Crash of an Embraer EMB-110 Bandeirante in Monte Dourado: 2 killed

Date & Time: Sep 14, 1999 at 2130 LT
Operator:
Registration:
PT-ODK
Flight Type:
Survivors:
No
Schedule:
Belém - Monte Dourado
MSN:
110-002
YOM:
1969
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
10000
Captain / Total hours on type:
1200.00
Copilot / Total flying hours:
1600
Copilot / Total hours on type:
1200
Circumstances:
The twin engine aircraft departed Belém-Val de Cans Airport on a cargo flight to Monte Dourado with two pilots on board and a load of 1,636 kilos of limestone grit divided into 36 bags of 45.45 kilos each. After a flight of 1 hour and 18 minutes, the crew was cleared to descend by night to Monte Dourado Airport. On final approach, the crew was able to send a brief message saying the aircraft was crashing. The aircraft was destroyed on impact and both pilots were killed.
Probable cause:
The following findings were identified:
- The total weight of the aircraft upon departure from Belém Airport was 650 kilos above MTOW,
- The cargo was not stowed in the cabin but simply stored on the floor,
- The left engine was not providing power at impact and the aircraft entered a left turn and then an uncontrolled descent until impact with the ground,
- Failure of the left engine due to the presence of an aluminum part obstructing the fuel pipe. Metallographic analyzes confirmed that this aluminum part likely came from a thread of the fuel pump,
- Complacency of the crew who failed to follow the published procedures of the operator.
Final Report:

Crash of a Piper PA-31-310 Navajo C in San Andros

Date & Time: Sep 9, 1999 at 1915 LT
Type of aircraft:
Operator:
Registration:
N6579L
Flight Type:
Survivors:
Yes
Schedule:
Nassau – San Andros
MSN:
31-504
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On September 9, 1999, about 1915 eastern daylight time, a Piper PA-31-310, N6579L, registered to Webs Planes, Inc., operating as a 14 CFR Part 91 personal flight, crashed about 50 yards east of San Andros Airport, Andros Island, Bahamas, following an inflight explosion and cockpit fire. Visual meteorological conditions prevailed, and a VFR flight plan was filed. The airplane was destroyed by ground fire and the commercially-rated pilot and six passengers were not injured. The flight originated from Nassau, New Providence, about 1910. According to the pilot, at about 15 miles from his destination, San Andros, he heard a loud explosion from under the floor, and then experienced fire in the cockpit. Attempts at extinguishing the fire were negative and he began to lose engine power. He tried to make the runway at San Andros, but impacted mangrove growth east of the airport, instead. He stated he thought the problem may have been a short circuit in electrical wiring under the airplane's floorboards.

Crash of a Douglas DC-9-31 in Nashville

Date & Time: Sep 9, 1999 at 1138 LT
Type of aircraft:
Operator:
Registration:
N993Z
Survivors:
Yes
Schedule:
Saint Louis - Nashville
MSN:
47082
YOM:
1967
Flight number:
TW600
Crew on board:
5
Crew fatalities:
Pax on board:
41
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13332
Captain / Total hours on type:
5022.00
Aircraft flight hours:
77374
Aircraft flight cycles:
34177
Circumstances:
The first officer failed to maintain the proper rate of descent (sink rate) resulting in a hard landing on touch down, and separation of the left main landing gear during landing rollout. The pilot-in-command stated he knew the first officer was not going to make a good landing. He did not take any corrective action other than informing the first officer initially to increase power. Examination of the left main landing gear assembly revealed a preexisting crack in the outer cylinder housing.
Probable cause:
A preexisting crack on the left main landing gear outer cylinder housing and the first officer's failure to maintain the proper rate of descent resulting in a hard landing on touchdown, and subsequent total failure and separation of the left main landing gear on landing rollout. Contributing to the accident was the pilot-in-commands improper supervision of the first officer during the approach phase of the landing.
Final Report:

Crash of a Beechcraft 200 Super King Air in Caen

Date & Time: Sep 9, 1999
Operator:
Registration:
F-GIAL
Survivors:
Yes
MSN:
BB-844
YOM:
1981
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Caen-Carpiquet Airport in poor weather conditions, the captain decided to initiate a go-around procedure. He increased engine power and asked the copilot to position the flaps in the appropriate angle. By mistake, the copilot raised the flaps. Due to a loss of lift, the aircraft stalled and struck the runway surface. On impact, the undercarriage were torn off and the aircraft slid for few dozen metres before coming to rest. All three occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Inadvertent retraction of the flaps while initiating a go-around procedure. Poor crew coordination.

Crash of a De Havilland Dash-7-102 in Port Harcourt

Date & Time: Sep 7, 1999
Operator:
Registration:
5N-EMP
Survivors:
Yes
MSN:
49
YOM:
1981
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
For unknown reasons, the four engine aircraft belly landed at Port Harcourt Airport and was damaged beyond repair. All 15 occupants escaped uninjured while the aircraft was damaged beyond repair. It is unknown if the mishap was the consequence of a technical issue or crew error.

Crash of a Cessna 208B Grand Caravan in Lerwick

Date & Time: Sep 6, 1999 at 1034 LT
Type of aircraft:
Registration:
LN-PBB
Flight Type:
Survivors:
Yes
Schedule:
Kirkwall - Lerwick
MSN:
208B-0302
YOM:
1992
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1780
Captain / Total hours on type:
500.00
Circumstances:
The operating company were involved in a Royal Mail contract to deliver mail from Aberdeen to Shetland Islands each day. The crew involved in the accident had flown LN-PBB from Stauning Airport in Denmark to Aberdeen in preparation for a two week period of duty delivering the mail; they arrived at Aberdeen at 1700 hrs on 5 September 1999. The next morning, the crew arrived for duty at approximately 0540 hrs and completed their normal checks of LN-PBB. Shortly after this, the mail arrived and was escorted to the aircraft by the company ground crew. The mail bags were sorted and loaded into the aircraft by the flight and ground crew under the supervision of the commander; the mail had been weighed by Royal Mail and the commander was given written confirmation of the total weight of 1,196 kg. At the completion of the loading, the commander was satisfied that the load was secure and correctly distributed. Prior to departure for Sumburgh Airport, the commander had checked the weather and was aware that it was 'poor' at Sumburgh but the indications were that it would improve; additionally, the weather at Kirkwall Airport was clear if they needed to divert. The aircraft appeared fully serviceable during start, taxi and take off from Aberdeen at 0640 hrs; for the flight to Sumburgh, the commander was the handling pilot. Cruise was at Flight Level (FL)90and, about half way to Sumburgh, ATC advised the crew of the latest weather at Sumburgh which indicated that they would not be able to land there. However, there was a preceding aircraft heading for the same destination and the commander elected to continue towards Sumburgh. Then, once the preceding aircraft crew had declared that they were diverting to Aberdeen, the commander decided to divert to Kirkwall. The diversion was uneventful and the aircraft landed at 0807 hrs. At Kirkwall, the crew uplifted sufficient fuel to bring the total up to the same with which they had left Aberdeen (1,200lb) and waited for a weather improvement at Sumburgh. By approximately 0930hrs, the crew were advised by Kirkwall ATC that the weather had improved at Sumburgh and they prepared the aircraft for departure. Take off was at 0950 hrs with the co-pilot as handling pilot. Cruise was at FL 70 and was uneventful up to the approach and landing. The airport was using Runway 27 as that is the only runway with full ILS. The ATIS information at 1020 hrs was broadcasting the following information: surface wind 340°/07 kt; 9,000 metres in rain; cloud few at 300 feet, scattered at 1,000 feet and broken at 1,600 feet; temperature 12°, dew point 12°; tempo cloud broken 1,500 feet with a wet runway. In accordance with ATC instructions, the crew commenced their descent to 2,000 feet amsl where they were instructed to intercept the ILS from a heading of 300°. Once fully established on the ILS, the commander noted that the co-pilot was having a little difficulty maintaining the aircraft on both the localizer and glide slope. The co-pilot was not sure of the height at which they broke cloud but the commander estimated that they were at 500 feet agl. At this point, the co-pilot considered that they were slightly high and fast; subsequently, the commander estimated the aircraft airspeed as 140 kt as they became visual with the runway. During the final approach, the air traffic controller gave three separate wind reports of 010°/11 kt, 010°/11 kt and010°/10 kt; these reports were based on the two minute mean surface winds. As the aircraft crossed the runway threshold, the co-pilot called out that he had too much speed and that "it wasn't going to work". With no reply from the commander, the co-pilot took this lack of response as an indication that the commander was content. For his part, the commander was concentrating on the runway aspect and, although he heard a comment from the co-pilot, did not make any response. The crew considered that touchdown was approximately halfway down the runway and the co-pilot was aware of the aircraft bouncing before a second touchdown; neither pilot could recall the speed at touchdown. Both pilots applied full foot braking but with little apparent result in retardation. Then, as the aircraft approached the end of the runway, the commander took control and applied full power; this was because he was aware of the concrete blocks positioned off the end of the runway as a sea defence and wished to clear them. The aircraft was now yawed slightly left and positioned to the left of the runway centreline. It left the runway surface, travelled across grass and a public road and came to rest on the concrete blocks.
Probable cause:
The aircraft overran the end of Runway 27 at Sumburgh following a touchdown which was too fast and well down the runway. There was insufficient runway remaining for the aircraft to stop. The landing resulted from a poor approach and no apparent co-operation between the crew. A positive decision from the co-pilot, or better monitoring and an active input from the commander, should have resulted in a go-around and a further approach or a diversion. While this crew may be unusual, it would be appropriate for the operating company to review their procedures to ensure that their crews are operating in a safe manner. The investigation also reviewed the rules under which the flight was conducted. Examination of the weather information available to the crew indicate doubts as to whether the flight could have been completed within the limitations contained within company manuals. Additionally, Article 32A of the UK ANO is not clear; it could be interpreted as only prohibiting flights when the weather conditions are not met at all of the relevant aerodromes. It would be appropriate for the CAA to review the content of Article 32A to ensure that the intent is clear.
Final Report:

Crash of a Dassault M.D.312 Flamant in Issoire-Le Broc: 2 killed

Date & Time: Sep 5, 1999 at 1715 LT
Type of aircraft:
Operator:
Registration:
F-AZAI
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Issoire-Le Broc - Issoire-Le Broc
MSN:
228
YOM:
1950
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The aircraft was dispatched at Issoire-Le Broc to take part to an airshow. The crew already completed several low passes and presentation to the public (about 8,000 people). At the end of the afternoon, the crew approached the grassy runway to perform a new low pass when the aircraft went out of control, overturned and crashed, bursting into flames. Both occupants were killed.
Crew:
Jean-Louis Escoffier, pilot,
Gérard Launois, pilot.

Crash of a Cessna 404 Titan II in Glasgow: 8 killed

Date & Time: Sep 3, 1999 at 1236 LT
Type of aircraft:
Registration:
G-ILGW
Flight Phase:
Survivors:
Yes
Schedule:
Glasgow – Aberdeen
MSN:
404-0690
YOM:
1980
Flight number:
Saltire 3W
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
4190
Captain / Total hours on type:
173.00
Copilot / Total flying hours:
2033
Copilot / Total hours on type:
93
Aircraft flight hours:
6532
Circumstances:
The aircraft had been chartered to transport an airline crew of nine persons from Glasgow to Aberdeen. The aircraft was crewed by two pilots and, so far as could be determined, its take-off weight was between 8,320 and 8,600 lb. The maximum permitted take-off weight was 8,400 lb. ATC clearance for an IFR departure was obtained before the aircraft taxied from the business aviation apron for take-off from runway 23, with a take-off run available of 2,658 metres. According to survivors, the take-off proceeded normally until shortly after the aircraft became airborne when they heard a thud or bang. The aircraft was then seen by external witnesses at low height, to the left of the extended runway centerline, in a wings level attitude that later developed into a right bank and a gentle descent. Witnesses reported hearing an engine spluttering and saw at least one propeller rotating slowly. There was a brief 'emergency' radio transmission from the commander and the aircraft was seen entering a steep right turn. It then entered a dive. A witness saw the wings levelled just before the aircraft struck the ground on a northerly track. Three survivors were helped from the wreckage by a nearby farm worker before flames from a severe post-impact fire engulfed the cabin.
Probable cause:
The following causal factors were identified:
- The left engine suffered a catastrophic failure of its accessory gear train leading to a progressive but complete loss of power from that engine,
- The propeller of the failed engine was not feathered and therefore the aircraft was incapable of climbing on the power of one engine alone,
- The commander feathered the propeller of the right-hand engine, which was mechanically capable of producing power resulting in a total loss of thrust,
- The commander attempted to return to the departure airfield but lost control of the aircraft during a turn to the right.
Final Report:

Crash of a Beechcraft B90 King Air in West Palm Beach: 8 killed

Date & Time: Sep 3, 1999 at 0325 LT
Type of aircraft:
Registration:
N338AS
Survivors:
No
Schedule:
Pontiac – Boca Raton
MSN:
LJ-493
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
11562
Captain / Total hours on type:
200.00
Aircraft flight hours:
8832
Circumstances:
At 0314, the pilot reported to the Air Traffic Control (ATC) Tower that he wanted to divert from his destination to land at a closer airport, and was cleared for a visual approach. At 0325, the pilot issued a "Mayday." On final approach the airplane struck a building and wires about 1/2 mile short of the runway. Witnesses that saw the airplane just before impact said that the airplane was low, there was no in-flight fire, and the engine sounds "...appeared to be a fluttering sound as if air [was] passing through the propeller." The pilot had filed for a cruise altitude of 15,000 feet, with a time en route of 5 hours, and fuel on board 6 hours. Weight and balance calculations showed that the pilot was operating about 722 pounds above the maximum gross weight for the takeoff, climb, and maximum cruise power settings. The Pilot Operating Handbook calculations showed that most of the fuel would have been used during the flight. The engine and propeller examinations revealed that both engines were not producing power at impact (windmilling). There were no discrepancies found with the engines or propellers. Examination of the propellers revealed that they were not in the feather position and they were not in beta/reverse position. Line personnel at the departure airport confirmed that all the tanks were topped off (282 gallons added). It took the flight 32 minutes to reach a cruise altitude of 15,000 feet, which calculated to about 293.3 pounds (1 gallon of Jet "A" equals 6.7 pounds), and a flight time of 4.9 hours from takeoff to impact. Sample calculations indicated that the fuel burn rate would have caused the airplane to use 2,649.3 pounds of Jet "A" turbine fuel during the flight. The flight departed with all tanks full 384 gallons usable (2,572.8 pounds), which calculates to insufficient fuel for the completion of the flight. Two gallons of fuel was drained from the right nacelle tank at the crash site, and there was no evidence of in-flight leakage. The sample calculations do not consider performance degradation for operating the airplane above the maximum allowable gross weight, which would cause the fuel consumption to go up because more power was required for the overweight conditions. The pilot's flight plan was for economy cruise, plus the airplane was over gross weight at takeoff, and there are no performance charts for that condition. So, the performance was even poorer than shown on the maximum power chart for climb and cruise. Calculations of the maximum allowable fuel that could be on board the aircraft showed that only 1851 pounds of turbine fuel could be carried to start the flight at the maximum allowable weight, or about 3.2 hours of flight. The en route winds aloft at the airplane's altitude indicated a slight tailwind for half the flight and a headwind of about 15 knots for the remainder of the flight.
Probable cause:
A total loss of engine power due to fuel exhaustion. Contributing factors in this accident were the pilot's operation of the airplane in an overweight condition, inadequate pre-flight and inflight planning.
Final Report:

Crash of a Boeing 737-204C in Buenos Aires: 65 killed

Date & Time: Aug 31, 1999 at 2054 LT
Type of aircraft:
Operator:
Registration:
LV-WRZ
Flight Phase:
Survivors:
Yes
Schedule:
Buenos Aires – Córdoba
MSN:
20389
YOM:
1970
Flight number:
MJ3142
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
95
Pax fatalities:
Other fatalities:
Total fatalities:
65
Captain / Total flying hours:
6500
Captain / Total hours on type:
1710.00
Copilot / Total flying hours:
4085
Copilot / Total hours on type:
560
Aircraft flight hours:
67864
Aircraft flight cycles:
41851
Circumstances:
LAPA flight 3142 was scheduled to depart from Buenos Aires-Jorge Newbery Airport at 20:36 for a 1 hour and 15 minute flight to Córdoba, Argentina. The first officer and cabin crew were the first to arrive at the Boeing 737-200. The first officer notified one of the mechanics that the total fuel requirement was 8,500 kg, all to be stored in the wing tanks. The mechanic noticed there was still some fuel in the central tank and commenced transferring the fuel from the central to the wing tanks. At that moment the captain boarded the flight. He threw his paperwork on the ground, showing annoyance, confirming that attitude by later shutting off the fuel transfer between the main tank and the wing tanks. During their first four minutes on board, the captain, the co-pilot and the purser talked about trivial matters in good spirits, focusing on the purser's personal issues. When the purser left the cockpit, the conversation changed tone as they discussed a controversial situation about the family problems of the captain. The captain said that he was "going through bad times", to which the copilot replied that he was also having a bad day. Without interrupting the conversation, the crew began working the checklists, mixed with the personal issues that worried them and that led them to misread the checklist. In the process they omitted to select the flaps to the appropriate takeoff position. This confusing situation, in which the checklist procedure was mixed with conversation irrelevant to the crew's task, persisted during push back, engine start and taxiing, up to the moment of take-off, which was delayed by other aircraft waiting ahead of the LAPA flight and heavy arriving traffic. During this final wait, the crew members were smoking in the cockpit and continued their conversation. Take-off was started on runway 13 at 20:53 hours. During the takeoff roll the Take-off warning system sounded because the flaps had not been selected. The crew ignored the warning and continued the takeoff. After passing Vr, the pilot attempted to rotate the aircraft. The stick shaker activated as the aircraft entered a stall. It successively impacted the ILS antenna, the perimeter fence, a waiting shelter for buses, two automobiles, two excavators and an embankment where it stopped. Immediately a fire erupted. Three flight crew members, 60 passengers and two persons inside an automobile were killed.
Probable cause:
The JIAAC considers as an immediate cause of the accident that the flight crew of the LAPA 3142 forgot to extend the flaps for takeoff and dismissed the alarm sound that warned about the lack of configuration for that maneuver.
The contributing factors were:
- Lack of discipline of the crew that did not execute the logical reaction of aborting the takeoff and verification of the failure when the alarm began to sound when adding engine power and continued sounding until the rotation attempt.
- Excess of conversations foreign to the flight and for moments of important emotional intensity between the pilots, that were mixed with the execution of the check lists, arriving at omitting the part of these last ones where the extension of flaps for takeoff had to be completed.
- Personal and/or family and/or economic and/or other problems of both pilots, which affected their operational behavior.
- Insufficiency of the psychic control system, which did not allow to detect when the pilots were suffering personal and/or family problems and/or of another type that influenced their operational capacity when diminishing their psychic stability.
- Knowledge and treatment of very personal and extra-occupational issues among the pilots and even with the onboard commissioner, who facilitated the atmosphere of scarce seriousness and concentration in the operational tasks.
- Background of negative flight characteristics of the commander that surfaced before his personal situation and relationship in the cockpit before and during the emergency.
- Background of flight characteristics of the co-pilot, which manifested themselves during compliance with the procedural checklists in a cockpit where its components participated with a completely dispersed attention to particular interests outside the flight.
- No immediate recognition or verification of both pilots, of the relationship between the type of intermittent audible alarm that indicated failure in the configuration for takeoff, with the absence of flaps in the position for this maneuver.
- Design of the take-off configuration alarm system that does not allow, in this type of aircraft, a simple check by the crews to ensure periodic listening to this type of intermittent alarm.
Final Report: