Crash of a Cessna T207A Skywagon in Bethel

Date & Time: Dec 24, 1999 at 1045 LT
Operator:
Registration:
N1864
Flight Phase:
Survivors:
Yes
Schedule:
Bethel – Chefornak
MSN:
207-0526
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2507
Captain / Total hours on type:
1080.00
Aircraft flight hours:
9809
Circumstances:
The certificated commercial pilot, with five passengers aboard, was departing runway 18 on a scheduled commuter flight. The pilot stated that the flight's original departure time was delayed for two hours due to ice fog, and low visibility. He said that just after takeoff, the engine surged followed by a loss of power. The airplane collided with snow-covered terrain during an off-airport emergency landing, and sustained substantial damage to the propeller, fuselage, and wings. Following retrieval of the airplane, an FAA airworthiness inspector examined the airplane, and found no mechanical anomalies. While still attached to the airplane, the engine was started and run at idle. The engine later produced full power on an engine test stand. A pilot-rated Alaska State Trooper, with extensive experience in the accident airplane make and model, examined the airplane soon after the accident. He said the wings, horizontal stabilizer, and elevators had an accumulation of frost.
Probable cause:
The pilot's failure to remove frost from the airplane prior to flight, and an inadvertent stall/mush.
Final Report:

Crash of a Boeing 747-2B5F in Stansted: 4 killed

Date & Time: Dec 22, 1999 at 1839 LT
Type of aircraft:
Operator:
Registration:
HL7451
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Stansted - Milan - Seoul
MSN:
22480
YOM:
1980
Flight number:
KE8509
Location:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
13490
Captain / Total hours on type:
8495.00
Copilot / Total flying hours:
1406
Copilot / Total hours on type:
195
Aircraft flight hours:
83011
Aircraft flight cycles:
15451
Circumstances:
Boeing 747 HL-7451 arrived at Stansted at 15:05 after a flight from Tashkent. Prior to leaving the aircraft, the flight engineer made an entry in the Technical Log stating "Captain's ADI [Attitude Director Indicator] unreliable in roll' he also verbally passed the details to the operator's ground engineer who met the aircraft on arrival. During turnover repair works on the ADI were carried out. Some cargo was offloaded and other cargo loaded for the flight to Milan-Malpensa (takeoff weight was 548,352 lb including 68,300 lb of fuel) and a new crew boarded the aircraft. After a delay of an hour, because ATC had not received the flight plan, Flight 8509 was cleared to depart Stand Alpha 6 and taxi to runway 23 holding point at 18:25. Subsequently, at 18:36 KAL 8509 was cleared to takeoff with a reported surface wind of 190deg/18 kt. The Dover 6R Standard Instrument Departure called for a climb ahead to 1.5 miles DME, then a left turn onto the 158 inbound radial to the Detling VOR. Climbing through 900 feet, the ADI 'Comparator' buzzer sounded three times. Shortly afterwards, the warning sounded a further two times, coincident with the captain expressing concerns over his DME indication. Climbing through 1400 feet, ATC instructed the crew to contact 'London Control'. And as the captain initiated the procedure turn to the left, the 'Comparator' warning sounded again some 9 times. The maximum altitude reached was 2,532 feet amsl. The aircraft then banked left progressively and entered a descent until it struck the ground in a approx. 40deg nose down pitch and 90deg bank to the left; the speed was high in the region of 250 to 300 kt.
Probable cause:
The following causal factors were identified:
- The pilots did not respond appropriately to the comparator warnings during the climb after takeoff from Stansted despite prompts from the flight engineer,
- The commander, as the handling pilot, maintained a left roll control input, rolling the aircraft to approximately 90° of left bank and there was no control input to correct the pitch attitude throughout the turn,
- The first officer either did not monitor the aircraft attitude during the climbing turn or, having done so, did not alert the commander to the extreme unsafe attitude that developed,
- The maintenance activity at Stansted was misdirected, despite the fault having been correctly reported using the Fault Reporting Manual. Consequently the aircraft was presented for service with the same fault experienced on the previous sector; the No 1 INU roll signal driving the captain's ADI was erroneous,
- The agreement for local engineering support of the Operator's engineering personnel, was unclear on the division of responsibility, resulting in erroneous defect identification, and misdirected maintenance action.
Final Report:

