Crash of a Casa 212 Aviocar 300 in Tres Esquinas

Date & Time: Dec 5, 2000
Type of aircraft:
Operator:
Registration:
FAC-1251
Flight Type:
Survivors:
Yes
Schedule:
Bogotá – Tres Esquinas
MSN:
450
YOM:
1991
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Bogotá on a flight to Tres Esquinas, carrying a team of engineers who were involved in the refurbishment of the runway at Tres Esquinas Airport. On final approach, the crew encountered technical problems and attempted an emergency landing when the aircraft crashed in a wooded area located 3 km short of runway. Two occupants were injured.

Ground fire of a Douglas DC-9-32 in Atlanta

Date & Time: Nov 29, 2000 at 1550 LT
Type of aircraft:
Operator:
Registration:
N826AT
Survivors:
Yes
Schedule:
Atlanta - Akron
MSN:
47359/495
YOM:
1969
Flight number:
FL956
Crew on board:
5
Crew fatalities:
Pax on board:
92
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
6000.00
Copilot / Total flying hours:
3100
Copilot / Total hours on type:
0
Aircraft flight hours:
78255
Aircraft flight cycles:
88367
Circumstances:
Shortly after takeoff, the airplane experienced electrical problems, including numerous tripped circuit breakers. The flight crew requested a return to airport. During the landing rollout, the lead flight attendant and air traffic control personnel reported to the flight crew that smoke was coming from the left side of the airplane; subsequently, the flight crew initiated an emergency evacuation on one of the taxiways. Examination of the airplane revealed fire damage to the left, forward areas of the fuselage, cabin, and forward cargo compartment. The greatest amount of fire damage was found just aft of the electrical disconnect panel located at fuselage station 237. There was no evidence that the drip shield normally installed over the disconnect panel was present at the time of the accident. Bluish stains caused by lavatory rinse fluid were observed on surfaces near the disconnect panel on the accident airplane and in the same areas on another of AirTran's DC-9 airplanes. Examination of one of the connectors from the disconnect panel on the accident airplane revealed light-blue and turquoise-green deposits on its internal surfaces and evidence of shorting between the connector pins. It could not be determined when the drip shield over the disconnect panel was removed; however, this likely contributed to the lavatory fluid contamination of the connectors. Following the accident, AirTran revised its lavatory servicing procedures to emphasize the importance of completely draining the waste tank to avoid overflows. Boeing issued an alert service bulletin recommending that operators of DC-9 airplanes visually inspect the connectors at the FS 237 disconnect panel for evidence of lavatory rinse fluid contamination and that they install a drip shield over the disconnect panel. Boeing also issued a service letter to operators to stress the importance of properly sealing floor panels and adhering to lavatory servicing procedures specified in its DC-9 Maintenance Manual. The Safety Board is aware of two incidents involving the military equivalent of the DC-9 that involved circumstances similar to the accident involving N826AT. Drip shields were installed above the FS 237 disconnect panels on both airplanes.
Probable cause:
The leakage of lavatory fluid from the airplane's forward lavatory onto electrical connectors, which caused shorting that led to a fire. Contributing to the accident were the inadequate servicing of the lavatory and the failure of maintenance to ensure reinstallation of the shield over the fuselage station 237 disconnect panel.
Final Report:

Crash of a Swearingen SA227AC Metro III in Trujillo

Date & Time: Nov 28, 2000 at 0625 LT
Type of aircraft:
Operator:
Registration:
N3107P
Flight Type:
Survivors:
Yes
Schedule:
Lima - Trujillo
MSN:
AC-496
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On November 28, 2000, at 0625 eastern standard time, a Fairchild SA227AC transport category airplane, N3107P, was substantially damaged while landing with an unsafe gear indication on the right main landing gear at the Trujillo International Airport, near Trujillo, Peru. The two commercial pilots aboard the cargo flight were not injured. The airplane was owned by Joda LLC, of Town and Country, Missouri, and was being operated as a cargo freighter by Aero Condor S.A., of Lima, Peru. Visual meteorological conditions prevailed for the cargo flight for which a VFR flight plan was filed. The scheduled cargo flight originated from the Lima International Airport, near Lima, Peru, approximately 0530. The operator reported that the flight crew had reported a complete loss of hydraulic power prior to initiating the approach. The flight crew was not able to extend the right main landing gear due to a leak in a hydraulic line in the right landing gear well. The runway was foamed and the crew performed an emergency landing with the other two landing gears extended. Examination of the airplane by the operator revealed structural damage to the right wing and the underside section of the tail section of the airplane. The right engine and the 4-propeller blades for the right engine were also damaged. Both pilots were uninjured.

Crash of an Aérospatiale SN.601 Corvette in Córdoba: 1 killed

Date & Time: Nov 25, 2000 at 0604 LT
Registration:
EC-DQG
Flight Type:
Survivors:
Yes
Schedule:
Málaga - Córdoba
MSN:
27
YOM:
1976
Flight number:
MYO611
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6232
Captain / Total hours on type:
3251.00
Copilot / Total flying hours:
1875
Copilot / Total hours on type:
22
Aircraft flight hours:
5743
Circumstances:
The aircraft departed Málaga-Pablo Ruiz Picasso Airport at 0543LT on a positioning flight to Córdoba. On board were two pilots who were flying to Córdoba to pick up a medical team for a transplantation mission. Fifteen minutes after takeoff, the crew started the descent but encountered poor visibility due to the night and foggy conditions. At that moment, the horizontal visibility was 300 metres and the vertical visibility about 500 feet. As Córdoba Airport was not equipped with an ILS system, the crew decided to attempt an approach via a GPS system. On final approach, the aircraft was too low, struck a utility pole then crashed onto a uninhabited house located 1,500 metres short of runway 21. The aircraft was destroyed, one pilot was killed and the second was seriously injured.
Probable cause:
The accident occurred when the aircraft crew carried out an approach maneuver to Córdoba Airport in conditions of very reduced visibility in fog, based exclusively on the GPS receiver of the communications navigation system installed in the aircraft and without reliably monitoring the ground separation. It is likely that the decision to carry out this maneuver was influenced by a pressure to complete the mission, self-generated by the crew members, or self-generated by the pilot-in-command, and induced or not by him and the copilot, as a consequence of an urgent humanitarian operation that entrusted about the confidence of the pilot-in-command and his experience, the navigation system that equipped the aircraft and the knowledge of the destination airport.
Final Report:

Crash of a Beechcraft F90 King Air in Lynchburg

Date & Time: Nov 24, 2000 at 1151 LT
Type of aircraft:
Registration:
N94U
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lynchburg - Lynchburg
MSN:
LA-124
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
250.00
Aircraft flight hours:
6788
Circumstances:
The pilot was conducting a post-maintenance test flight. An overhauled engine had been installed on the right side of the airplane, and both propeller assemblies had been subsequently re-rigged. Ground checks were satisfactory, although the right engine propeller idled 90-100 rpm higher than the left engine propeller. Test flight engine start and run-up were conducted per the checklist, with no anomalies noted. Takeoff ground roll and initial climb were normal; however, when the airplane reached about 100 feet, it stopped climbing and lost airspeed. The pilot could not identify the malfunction, and performed a forced landing to rough, hilly terrain. Upon landing, the landing gear collapsed and the engine nacelles were compromised. The airplane subsequently burned. Post-accident examination of the airplane revealed that the propeller beta valves of both engines were improperly rigged, and that activation of the landing gear squat switch at takeoff resulted in both propellers going into feather. The maintenance personnel did not have rigging experience in airplane make and model. As a result of the investigation, the manufacturer clarified maintenance manual and pilot handbook procedures.
Probable cause:
Improper rigging of both propeller assemblies by maintenance personnel, which resulted in the inadvertent feathering of both propellers after takeoff. Factors included a lack of rigging experience in airplane make and model by maintenance personnel, unclear maintenance manual information, and unsuitable terrain for the forced landing.
Final Report:

Crash of a Britten-Norman BN-2B-21 Islander in Datah Dawai

Date & Time: Nov 18, 2000 at 1053 LT
Type of aircraft:
Operator:
Registration:
PK-VIY
Flight Phase:
Survivors:
Yes
Schedule:
Datah Dawai - Samarinda
MSN:
2133
YOM:
1981
Flight number:
AW3130
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7560
Captain / Total hours on type:
3632.00
Aircraft flight hours:
21336
Aircraft flight cycles:
20374
Circumstances:
The aircraft departed from Datah Dawai Airport for a regular commercial flight with destination airport, Samarinda, East Kalimantan. There were 18 persons on board including the pilot. Minutes after airborne, the aircraft crashed at a location of about 2 km north of the runway 02 extension. The pilot and 11 passengers were found seriously injured, while six sustained minor injuries or none. Weather was reported clear at the time of the occurrence.
Probable cause:
The following findings were identified:
- There are no signs of engine failure prior to the impact,
- The aircraft exceeded its manufacturer's MTOW on the flight from Datah Dawai to Samarinda,
- The aircraft center of gravity is near the aft limit of the CG flight envelope,
- The PIC apparently has a wrong perception on takeoff procedure. He thought that the optimum takeoff performance could be achieved by taking-off with a higher velocity. Meanwhile, in achieving high velocity one has to roll closer to the obstacle, which forced the aircraft to maintain a higher rate of climb,
- The PIC and Datah Dawai ground crews have endangered his passengers by letting more passengers loaded into the aircraft than the number of seats available,
- The PIC and Datah Dawai ground crews have endangered their passengers by improperly calculating the weight of aircraft payload,
- The operator did not have proper supervision system that may prevent such practice to happen,
- The operator has never filled out Flight Clearance, for its Samarinda - Datah Dawai operation,
- There are a lot more passengers or demand than the capacity of the Pioneer Flight Samarinda - Datah Dawai,
- There are not enough flight operation documents published (such as visual track and single engine emergency return guidance) to fly safely in and out of Datah Dawai,
- The exceeding MTOW, small stability margin, PIC takeoff habit, and lack of published safety documents for the area are the contributing factors to the accident.
There were found indications of practices that fit into the category of negligence, willful misconduct and violations of existing flight safety rules and regulations.
Final Report:

Crash of an Antonov AN-26 in Luanda: 57 killed

Date & Time: Nov 15, 2000 at 1303 LT
Type of aircraft:
Operator:
Registration:
D2-FCG
Flight Phase:
Survivors:
No
Schedule:
Luanda - Namibe
MSN:
2 73 081 04
YOM:
1972
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
52
Pax fatalities:
Other fatalities:
Total fatalities:
57
Circumstances:
Shortly after takeoff from Luanda-4 de Fevereiro Airport, while climbing to a height of about 200 feet, the aircraft banked left, lost height and crashed 5 km from the airport, bursting into flames. The aircraft was totally destroyed by impact forces and a post crash fire and all 57 occupants were killed. The five crew members were four Ukrainian citizens and one Angolan.
Probable cause:
It is believed that the loss of control was the consequence of the failure of the left engine during climbout. The exact cause of the engine failure remains unknown but discrepancies were noted concerning operations, manifest and W&B documents (fuel and pax). Since last October 31, all Antonov AN-24, AN-26 and AN-32 flights were suspended in all Angolan airspace, except on the route Luanda - Namibe.

Crash of a Douglas DC-9-51 in Conakry

Date & Time: Nov 13, 2000 at 1813 LT
Type of aircraft:
Operator:
Registration:
9G-ADY
Survivors:
Yes
Schedule:
Accra – Abidjan – Monrovia – Freetown – Conakry
MSN:
47679
YOM:
1975
Flight number:
GH530
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
42
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
45600
Aircraft flight cycles:
64300
Circumstances:
While descending to Conakry-Gbessia Airport, the crew encountered technical problems with the undercarriage that could not be lowered. Several attempts were made to lower the gear manually but this was unsuccessful. The crew decided to complete a belly landing. After touchdown, the aircraft slid for few dozen metres and came to rest on the runway. All 50 occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of a Beechcraft E90 King Air in Reims: 2 killed

Date & Time: Nov 13, 2000 at 1338 LT
Type of aircraft:
Operator:
Registration:
F-GIML
Flight Type:
Survivors:
No
Schedule:
Paris - Reims
MSN:
LW-180
YOM:
1976
Flight number:
CPH030
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6568
Captain / Total hours on type:
2000.00
Copilot / Total flying hours:
1006
Copilot / Total hours on type:
670
Aircraft flight hours:
8772
Aircraft flight cycles:
8441
Circumstances:
The twin engine aircraft departed Paris-Le Bourget Airport at 1309LT on a flight to Reims-Champagne with two pilots on board, one instructor and one pilot that should complete a transition program. While descending at an altitude of 2,000 to Reims-Prunay Airport, the crew informed ATC that he would perform an exercise consisting of a go-around procedure with the simulation of an engine failure. On a left downwind approach to runway 25, the crew started the exercise when the aircraft rolled to the left, lost height and crashed in an open field, bursting into flames. The wreckage was found 425 metres short of runway 25 and both pilots were killed.
Probable cause:
The accident resulted from the performance of a single-engine go-around exercise at low height, in an unfavorable configuration.
Final Report:

Crash of a Cessna 425 Conquest I in Idaho Falls: 2 killed

Date & Time: Nov 10, 2000 at 1215 LT
Type of aircraft:
Registration:
N41054
Flight Type:
Survivors:
No
Schedule:
Idaho Falls - Idaho Falls
MSN:
425-0172
YOM:
1983
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8000
Aircraft flight hours:
4027
Circumstances:
The accident aircraft had recently had maintenance work performed on its autofeather system pressure sensing switches, due to reports of the left engine not autofeathering properly in flight. The purpose of the accident flight was to verify proper inflight operation of the autofeather system following the maintenance work on the autofeather pressure sensing switches and a successful ground check of the autofeather system. Air traffic control (ATC) communications recordings disclosed that the pilot called ready for takeoff from runway 2 approximately 1207, and requested to orbit above the airport at 8,000 feet (note: the airport elevation is 4,740 feet.) The pilot subsequently reported established in a hold above the airport at 8,000 feet approximately 1213, and was instructed by ATC to report leaving the hold. Approximately 1215, an abbreviated radio transmission, "zero five four," was recorded. The Idaho Falls tower controller responded to this call but never got a response in return from the accident aircraft, despite repeated efforts to contact the aircraft. Witnesses reported that the aircraft banked to the left, or to the west, and that it entered a spiral from this bank and crashed (one witness reported the aircraft was flying at 200 to 300 feet above ground level when it entered this bank, and that it performed a "skidding" or "sliding" motion part way through the bank, about 1 second before entering the spiral.) The aircraft crashed about 2 miles north of the airport. On-site examination disclosed wreckage and impact signatures consistent with an uncontrolled, relatively low-speed, moderate to steep (i.e. greater than 22 degrees) angle, left-wing-low impact on an easterly flight path. No evidence of flight control system malfunction was found, and a large quantity of jet fuel was noted to be aboard the aircraft. Post-accident examination of the aircraft's engines indicated that the left engine was most likely operating in a low power range and the right engine was most likely operating in a mid to high power range at impact, but no indications of any anomalies or distress that would have precluded normal operation of the engines prior to impact was found. Post-accident examination of the aircraft's propellers disclosed indications that 1) both propellers were rotating at impact, 2) neither propeller was at or near the feather position at impact, 3) both propellers were being operated with power at impact (exact amount unknown), 4) both propellers were operating at approximately 14º to 20º blade angle at impact, and 5) there were no propeller failures prior to impact. Post-accident examination of the autofeather pressure sensing switches disclosed evidence of alterations, tampering, or modifications made in the field on all but one switch (a replacement switch, which had been installed just before the accident flight during maintenance) installed on the aircraft at the time of the accident. All switches except for the replacement switch operated outside their design pressure specifications; the replacement switch operated within design pressure specifications. Examination of the switches indicated that all switches were installed in the correct positions relative to high- or low-pressure switch installations. Engineering analyses of expected autofeather system performance with the switches operating at their "as-found" pressure settings (vice at design pressure specifications) did not indicate a likelihood of any anomalous or abnormal autofeather system operation with the autofeather switches at their "as-found" pressure settings. Also, cockpit light and switch evidence indicated that the autofeather system was not activated at the time of impact. The combination of probable engine power and propeller pitch on the left engine (as per the post-accident engine and propeller teardown results) was noted to be generally consistent with the "zero-thrust" engine torque and propeller RPM settings specified for simulated single-engine practice in the aircraft Information Manual.
Probable cause:
The pilot-in-command's failure to maintain adequate airspeed with an asymmetric thrust condition, resulting in a loss of aircraft control. A factor was an asymmetric engine thrust condition, which was present for undetermined reasons.
Final Report: