax – Saint John’s
MSN:
20681
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
At 2320, Newfoundland daylight time, on 03 April 2001, the Royal Cargo flight, a Boeing 737-200, left Mirabel, Quebec, for a scheduled instrument flight rules cargo flight with two pilots on board. The flight was headed for Hamilton, Ontario; Mirabel; Halifax, Nova Scotia; St. John's, Newfoundland; and Mirabel. The flights from Mirabel to Halifax were uneventful. Before departure from Halifax, the pilot flying (PF) received the latest weather information for the flight to St. John's from the company dispatch; he did not ask for, or receive, the latest notices to airmen (NOTAMs). At 0545, the aircraft departed Halifax for St. John's. The PF was completing his line indoctrination training after having recently upgraded to captain. The training captain, who was the pilot not flying (PNF), occupied the right seat. After departure from Halifax, he contacted Halifax Flight Service Station (FSS) and received the latest weather report for St. John's, the 0530 aviation routine weather report (METAR). The weather was as follows: wind 050° magnetic (M) at 35, gusting to 40, knots; visibility 1 statute mile in light snow and blowing snow; ceiling 400 feet overcast; temperature -1°C; dew point -2°C; and altimeter 29.41 inches of mercury. The FSS passed runway surface condition (RSC) reports for both runways (11/29 and 16/34), including Canadian runway friction index (CRFI) readings of 0.25 for Runway 11/29 and 0.24 for Runway 16/34. The FSS specialist also provided the NOTAMs for St. John's, which included a NOTAM released more than five hours earlier advising of the unserviceability of the instrument landing system (ILS) for Runway 11. The flight crew had initially planned an ILS approach, landing on Runway 11 at St. John's. Because of the marginal weather, the loss of Runway 11/29, and his greater experience, the training captain decided to switch seats and assume the duties and full responsibilities as captain and PF. Returning to Halifax was not considered because the aircraft would be overweight for landing there. The option of diverting the flight to the alternate airport was also discussed by the crew; however, in the end, they felt that a safe landing was achievable in St. John's. At 0638:27, the PF contacted St. John's tower to ask if the approach to Runway 34 was still an option. The response indicated that Runway 34 was probably the only option because of the wind: 050°M (estimated) at 35, gusting to 40, knots. The ILS on Runway 11 was unserviceable, and the glidepath for Runway 29 was unserviceable. The only instrument approaches available were the localizer back course Runway 34 and the ILS Runway 16. Also, at about 0638, the Gander Area Control Centre (ACC) controller suggested to the crew that they obtain the 0630 automatic terminal information service (ATIS) for St. John's. The ATIS was reporting surface winds of 055°M at 20, gusting to 35, knots. The PNF attempted to obtain the ATIS information; however, because of a simultaneous radio transmission on the second VHF radio between the PF and St. John's tower, the ATIS information was not obtained. At 0641, the PNF contacted Gander ACC, which reported the winds at St. John's as 040°M at 13, gusting to 18, knots. The PNF pointed out the discrepancy in the two wind reports to the PF; however, there was no acknowledgement of the significance of the discrepancy. It was later determined that the discrepancy was an unserviceable anemometer at the St. John's airport due to ice accretion on the anemometer. The anemometer was providing a direct reading of the incorrect wind information to Gander ACC. Gander ACC was unaware of the unserviceability and unknowingly passed the incorrect wind information on to the flight crew. At 0644, Gander ACC transmitted a significant meteorological report (SIGMET), issued at 0412 and valid from 0415 to 0815, that included St. John's. The SIGMET forecast severe mechanical turbulence below 3000 feet due to surface wind gusts in excess of 50 knots. However, the crew may not have been listening to the SIGMET broadcast: while the ACC transmitted the SIGMET, the crew were discussing the application of an 18-knot quartering tailwind for the approach to Runway 16. This tailwind was well under the 50 knots described by the SIGMET. The crew did not acknowledge receipt of the SIGMET until prompted by the controller. Before the descent into St. John's, the crew discussed approach options. The approach to Runway 11 was discounted because of the unserviceability of the ILS, and Runway 34 was eliminated as an option because the weather was below its published approach minimums. The crew discussed the ILS approach to Runway 16. Although the PNF expressed concern about the tailwind, it was decided to attempt the approach because the wind reported by Gander ACC was within the aircraft's landing limits. In calculating the approach speed in preparation for the approach, there was confusion during the application of the tailwind and gust corrections to the landing reference speed (Vref ). The crew had correctly established a flap-30 Vref of 132 knots indicated airspeed (KIAS) and ultimately an approach speed of 142 KIAS. The approach speed calculations were derived using the incorrect wind information from Gander ACC; further, the crew added five knots for the gust increment to the nominal approach speed (Vref + 5 knots), that is, Vref + 10 knots. This incorrect calculation (adding the gust factor) was consistent with company practice at the time of the accident. During the descent, the crew also had difficulty completing the descent and approach checklists; there were several missteps and repeated attempts at completion of checks. Clearance for an ILS approach to Runway 16 was obtained from Gander ACC , and the crew was advised to contact St. John's tower. Just over two minutes before landing, the tower advised that the wind was 050°M (estimated) at 20, gusting to 35, knots and provided the following RSC report for Runway 16: Full length 170 feet wide, surface 30% very light dusting of snow and 70% compact snow and ice; remainder is 20% light snow, 80% compact snow and ice, windrow along the east side of the runway; friction index 0.20; and temperature -1°C at 0925. The aircraft crossed the final approach fix on the ILS glideslope at 150 KIAS. During the final approach, the airspeed steadily increased to 180 KIAS (ground speed 190 knots); the glidepath was maintained with a descent rate of 1000 feet per minute. From 1000 feet above sea level, no airspeed calls were made; altitude calls were made and responses were made. The Royal Boeing 737 operations manual states that the PNF shall call out significant deviations from programmed airspeed. In the descent, through 900 feet above sea level, the aircraft encountered turbulence resulting in uncommanded roll and pitch deviations and airspeed fluctuations of +/- 11 knots. At about 300 feet above decision height, the crew acquired visual references for landing. Approximately one minute before landing, St. John's tower transmitted the runway visual range, repeated the estimated surface wind (050°M [estimated] at 20, gusting to 35, knots), and issued a landing clearance to the aircraft; the PNF acknowledged this information. The aircraft touched down at 164 KIAS (27 KIAS above the desired touchdown speed of Vref), 2300 to 2500 feet beyond the threshold. Radar ground speed at touchdown was 180 knots. The wind at this point was determined to be about 050°M at 30 knots. Shortly after touchdown, the speed brakes and thrust reversers were deployed, and an engine pressure ratio (EPR) of 1.7 was reached 10 seconds after touchdown. Longitudinal deceleration was -0.37g within 1.3 seconds of touchdown, suggesting that a significant degree of effective wheel braking was achieved. With approximately 1100 feet of runway remaining, through a speed of 64 KIAS, reverse thrust increased to about 1.97 EPR on engine 1 and 2.15 EPR on engine 2. As the aircraft approached the end of the runway, the captain attempted to steer the aircraft to the right, toward the Delta taxiway intersection. Twenty-two seconds after touchdown, the aircraft exited the departure end of the runway into deep snow. The aircraft came to rest approximately 75 feet beyond and 53 feet to the right of the runway centreline on a heading of 235°M.
Probable cause:
Findings as to Causes and Contributing Factors:
1. A combination of excessive landing speed, extended touchdown point, and low runway friction coefficient resulted in the aircraft overrunning the runway.
Findings as to Risk:
1. Before departure from Halifax, the flight crew did not request nor did dispatch personnel inform the crew of the notice to airmen (NOTAM) advising of the instrument landing system's failure for Runway 11 at St. John's International Airport.
2. The St. John's dynamic wind information provided to the Gander Area Control Centre controller was inaccurate. The controller was not aware of this inaccuracy.
3. The crew applied tailwind corrections in accordance with company practices; however, these practices were not in accordance with those stated in the operations manual.
Final Report:

Crash of an Antonov AN-24 in Adar Yeil: 14 killed

Date & Time: Apr 4, 2001
Type of aircraft:
Operator:
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Adar Yeil – Khartoum
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
26
Pax fatalities:
Other fatalities:
Total fatalities:
14
Circumstances:
Just after liftoff, while climbing in a sandstorm, the crew lost control of the airplane that crashed near the runway end. Sixteen people were rescued while 14 others were killed, among them 13 high ranking Army officers and Ibrahim Shamsul-Din, vice-minister of Defence.

Crash of a De Havilland DHC-3 Otter in Decatur

Date & Time: Mar 31, 2001 at 1215 LT
Type of aircraft:
Registration:
N120BA
Flight Phase:
Survivors:
Yes
Schedule:
Decatur - Decatur
MSN:
115
YOM:
1956
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
33000
Captain / Total hours on type:
169.00
Aircraft flight hours:
6633
Circumstances:
The pilot and 21 jumpers were aboard the airplane for the local skydiving flight. The airplane took off to the north on the wet grass runway. Jumpers reported that during the initial takeoff climb, the aircraft assumed a "very steep angle of attack," and described the pilot "winding the wheel on the lower right side of the chair clockwise, frantically," and "busy with a wheel between the seats." The airplane impacted trees and terrain approximately 250 yards east of the runway. The pilot reported that the "airplane flew through a dust devil" and did not have enough altitude for a complete recovery. The pilot stated the winds were northerly at 6 to 8 knots with "extreme" turbulence. The nearest weather observation facility reported clear skies with calm wind. Takeoff weight and center of gravity (CG) were calculated at 9,118.05 lbs and 161.92 inches. The AFM listed the maximum gross weight at 8,000 pounds and the aft CG limit at 152.2 inches. Further, an AFM WARNING stated: C. G. POSITION OF THE LOADED AIRCRAFT MUST BE CHECKED AND VERIFIED PRIOR TO TAKE-OFF, AND APPROPRIATE TRIM SETTINGS SHOULD BE USED; OTHERWISE ABNORMAL STICK FORCES AND POSITIONS MAY RESULT. The elevator trim wheel is located on the righthand side of the pilot's seat. Post-accident examination of the airplane revealed that there were 16 seatbelts in the cabin section and 2 seatbelts in the cockpit. Additionally, a placard installed in the cockpit stated, in part, THIS AIRPLANE IS LIMITED TO THE OPERATION OF NINE PASSENGERS OR LESS. Regarding the discrepancy between the placarded 9 passenger limit and the 21 jumpers aboard, the pilot stated that parachute jumpers are not considered to be passengers and therefore, he did not have to comply with the placarded limit.
Probable cause:
The pilot's failure to maintain aircraft control during the takeoff/initial climb. Contributing factors were the pilot's exceeding aircraft weight and balance limits and the dust devil.
Final Report: