Crash of a Cessna 421C Golden Eagle III in Heringsdorf

Date & Time: Jan 16, 2000 at 1145 LT
Registration:
D-ILMS
Flight Type:
Survivors:
Yes
Schedule:
Hamburg - Heringsdorf
MSN:
421C-0891
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Heringsdorf Airport in poor weather conditions, the twin engine aircraft collided with trees and crashed in a wooded area located 750 metres short of runway 28, bursting into flames. The pilot, sole on board, was seriously injured and the aircraft was destroyed by impact forces and a post crash fire. At the time of the accident, the visibility was about 400 metres with a ceiling at 100 feet, below minimums.

Crash of a Lockheed C-130B Hercules in Chimore: 5 killed

Date & Time: Jan 14, 2000 at 1216 LT
Type of aircraft:
Operator:
Registration:
TAM-60
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Chimore - Trinidad
MSN:
3559
YOM:
1960
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
24
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
During the takeoff roll on runway 35 at Chimore Airport, about 600 meters from the end, the airplane went out of control, veered off runway to the left, impacted a drainage ditch (3 metres deep) and crashed in a wooded area. Five occupants were killed while 26 other occupants were injured. The aircraft was destroyed.

Crash of a Beechcraft D18S in Everett

Date & Time: Jan 10, 2000 at 2024 LT
Type of aircraft:
Operator:
Registration:
N1827M
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Everett - Burlington
MSN:
A-394
YOM:
1947
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5900
Captain / Total hours on type:
404.00
Aircraft flight hours:
10429
Circumstances:
The pilot reported that the start, taxi and run-up were normal. The engines were producing full power for the takeoff ground roll. The pilot stated that the airplane lifted off and attained an altitude of approximately five feet when it began to bank and roll to the left. The pilot applied corrective action, however, the airplane would not respond. The pilot elected to abort the take off and reduced engine power. The airplane touched down in the soft dirt/grass next to the runway. The main landing gear collapsed and the airplane slid to a stop. The pilot reported that there was no indication of a mechanical failure or malfunction with the engines. An FAA inspector verified flight control continuity with no abnormalities noted.
Probable cause:
Loss of aircraft control during initial climb for undetermined reasons.
Final Report:

Crash of a Saab 340B in Nassenwil: 10 killed

Date & Time: Jan 10, 2000 at 1756 LT
Type of aircraft:
Operator:
Registration:
HB-AKK
Flight Phase:
Survivors:
No
Schedule:
Zurich - Dresden
MSN:
213
YOM:
1990
Flight number:
LX498
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
8452
Captain / Total hours on type:
1870.00
Copilot / Total flying hours:
2332
Copilot / Total hours on type:
1162
Aircraft flight hours:
21676
Aircraft flight cycles:
20589
Circumstances:
Aircraft HB-AKK had landed in Zurich on 10 January 2000 as Crossair flight CRX 842 from Guernsey and reached stand F74 at 16:00 UTC, which is located near to the threshold of runway 28. The aircraft was then prepared for the next flight at this stand. According to statements from the Swissport ground personnel the preparation of the aircraft took place without any special occurrence. During its time on the ground, the aircraft was supplied with electric power by a ground power unit (GPU). An air-conditioning truck was not used and the aircraft was not de-iced. The crew prepared for the flight using the computer-aided briefing system. The following description of the history of the flight was reconstructed with the help of recordings from the cockpit voice recorder (CVR), digital flight data recorder (DFDR), voice radio communications and ATC radar (cf. Annex 1). According to the available recordings, the commander, as planned by the crew, was pilot flying (PF) and the first officer was pilot non flying (PNF) throughout the flight. At 16:39:14 UTC, flight CRX 498 to Dresden received from clearance delivery (DEL) the following ATC-clearance: "runway two eight, Dresden, Zurich East One Yankee Departure, squawk three zero zero four". The crew was then instructed to change to the apron (APR) frequency. Permission to start engines was given at 16:45:00 UTC by APR. At 16:49:22 UTC the first officer signaled readiness to taxi to APR. While the crew waited for taxi clearance, a few points of the taxi checklist were performed. At 16:50:30 UTC APR cleared flight CRX 498 to follow a Swissair Airbus A320 (SWR 014) to the holding position of runway 28. In accordance with this clearance, CRX 498 started to move. The flight crew performed the outstanding items on the taxi checklist and contacted the tower (TWR), which gave line-up clearance at 16:52:36 UTC. Take-off clearance was given at 16:54:00 UTC: "Crossair four nine eight, wind three zero zero degrees, three knots, cleared take-off runway two eight". According to the automatic terminal information service (ATIS) at 16:50 UTC the following meteorological conditions existed: wind 290° at 2 knots, visibility 6 km in drizzle, broken, cloud base at 500 feet above ground level, temperature 2 °C, dew point 1 °C, QNH 1032 hPa. The aircraft began its take-off roll at 16:54:10 UTC in darkness. The landing lights were on and the flaps were fully retracted. After take-off at 16:54:31 UTC the landing gear was retracted. Then, on the commander's order, the flight director (FD) was switched on and the NAV mode was armed. Both pilots confirmed that the long range navigation system number 1 (LRN 1) was following the track (LRN 1 captured). The commander controlled the aircraft in a stable climb with a pitch of 15° attitude nose up (ANU) and a speed of 136 knots indicated airspeed (KIAS). For the remaining flight, the autopilot was never engaged. Since the cloud base was indicated as 500 ft above ground level (AGL), it can be assumed that the aircraft, once above an altitude of approx. 1900 ft above mean sea level (AMSL) entered instrument meteorological conditions (IMC). The initial flight path, at a heading of 276°, followed the centre line of the runway. After the request from TWR, CRX 498 switched to the departure control frequency (DEP) at 16:55:07 UTC. The radar recording then showed a deviation in the flight path by 5° to the south. However, this slight deviation was reduced before waypoint DME 2.1 KLO was reached by initiating a right turn. At 16:55:15 UTC flight CRX 498 was cleared to climb to flight level 110. At 16:55:39 UTC, Zurich departure issued the instruction to turn to VOR ZUE: "four nine eight, turn left to Zurich East". The first officer confirmed by radio: "turning left to Zurich East, Crossair four niner eight". At the same time the aircraft reached waypoint DME 2.1 KLO. At this point the departure procedure ZUE1Y specifies a left turn, in order to capture and follow radial 255 of VOR KLO. At 16:55:45 the bank angle to the left reached a maximum of 16.9° on a compass heading of 270°. At 16:55:47 UTC the first officer informed the commander that the LRN system was programmed from the present position to ZUE: "from present, LRN is to Zurich East, yeah". The commander confirmed with: "checked". The left turn instruction from DEP was not mentioned. After the aircraft had remained briefly at a 16° bank angle to the left, it began to roll to the right. From 16:55:47 UTC the bank angle rate amounted to 3°/s to the right. In this phase the first officer was very busy carrying out the orders routinely issued by the commander ("CTOT/APR off, yaw damper on, bleed air on"). All relevant flight parameters in this phase indicated a stable climb with a pitch of 13-14° ANU. The communication being conducted internally did not give any indication of difficulties of any kind. At 16:55:55 UTC, at a bank angle of 8.4° to the right, the bank angle rate increased and the nose of the aircraft began to drop from 14.2° to 10.8° ANU. At 16:56:00 UTC the right bank angle attained a value of 31.0°, when the commander gave the order to set climb power: "set climb power". The first officer confirmed with a whispered "coming" and began to set the climb power – a procedure which takes quite some time. Between 16:56:03 UTC and 16:56:10 UTC the commander stabilized the bank angle to the right between 39° and 42° by corresponding flight control inputs. The pitch reduced further and stabilized at a value of 1° ANU at 16:56:06 UTC as a result of corresponding elevator inputs for four seconds. As a consequence, the trajectory reached its maximum altitude of 4720 ft AMSL. According to information from the crew of the preceding flight SWR 014 the cloud top at that time was approx. 5000 ft AMSL. The speed of the aircraft involved in the accident increased to 158 KIAS. 16:56:10 UTC marked the beginning of a nine-second period which was characterized by destabilization of the attitude. It featured uncoordinated deflections of the ailerons to the left and right. Meanwhile, the elevator remained practically in the neutral position. Since the rightward deflections of the aileron were dominant, the bank angle increased from 42° to 80° to the right. Given the neutral position of the elevator, because of the high bank angle the pitch increased to 25° attitude nose down (AND). The aircraft therefore quickly lost altitude and its speed increased to 207 KIAS. At 16:56:12 UTC the first officer made the commander aware that they should turn left to ZUE: "turning left to Zurich East, we should left". At 16:56:15 UTC, at a bank angle of 65.8° to the right, the commander muttered unclearly: "ohna-na". Three seconds later at 16:56:18 UTC, DEP requested confirmation that the aircraft was turning to the left: "Crossair four nine eight, confirm you are turning left". The first officer responded immediately: "moment please, standby". DEP then instructed the crew to continue the right turn: "ok, continue right to Zurich East." In the final phase of flight, beginning at 16:56:20 UTC, the aircraft went into a spiral dive. As a result of massive aileron deflections, the aircraft attained a maximum bank angle of 137° to the right. The engines still provided high power, since setting of climb power had not yet been terminated. At a speed of 250 KIAS the over speed warning horn sounded. At 16:56:24 UTC the first officer vigorously warned the commander to turn left: "turning left, left, left, left... left!" At the end of the data recording at 16:56:25 UTC the aircraft still exhibited a bank angle of 76° to the right. The nose of the aircraft had dropped to 63° AND at an air speed of 285 KIAS. Several witnesses observed the aircraft breaking out of the clouds in a steep descent and performing a right turn. At 16:56:27.2 UTC the aircraft crashed in an open field near Au, Nassenwil, ZH. None of the three crew members and seven passengers survived the impact.
Probable cause:
The accident is attributable to a collision with the ground, after the flight crew had lost control of the aircraft for the following reasons:
• The flight crew reacted inappropriately to the change in departure clearance SID ZUE 1Y by ATC.
• The co-pilot made an entry in the FMS, without being instructed to do so by the commander, which related to the change to the SID ZUE 1 standard instrument departure. In doing so, he omitted to select a turn direction.
• The commander dispensed with use of the autopilot under instrument flight conditions and during the work-intensive climb phase of the flight.
• The commander took the aircraft into a spiral dive to the right because, with a probability bordering on certainty, he had lost spatial orientation.
• The first officer took only inadequate measures to prevent or recover from the spiral dive.
The following factors may have contributed to the accident:
• The commander remained unilaterally firm in perceptions which suggested a left turn direction to him.
• When interpreting the attitude display instruments under stress, the commander resorted to a reaction pattern (heuristics) which he had learned earlier.
• The commander’s capacity for analysis and critical assessment of the situation were possibly limited as a result of the effects of medication.
• After the change to standard instrument departure SID ZUE 1Y the crew set inappropriate priorities for their tasks and their concentration remained one-sided.
• The commander was not systematically acquainted by Crossair with the specific features of western systems and cockpit procedures.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Coatesville: 2 killed

Date & Time: Jan 10, 2000 at 0519 LT
Registration:
N905DK
Flight Type:
Survivors:
No
Schedule:
Millville – Coatesville
MSN:
61-0308-081
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
350
Circumstances:
While operating in IMC, the pilot was vectored to the final approach course for an ILS approach. Weather at the airport was ceiling 200 feet and visibility 3/4 mile in mist. The pilot was cleared for the approach, which he acknowledged. No other transmissions were received from the accident airplane. Radar data showed the airplane intercept the final approach course, then track inbound. The airplane crossed the outer marker 420 feet below the glide slope. The last radar return showed the airplane at 440 feet agl, 3.9 miles from the runway. The airplane impacted the ground at a shallow angle about 1 mile north of the airport on the opposite side of the missed approach procedure. The elevation of the accident site was approximately 40 feet lower than the airport. The pilot had about 350 hours of total flight
experience. No pre-impact failures were identified with the airframe, engines, flight controls, or flight instruments.
Probable cause:
The pilot's failure to follow the published instrument approach procedure, and his failure to establish a climb after passing the missed approach point.
Final Report:

Crash of an Embraer EMB-110P1A Bandeirante in Abuja: 2 killed

Date & Time: Jan 5, 2000 at 1325 LT
Operator:
Registration:
5N-AXL
Survivors:
Yes
Schedule:
Lagos - Abuja - Ilorin
MSN:
110-455
YOM:
1984
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
On final approach to Abuja-Nnamdi Azikiwe Airport runway 22, the crew declared an emergency and reported smoke in the cockpit and cabin. Shortly later, the aircraft stalled and crashed 120 metres short of runway. A passenger and one people on the ground were killed while 12 other occupants were injured.

Crash of a Beechcraft 99A Airliner in Saint-Barthélemy

Date & Time: Dec 31, 1999 at 1055 LT
Type of aircraft:
Registration:
N491BB
Survivors:
Yes
Schedule:
Christiansted - Saint-Barthélemy
MSN:
U-97
YOM:
1969
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On December 31, 1999, at about 1055 Atlantic standard time, a Beech 99A, N491BB, registered to Alberta Aircraft Leasing Inc., operated by Bohlke International Airways, as a 14 CFR Part 135 on-demand air taxi, experienced a collapse of the main landing gear on landing at St. Barthelemy, (TFFJ) French Antilles. Visual meteorological conditions prevailed and no flight plan was filed. The airplane sustained substantial damage. The airline transport-rated pilot, copilot, and seven passengers reported no injuries. The flight originated from St. Croix, (STX) Virgin Islands, about 55 minutes before the accident. The accident was initially reported to the NTSB on January 5, 2000, by the FBI. The pilot stated they departed STX at about 1000. They had to make a 360-degree turn upon arrival at TFFJ due to other arriving traffic. They completed the descent arrival checklist and turned an 8- mile final. At a 1 1/2-mile final the flaps were lowered to the full down position, the propellers were set at 2,000 rpm, airspeed 95 knots, and all three landing gear lights were illuminated. On touchdown the airplane yawed to the left. Right rudder and aileron was applied with negative results. Power was increased and the airplane continued to yaw to the left. The airplane went off the left side of the runway and ground looped, separating the right main landing gear. The airplane came to a complete stop on its fuselage with the nose gear extended. They returned to the airplane on January 3, 2000. The airplane was lifted with a forklift and the left main landing gear was observed in the retracted position. A commuter pilot informed them that he observed the landing on the day of the accident. He stated he observed the left main landing gear moving forward and backwards.

Crash of a Cessna 208A Caravan 675 in Abbotsford

Date & Time: Dec 28, 1999 at 0917 LT
Type of aircraft:
Operator:
Registration:
C-FGGG
Flight Phase:
Survivors:
Yes
Schedule:
Abbotsford - Billings - Nassau
MSN:
208-0310
YOM:
1999
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
85.00
Circumstances:
At 0916 Pacific standard time, the Seair Cessna 208 Caravan amphibious aircraft, serial number 20800310, took off from runway 19 at Abbotsford Airport, British Columbia, on the first leg of a private flight to the Bahamas. One pilot and five passengers were on board. About one minute later, as the aircraft was climbing through an altitude of about 400 feet above ground level and as the pilot retracted flaps from 10 to zero degrees, the aircraft became uncontrollable. The aircraft banked left, descended rapidly, and crashed in a field about one-half mile south of the runway threshold, in a left bank with a near-level pitch attitude. The aircraft was destroyed, and the pilot received serious injuries. Two passengers were also seriously injured, and three passengers received minor injuries. Daylight visual meteorological conditions prevailed at the time of the accident. There was no fire.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot took off with frost adhering to the aircraft's lifting surfaces, which increased drag and reduced the ability of the wings to produce lift.
2. At take-off, the aircraft was about 510 pounds in excess of its maximum take-off weight, adversely affecting aircraft performance.
3. The aircraft experienced an aerodynamic stall and loss of control when the flaps were retracted from 10 degrees to zero. Retracting the flaps reduced the amount of lift being produced by the wing, already performing poorly because of contamination.
Other Findings:
1. Appropriate entries were not recorded in the aircraft=s journey and maintenance logs, and the weight and balance documentation was not amended.
2. The floats absorbed much of the impact energy and likely enhanced survivability of the accident.
Final Report:

Crash of a Lockheed L-382G Hercules in Luzamba

Date & Time: Dec 28, 1999 at 0545 LT
Type of aircraft:
Operator:
Registration:
S9-BOP
Flight Type:
Survivors:
Yes
MSN:
4477
YOM:
1972
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following a night visual approach to Luzamba Airport, the crew landed the aircraft in the first metres of the runway. For unknown reasons, the aircraft lifted off and floated few cm above the runway surface for few seconds before landing a second time. Unable to stop within the remaining distance (the gravel runway is 1,500 metres long), the aircraft overran, went down an embankment and came to rest 16 metres further. All four crew members escaped uninjured while the aircraft was damaged beyond repair.

Ground fire of an IAI-1124A Westwind II in Milwaukee

Date & Time: Dec 26, 1999 at 0715 LT
Type of aircraft:
Registration:
N422BC
Flight Phase:
Survivors:
Yes
Schedule:
Milwaukee - Waukesha
MSN:
302
YOM:
1980
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14363
Captain / Total hours on type:
2024.00
Aircraft flight hours:
7975
Circumstances:
During the activation of the crew oxygen system a fire erupted which consumed the entire pressure vessel. Representatives from the National Aeronautics and Space Administration's (NASA) Johnson Space Center (JSC), White Sands Testing Facility (WSTF), Las Cruces, New Mexico, examined the retained oxygen system components. Examination of these components revealed that the fire's initiation location was the first stage pressure reducer located in the oxygen regulator assembly.
Probable cause:
The failure of the first stage pressure reducer in the oxygen regulator assembly.
Final Report: