Crash of a Boeing 737-200 in Davao City: 131 killed

Date & Time: Apr 19, 2000 at 0701 LT
Type of aircraft:
Operator:
Registration:
RP-C3010
Survivors:
No
Schedule:
Manila - Davao City
MSN:
21447
YOM:
1978
Flight number:
2P541
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
124
Pax fatalities:
Other fatalities:
Total fatalities:
131
Aircraft flight hours:
68475
Aircraft flight cycles:
79522
Circumstances:
The aircraft was being flown as a route check for for a captain. Another captain was acting as Pilot Monitoring on the flight. The en route part of the flight was uneventful. The aircraft was conducting an ILS approach to runway 05 and the controller reported that they would be behind Philippine Airlines flight 809, an Airbus A319. As the Boeing 737 broke out of clouds, the A319 was observed on runway 05. The Pilot Flying informed ATC of his intention to perform a 360° maneuver, but the Pilot Monitoring advised ATC of the opposite, stating that the aircraft would turn right instead of following the missed approach procedure, which called for a left hand turn to a 020° heading. The aircraft re-entered clouds and attempted to fly visually at a lower altitude in instrument conditions when in fact it should have climbed to 4,000 feet. The flight continued over Samal Island and the flight requested a VOR/DME approach and landing in the opposite direction (runway 23), which was approved by the controller. After having aligned with the runway heading, the aircraft descended below the normal glide path for this approach. It continued down to 570 feet at a point where the aircraft should have been at 1,500 feet. The aircraft crashed into a coconut plantation on a hillside in Barangay San Isidro, disintegrated and caught fire. All 131 occupants were killed.
Probable cause:
Controlled flight into terrain.

Crash of an Antonov AN-8 in Pepa: 24 killed

Date & Time: Apr 19, 2000
Type of aircraft:
Operator:
Registration:
TL-ACM
Flight Phase:
Survivors:
No
Schedule:
Pepa - Kigali
MSN:
9340706
YOM:
1959
Location:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
24
Circumstances:
Shortly after takeoff from Pepa Airport, while in initial climb, the aircraft collided with a flock of birds that struck both engines. The aircraft lost height and crashed past the runway end, bursting into flames. All 24 occupants were killed, among them several officers from the Rwanda Army, one major, two captains, two lieutenants and some soldiers who were returning to Kigali after taking part to a presidential ceremony.
Probable cause:
Loss of control during initial climb following a bird strike.

Crash of a Grumman US-2C Tracker in Reno: 3 killed

Date & Time: Apr 17, 2000 at 1035 LT
Type of aircraft:
Operator:
Registration:
N7046U
Flight Phase:
Survivors:
No
Schedule:
Reno - Reno
MSN:
27
YOM:
1957
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
8170
Copilot / Total flying hours:
3700
Circumstances:
During the takeoff climb, the airplane turned sharply right, went into a steep bank and collided with terrain. The airplane began a right turn immediately after departure and appeared to be going slow. A witness was able to distinguish the individual propeller blades on the right engine, while the left engine propeller blades were indistinguishable. The airplane stopped turning and flew for an estimated 1/4-mile at an altitude of 100 feet. The airplane then continued the right turn at a steep bank angle before disappearing from sight. Then the witness observed a plume of smoke. White and gray matter, along with two ferrous slivers, contaminated the chip detector on the right engine. The airplane had a rudder assist system installed. The rudder assist provided additional directional control in the event of a loss of power on either engine. The NATOPS manual specified that the rudder assist switch should be in the ON position for takeoff, landing, and in the event of single-engine operation. The rudder boost switch was in the off position, and the rudder boost actuator in the empennage was in the retracted (off) position. The owner had experienced a problem with the flight controls the previous year and did not fly with the rudder assist ON. The accident flight had the lowest acceleration rate, and attained the lowest maximum speed, compared to GPS data from the seven previous flights. It was traveling nearly 20 knots slower, about 100 knots, than the bulk of the other flights when it attempted to lift off. The airplane was between the 2,000- and 3,000-foot runway markers (less than halfway down the runway) when it lifted off and began the right turn. Due to the extensive disintegration of the airplane in the impact sequence, the seating positions for the three occupants could not be determined. One of the occupants was the aircraft owner, who held a private certificate with a single-engine land rating, was known to have previously flown the airplane on contract flights from both the left and right seats. A second pilot was the normal copilot for all previous contract flights; his certificates had been revoked by the FAA. The third occupant held an airline transport pilot certificate and had never flown in the airplane before. Prior to the accident flight, the owner had told an associate that the third occupant was going to fly the airplane on the accident flight.
Probable cause:
The flying pilot's failure to maintain directional control following a loss of engine power. Also causal was the failure of the flight crew to follow the published checklist and use the rudder assist system, and the decision not to abort the takeoff.
Final Report:

Crash of a Cessna 404 Titan II in Lansing

Date & Time: Apr 15, 2000 at 0743 LT
Type of aircraft:
Operator:
Registration:
N26SA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lansing - Caro
MSN:
404-0225
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3600
Aircraft flight hours:
17393
Circumstances:
The pilot was departing from Lansing, Michigan, when he reported engine problems. The aircraft subsequently lost power to both engines. Fuel receipts were found that indicate that the aircraft was serviced with 25 gallons of jet fuel in each wing tank. No preexisting anomalies were found with regard to the aircraft or its systems. An FAA inspector interviewed the person that had fueled the aircraft and that person stated he had used a JET-A fuel truck to fuel the accident aircraft. The inspector also interviewed the safety director of the company that provided the fueling service. The safety director told the inspector that the fuel truck used to fuel the accident aircraft was found to have a small nozzle installed on one of the hoses and not the wide nozzle used on jet fueling trucks. He also said that, '...the small nozzle was used for the purpose of fueling tugs at the airport and that the small nozzles were immediately removed from all jet refueling trucks so that this could not happen again.'
Probable cause:
A loss of engine power due to improper fuel. Also causal was the improper aircraft service by the fixed base operator personnel and the unsuitable terrain for the forced landing encountered by the pilot. Factors were the improper grade of fuel and the lack of suitable terrain for the landing.
Final Report:

Crash of a Pilatus PC-6/B2-H4 Turbo Porter in Breitscheid: 2 killed

Date & Time: Apr 8, 2000 at 1852 LT
Operator:
Registration:
HB-FMC
Survivors:
No
Schedule:
Breitscheid - Breitscheid
MSN:
938
YOM:
2000
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
10
Circumstances:
The single engine airplane departed Breitscheid Airfield on a local skydiving flight. Once the appropriate altitude was reached, 11 skydivers jumped out and the pilot returned to the airfield with another passenger on board. On final approach, at an altitude of about 280 metres, the parachute of the passenger mistakenly opened in the cockpit. The passenger was caught outside the cabin and collided with the elevators. The aircraft went out of control and crashed in an open field located 1,500 metres short of runway 07 threshold. The aircraft was totally destroyed and the pilot and the passenger were killed.
Probable cause:
Loss of control on final approach after the parachute of a passenger mistakenly opened in the cockpit and the passenger was caught outside the cabin and collided with the elevators.
Final Report:

Crash of a PZL-Mielec AN-2R in Malye Alabukhi

Date & Time: Apr 6, 2000
Type of aircraft:
Registration:
RA-31486
Flight Type:
Survivors:
Yes
Schedule:
Saransk – Malye Alabukhi
MSN:
1G198-51
YOM:
1982
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft departed Saransk on a positioning flight to Malye Alabukhi, carrying two technicians and two pilots who were dispatched in Malye Alabukhi to proceed to crop spraying missions. After touchdown at Malye Alabukhi Airfield, the aircraft was caught by strong crosswinds. It went out of control, veered off runway to the left and eventually collided with a tree. All four occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Loss of control after landing due to strong crosswinds. The crew failed to prepare the flight properly and failed to obtain appropriate information about weather conditions and wind component for Malye Alabukhi Airfield.

Crash of a Piper PA-60 Aerostar (Ted Smith 602P) near Hahn: 2 killed

Date & Time: Apr 5, 2000 at 1352 LT
Operator:
Registration:
D-ILIA
Flight Type:
Survivors:
No
Schedule:
Aschaffenburg – Hahn
MSN:
62-0917-8165042
YOM:
1981
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6385
Captain / Total hours on type:
844.00
Copilot / Total flying hours:
3082
Copilot / Total hours on type:
4
Aircraft flight hours:
2348
Circumstances:
The twin engine aircraft departed Aschaffenburg Airport on a training flight to Hahn with two pilots on board, one instructor and one pilot under supervision who was completing his type rating qualification. On approach to Hahn Airport runway 03 in marginal weather conditions, at an altitude of 4,350 feet and at a speed of 150 knots, the aircraft entered an uncontrolled descent. The rate of descent was up to 2,800 feet during the last four seconds before the aircraft crashed in an almost vertical position in a wooded area located about 9 km short of runway. The aircraft disintegrated on impact and both occupants were killed. At the time of the accident, weather conditions were as follow: overcast with few clouds at 200 feet, light rain possible on approach, moderate icing conditions possible in clouds, visibility one km and RVR runway 03 1,300 metres.
Probable cause:
Due to the extreme degree of destruction of the aircraft, it was not possible to determine if a possible technical issue was the cause of the accident but this was not ruled out.
Final Report:

Crash of a Learjet 35A in Marianna: 3 killed

Date & Time: Apr 5, 2000 at 0930 LT
Type of aircraft:
Operator:
Registration:
N86BE
Flight Type:
Survivors:
No
Schedule:
Miami - Marianna
MSN:
35-194
YOM:
1978
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
12000
Copilot / Total flying hours:
1776
Copilot / Total hours on type:
343
Aircraft flight hours:
13262
Circumstances:
The pilot canceled the IFR flight plan as the aircraft crossed the VOR and reported the airport in site. The last radio contact with Air Traffic Control was at 0935:16. The crew did not report any problems before or during the accident flight. The distance from the VOR to the airport was 4 nautical miles. Witnesses saw the airplane enter right traffic at a low altitude, for a landing on runway 36, then turn right from base leg to final, less than a 1/2-mile from the approach end of the runway. Witnesses saw the airplane pitch up nose high, and the right wing dropped. The airplane than struck trees west of the runway, struck wires, caught fire, and impacted on a hard surface road. This was a training flight for the left seat pilot to retake a Learjet type rating check ride he had failed on March 24, 2000. He failed the check ride, because while performing an ILS approach in which he was given a simulated engine failure, and he was transitioning from instruments to VFR, he allowed the airspeed to decrease to a point below Vref [landing approach speed]. According to the company's training manual, "...if a crewmember fails to meet any of the qualification requirements because of a lack in flight proficiency, the crewmember must be returned to training status. After additional or retraining, an instructor recommendation is required for reaccomplishing the unsatisfactory qualification requirements." The accident flight was dispatched by the company as a training flight. On the accident flight a company check airman was in the right seat, and the check ride was set up for 0800, April 5,2000. The flight arrived an hour and a half late. The left seat pilot's, and the company's flight records did not indicate any training flights, or any other type of flights, for the pilot from March 24, 2000, the date of the failed check flight, and the accident flight on April 5, 2000. The accident flight was the first flight that the left seat pilot was to receive retraining, and was the only opportunity for him to demonstrate the phase of flight that he was unsuccessful at during the check flight on March 24th. Examination of the
airframe and engine did not reveal any discrepancies.
Probable cause:
The pilot's failure to maintain control of the airplane while on final approach resulting in the airplane striking trees. Factors in this accident were: improper planning of the approach, and not obtaining the proper alignment with the runway.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Manzini: 2 killed

Date & Time: Apr 2, 2000
Registration:
ZS-NGV
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
31-7952071
YOM:
1979
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Following a night takeoff from Manzini-Matsapha Airport, the twin engine aircraft struck power cables and crashed. The captain survived while the copilot and the passenger, a company mechanic, were killed. It was reported that a turbocharger fitted to one of the engines was not compliant. Also, the pilot's licence was forged. Poor engine maintenance was identified.

Crash of a Cessna 421C Golden Eagle III in La Paz: 4 killed

Date & Time: Apr 1, 2000 at 0950 LT
Operator:
Registration:
FAB-014
Flight Type:
Survivors:
No
Schedule:
La Paz - Santa Cruz
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The twin engine aircraft departed La Paz-El Alto Airport on a flight to Santa Cruz, carrying two pilots and two technicians. After takeoff, the crew declared an emergency after the right engine failed during initial climb and was cleared to return. On final, the aircraft crashed 500 metres short of runway, bursting into flames. All four occupants were killed.
Probable cause:
Failure of the right engine during initial climb for unknown reasons.