Crash of a Cessna 414 Chancellor in Monterrey: 2 killed

Date & Time: Dec 22, 1999 at 1830 LT
Type of aircraft:
Operator:
Registration:
XB-EXF
Flight Type:
Survivors:
No
Schedule:
San Antonio - Monterrey
MSN:
414-0827
YOM:
1975
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Following an uneventful flight from San Antonio, the pilot started a night approach to Monterrey-Del Norte. On final in good weather conditions, the twin engine aircraft crashed in unknown circumstances few km from the airfield. Both occupants were killed.

Crash of a Rockwell Aero Commander 500 in Georgetown: 2 killed

Date & Time: Dec 22, 1999 at 1525 LT
Registration:
N6261B
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Georgetown - Orlando
MSN:
500-0688-34
YOM:
1958
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
564
Captain / Total hours on type:
69.00
Aircraft flight hours:
3783
Circumstances:
The non instrument-rated pilot attempted VFR flight into known instrument flight conditions after being briefed by an FAA Automated Flight Service Station that VFR flight was not recommended. The pilot encountered instrument flight conditions while maneuvering on initial takeoff climb, experienced an in-flight loss of control (stall/spin) due to failure to maintain airspeed, and subsequent in-flight collision with trees and terrain.
Probable cause:
The non instrument-rated pilot's improper decision to attempt VFR flight into known instrument flight conditions, willful disregard of FAA Automated Flight Service Station weather forecast/weather observations, failure to maintain airspeed (VSO) while maneuvering on initial takeoff climb, resulting in an in-flight loss of control (inadvertent stall/spin), and subsequent in-flight collision with trees and terrain.
Final Report:

Crash of a Cessna 551 Citation II/SP in Cordele: 1 killed

Date & Time: Dec 21, 1999 at 2130 LT
Type of aircraft:
Registration:
N1218S
Flight Type:
Survivors:
No
Schedule:
Dallas - Cordele
MSN:
551-0428
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4229
Captain / Total hours on type:
1108.00
Aircraft flight hours:
3741
Circumstances:
The Cessna 551, collided with trees and subsequently the ground following a missed approach to runway 10, at the Crisp County Airport in Cordele, Georgia. According to the Jacksonville Air Traffic Control Center, the pilot was given radar vectors to the outer marker and cleared him for the non-precision localizer approach to runway 10. Recorded radar data showed the airplane initiating the approach at 1900 feet mean sea level (MSL) as published. The airplane descended to 600 feet MSL as published and over-flew the airport. The controller stated that he was waiting for the missed approach call, as he observed the airplane climb to 700 feet MSL. The airplane then descended back to 600 feet MSL and disappeared from radar. The controller never received a missed approach call. A witness near the airport stated that he heard the airplane fly over but did not see it due to haze and fog.
Probable cause:
The pilot's failure to follow the published missed approach procedures, and to maintain proper altitude. Factors contributing to the severity of the accident were the low ceilings and trees.
Final Report:

Crash of a Douglas DC-10-30 in Guatemala City: 18 killed

Date & Time: Dec 21, 1999 at 0940 LT
Type of aircraft:
Operator:
Registration:
F-GTDI
Survivors:
Yes
Schedule:
Havana - Guatemala City
MSN:
46890
YOM:
1973
Flight number:
CU1216
Country:
Crew on board:
18
Crew fatalities:
Pax on board:
296
Pax fatalities:
Other fatalities:
Total fatalities:
18
Captain / Total flying hours:
16117
Captain / Total hours on type:
4872.00
Copilot / Total flying hours:
8115
Copilot / Total hours on type:
4156
Aircraft flight hours:
85760
Aircraft flight cycles:
27331
Circumstances:
Leased from AOM French Airlines, the aircraft was completing a charter flight (service CU1216) from Havana to Guatemala City on behalf of Cubana de Aviacion, carrying 18 crew members and 296 passengers who were mostly young Guatemalan citizens studying medicine in Cuba. After touchdown on runway 19, the crew started the braking procedure but the aircraft was unable to stop within the remaining distance. It overran, went down an embankment and eventually crashed onto several houses located in the district of La Libertad. Both pilots, six other crew members, eight passengers and two people on the ground were killed. Also, 57 people were injured (among them 20 on the ground) while 261 other occupants escaped uninjured. The aircraft was destroyed.
Probable cause:
Wrong approach configuration on part of the crew who landed too far down the runway with an excessive speed, between 1,220 and 1,320 metres past the runway threshold. Runway 29 is 2,767 metres long and it was calculated that the landing distance available was reduced by 1,450 to 1,500 metres. The following contributing factors were identified:
- The crew failed to initiate a go-around procedure while the landing procedure was obviously missed,
- An indicated airspeed (IAS) of the aircraft greater than the specified one, with an increase due to elevation and temperature,
- The initial gradient of the track that requires a vertical speed descent, during leveling, May than usual,
- The flotation of the aircraft during the leveling phase (flare), facilitated by the use of the “CWS” mode of the autopilot (procedure approved by the aircraft flight manual), without corrective action by the Commander,
- A probable tailwind component over which there was no exact information provided by the control tower and that was not monitored by the crew, as it was not in their procedures nor did he feel the need to,
- The failure of the crew to immediately start the braking procedure after touchdown, probably caused by a false visual impression of the crew which was facilitated by their lack of prior experience for the approach and landing on runway 19 at the Aurora Airport with this type of aircraft,
- The runway surface condition,
- A tailwind component.
Final Report:

Crash of a Beechcraft King Air 90 in Beaufort: 1 killed

Date & Time: Dec 19, 1999 at 2035 LT
Type of aircraft:
Operator:
Registration:
N75CF
Flight Type:
Survivors:
Yes
Schedule:
Hilton Head - Beaufort
MSN:
LW-212
YOM:
1977
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
21250
Aircraft flight hours:
10316
Circumstances:
The PIC was cleared for an ASR approach to the destination airport. The co-pilot was looking outside to obtain a visual reference on the destination airport. They broke out of the clouds at about 900 feet, and were descending at about 480 feet per minute. The ceiling was overcast, ragged, and very dark with no visible horizon. The co-pilot looked back inside the cockpit to check the radios when he heard a thump. The PIC had continued the descent below the minimum descent altitude, the airplane collided with the marsh and crashed.
Probable cause:
The pilot-in-commands failure to maintain the appropriate altitude (minimum descent altitude) during an area surveillance radar (ASR) approach, resulting in an in-flight collision with swampy terrain. Contributing to the accident was the co-pilot's failure to maintain a visual lookout during the ASR approach.
Final Report:

Crash of a Piper PA-31T Cheyenne I in Santa Fe

Date & Time: Dec 16, 1999 at 1515 LT
Type of aircraft:
Registration:
N919RD
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Santa Fe - Olathe
MSN:
31-8104037
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1098
Captain / Total hours on type:
401.00
Aircraft flight hours:
3558
Circumstances:
On takeoff during the initiation of a cross-country flight, the pilot raised the landing gear following liftoff and the aircraft settled back onto the ground off the end of the runway. According to the pilot and the FAA inspector who examined the aircraft, both engines were producing normal power. The elevator trim was set at 12 degrees nose up vice 3-6 degrees required, and the aircraft was within weight and balance limits. The pilot lowered the landing gear prior to impact. According to information provided by the aircraft manufacturer, induced drag increases during landing gear retraction and extension due to the landing gear doors being extended into the air stream as the landing gear cycles.
Probable cause:
The pilot initiating lift off at an airspeed insufficient to maintain flight and retracting the landing gear prematurely resulting in a stall mush. A factor was the pilot incorrectly setting the elevator trim.
Final Report:

Crash of a Beechcraft 200 Super King Air in Apache-Hamburg

Date & Time: Dec 15, 1999 at 1615 LT
Operator:
Registration:
C-GKBN
Survivors:
Yes
MSN:
BB-29
YOM:
1975
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew of C-GKBN, a Beechcraft 200 Super King Air with 5 passengers, made a straight-in approach, with approach flap settings, to a snow-covered and icy runway at Hamburg, AB, Canada. Upon touchdown in 2 inches of snow, directional control was lost. The aircraft turned sideways on the strip, struck a snow windrow, which then pulled the aircraft off the strip into a stand of trees. The First Officer had made the landing. The aircraft had picked up about 1/8 inch of ICA on the approach. Approach flap had been used for the landing instead of landing flap. The aircraft had landed with a five knot tail wind. The landing touchdown was reported to be very firm. There were no injuries but the aircraft was substantially damaged. Company representatives examining the runway surface after the accident discovered a rut running diagonally across the runway, which was apparently present prior the landing and may have contributed to the loss of directional control of the aircraft.

Crash of a Cessna 402C in Chankonde

Date & Time: Dec 13, 1999 at 1538 LT
Type of aircraft:
Operator:
Registration:
5H-GTO
Flight Phase:
Survivors:
Yes
Schedule:
Zanzibar – Chankonde – Dar es-Salaam
MSN:
402C-0213
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2667
Captain / Total hours on type:
227.00
Circumstances:
On 13 December 1999 at 1029 5H-GTO took off from Zanzibar airport for a direct VFR flight to Chankonde. The endurance was six hours and the pilot was the only occupant. The aircraft was destined to pick a party of five hunters at Chankonde hunting airstrip for a flight to Dar es Salaam. The forward leg of the flight was uneventful and the pilot reported to Dar Control at 1153 hours that he has Chankonde in site and was estimating to land at 1215 hours. The aircraft did in fact land at 1216 hours. The pilot reported that shortly before he landed at Chankonde he circled around the airstrip and noticed that there were some pools of water on the runway. Five passengers boarded the aircraft at Chankonde for a flight to Dar es Salaam. The pilot said that all the heavy baggage and two members of the hunting party left by road for Dar es Salaam. The remaining five who boarded the aircraft carried only hand luggage. In the preparation for take-off the pilot taxied to the threshold of runway 07, made the "first selection" of flaps and applied full power on brakes. He testified that he did not lean the mixtures since he saw no requirement for this. The initial phase of the take-off rolI appeared' normal to the pilot. When the aircraft 'had' covered about 600 metres and was accelerating through 65/70 kt it went through a muddy ditch causing the pilot to feeI deceleration. It immediately became apparent that he was not going to achieve the take off speed and clear the trees in the foreground. The pilot subsequently decided to abort the take-off. When the engines were throttled back and brakes were applied the aircraft continued to rolI on wet and slippery sandy surface till it overran the end of runway 07 and collided with trees located about 60 metres beyond the end of the runway. As the aircraft impacted the trees in the accident sequence, both wing sections outboard of the engines separated and caught fire. The aircraft came to rest about 56 metres forward of the detached wing sections. The grass beneath the aircraft and the right engine were also on fire. The pilot was unable to open the cockpit door because it was blocked by a tree. He subsequently rushed behind and opened the main door. As he did so, one passenger, "who was tall and muscular" pushed the pilot causing him to falI by the doorway on the ground where grass surface was on fire. All the five passengers stepped on the pilot and escaped. The pilot managed to rise an his own, returned to the cabin and picked the fire extinguisher. He subsequently fought the fire under the fuselage, the tail and the right engine. He was also joined by a vehicle which had 20 litres of water and this was used to put out the fire on the left hand side of the fuselage. The passenger who was in the copilot seat sustained a cut on his eyebrow and another passenger suffered minor burns on his fingers. The pilot whom the passengers used as a stepping stone and a fire blanket sustained first degree burns to his face and both arms. Both wings and parts of the tail plane were torn off the fuselage by impact with the trees. They were also partly destroyed by fire. The fuselage suffered relatively less "damage and the cabin remained intact. However, much of the interior equipment was destroyed by unknown persons a few days after the accident when the wreckage was left unguarded. The weather at the time of the accident was reported to be sunny with no wind. The ground was wet from rains which had been falling in the area. Chankonde Airstrip, elevation 3,386 feet, has one runway 07/25 which is 1,000 metres long and 30 metres wide. The surface is sand with some patches of scattered grass. There are tall trees starting 60 metres beyond the end of runway 07.
Final Report: