Crash of a Cessna 414 Chancellor in Alpine

Date & Time: Aug 28, 1999 at 1021 LT
Type of aircraft:
Operator:
Registration:
N67JM
Flight Phase:
Survivors:
Yes
Schedule:
Alpine - Lajitas
MSN:
414-0066
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
383
Captain / Total hours on type:
24.00
Aircraft flight hours:
5581
Circumstances:
The pilot had the main and auxiliary fuel tanks filled and performed an abbreviated preflight prior to departing the Alpine Airport. The pilot did not perform an engine run-up prior to takeoff. The pilot stated that while the airplane was climbing through 100 feet agl, the left engine 'started to surge.' The pilot reported that he knew the airplane would not be able to climb at field elevation with one engine inoperative. The pilot switched the left engine's boost pump from low to high; however, the left engine continued to surge while the airplane lost altitude. The pilot initiated a forced landing with the landing gear and flaps retracted and the left propeller unfeathered. The airplane impacted the ground left wing tip first and a fire erupted, which damaged the left wing and left side of the fuselage. The left engine's spark plugs were found covered with thick black soot. The left engine's magnetos were rotated using an electric hand-held drill, and the left magneto did not produce any spark and the right magneto produced a spark in three of its six distributor cap posts. The left magneto's primary winding resistance and capacitor leakage were found to be beyond the manufacturer's specified limits. The internal components of both magnetos were covered in a dark oil and debris. The maximum takeoff weight for the accident airplane was 6,350 pounds; however, the takeoff weight at the time of the accident was calculated to be 6,509 pounds. The aircraft's single engine performance charts indicated that the airplane would obtain a 29 fpm climb at maximum gross weight with the inoperative engine feathered. The pilot operating handbook's supplement section indicated that the auxiliary fuel pump should only be used when the engine-driven fuel pump failed. A caution statement states in bold print, 'If the auxiliary fuel pump switches are placed in the HIGH position with the engine-driven fuel pump(s) operating normally, total loss of engine power may occur.'
Probable cause:
The pilot's improper use of the emergency fuel boost pump, which resulted in excessive fuel flow to the engine and subsequent total loss of left engine power. Factor's were the high density altitude, the pilot exceeding the airplane's weight and balance, the partial loss of left engine power as a result of the faulty magnetos, and the pilot's inadequate preflight inspection by not performing an engine run-up.
Final Report:

Crash of a Yakovlev Yak-40 in Turtkul: 2 killed

Date & Time: Aug 26, 1999 at 1051 LT
Type of aircraft:
Operator:
Registration:
UK-87848
Survivors:
Yes
Schedule:
Tashkent - Turtkul
MSN:
9 33 17 30
YOM:
1973
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
29
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
On approach to Turtkul Airport, the aircraft was not properly aligned on the glide and the captain initiated a go-around procedure. During a second attempt to land, the aircraft position was wrong so the pilot passed over the runway 20 at a height of about 4-7 metres then initiated a second go-around procedure. The aircraft passed over the runway end at a height of 10 metres when the landing gear were retracted. At a distance of 2 km past the runway end, the aircraft collided with trees and power cables, crash landed, slid for about 130 metres and came to rest against an embankment. Two passengers were killed while four others were injured.
Probable cause:
Wrong approach configuration on part of the crew. The following findings were identified:
- Poor approach planning,
- Poor crew coordination and lack of crew interaction during the approach and go-around procedure,
- Lack of ATC assistance,
- The go-around procedure was poorly negotiated.

Crash of a McDonnell Douglas MD-90-30 in Hualien

Date & Time: Aug 24, 1999 at 1236 LT
Type of aircraft:
Operator:
Registration:
B-17912
Survivors:
Yes
Schedule:
Taipei - Hualien
MSN:
53536
YOM:
1996
Flight number:
UNI873
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
90
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6532
Captain / Total hours on type:
1205.00
Copilot / Total flying hours:
5167
Copilot / Total hours on type:
96
Aircraft flight hours:
4929
Aircraft flight cycles:
7736
Circumstances:
As the MD-90 touched down following a 25-minute flight from Taipei, there was a loud noise from the front of the cabin and thick black smoke poured from one of the overhead luggage compartments on the right hand side of the plane. Insulation and charred luggage littered the runway. Passengers were swiftly evacuated, but it took firefighters more than half an hour to control the fire. Twenty-eight people were injured. Preliminary investigation reports in 1999 indicated that the blast was caused by two bottles of household bleach. However, the Hualien District Court judges decided the bottles contained gasoline. According to the judges, Ku Chin-shui had put the gasoline into two plastic bleach bottles and gave them to his nephew. The gasoline leaked during the flight and exploded when it caused a short-circuit in a motorbike battery in a nearby overhead luggage compartment. In July 2003 Ku appealed a seven-and-a-half-year prison term. Considering the prosecutor's case against Ku to be full of holes, the Supreme Court ordered a retrial.
Probable cause:
A flammable liquid (gasoline) inside bleach and softener bottles and sealed with silicone was carried on board the aircraft. A combustible vapor formed as the leaking gasoline filled the stowage bin, and the impact of the landing aircraft created a short in a battery. The short ignited the gasoline vapor and created the explosion. Contributing factors to the accident were:
- The Civil Aeronautical Administration Organic Regulations and its operational bylaws fail to designate any entity as responsible for hazardous materials;
- The Aviation Police fail to properly recruit and train personnel, to include preparing training materials and evaluating training performance. Some new recruits were found to have not received any formal security check training, but instead were following instructions from senior inspectors. Consequently, new inspectors cannot be relied upon to identify hazardous materials;
- The detectors and inspectors failed to detect the hazardous materials. The detectors used by the Aviation Police did not detect the banned motorcycle batteries, nor did security inspectors detect the liquid bleach, a banned corrosive substance.
Final Report:

Crash of a McDonnell Douglas MD-11 in Hong Kong: 3 killed

Date & Time: Aug 22, 1999 at 1843 LT
Type of aircraft:
Operator:
Registration:
B-150
Survivors:
Yes
Schedule:
Bangkok - Hong Kong - Taipei
MSN:
48468
YOM:
1992
Flight number:
CI642
Country:
Region:
Crew on board:
15
Crew fatalities:
Pax on board:
300
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
17900
Captain / Total hours on type:
3260.00
Copilot / Total flying hours:
4630
Copilot / Total hours on type:
2780
Aircraft flight hours:
30700
Aircraft flight cycles:
5800
Circumstances:
China Airline’s flight CI642 was scheduled to operate from Bangkok to Taipei with an intermediate stop in Hong Kong. The crew had carried out the sector from Taipei to Bangkok, passing through Hong Kong on the previous day. On that flight, the crew were aware of the Severe Tropical Storm (STS) ‘Sam’ approaching Hong Kong and the possibility that it would be in the vicinity of Hong Kong at about the scheduled time of arrival on the following evening. Weather information provided at the preflight briefing for the return flight indicated the continuing presence of STS ‘Sam’ with its associated strong winds and heavy precipitation. The flight departed from Bangkok on schedule with 300 passengers and 15 crew on board, with an estimated time of arrival (ETA) of 1038 hour (hr) in Hong Kong. The commander had elected to carry sufficient fuel to permit a variety of options on arrival – to hold, to make an approach, or to divert. If an immediate approach was attempted, the aircraft would be close to its Maximum Landing Weight (MLW) involving, in consequence, a relatively high speed for the approach and landing. Throughout the initial stages of the flight and during the cruise, the commander was aware of the crosswind component to be expected in Hong Kong and reviewed the values of wind direction and speed which would bring it within the company’s crosswind limit as applicable to wet runways of 24 kt. In the latter stage of the cruise, the crew obtained information ‘Whisky’ from the Automatic Terminal Information Service (ATIS) timed at 0940 hr, which gave a mean surface wind of 320 degrees (º) / 30 knots (kt) maximum 45 kt in heavy rain, and a warning to expect significant windshear and severe turbulence on the approach. Although this gave a crosswind component of 26 kt which was in excess of the company’s wet runway limit of 24 kt, the commander was monitoring the gradual change in wind direction as the storm progressed, which indicated that the wind direction would possibly shift sufficiently to reduce the component and thus permit a landing. Hong Kong Area Radar Control issued a descent clearance to the aircraft at 1014 hr and, following receipt of ATIS information ‘X-ray’ one minute later, which included a mean surface wind of 300º at 35 kt, descent was commenced at 1017 hr. Copies of the information sheets used by Air Traffic Control (ATC) as the basis for ATIS broadcasts ‘Whisky’ and ‘X-ray’ are at Appendix 1. The approach briefing was initiated by the commander just after commencing descent. The briefing was given for an Instrument Landing System (ILS) approach to Runway 25 Right (RW 25R) at HKIA. However, the active runway, as confirmed by the ATIS was RW 25L. Despite the inclusion in the ATIS broadcasts of severe turbulence and possible windshear warnings, no mention was made in the briefing of the commander’s intentions relating to these weather phenomena nor for any course of action in the event that a landing could not be made, other than a cursory reference to the published missed approach procedure. The descent otherwise continued uneventfully and a routine handover was made at 1025 hr to Hong Kong Approach Control which instituted radar vectoring for an ILS approach to what the crew still believed was RW 25R. At 1036 hr, after having been vectored through the RW 25L localizer for spacing, CI642 was given a heading of 230º to intercept the localizer from the right and cleared for ILS to RW 25L. The co-pilot acknowledged the clearance for ILS 25L but queried the RVR (runway visual ranges); these were passed by the controller, the lowest being 1300 m at the touchdown point. The commander then quickly re-briefed the minimums and go-around procedure for RW 25L. At 1038 hr, about 14 nautical miles (nm) to touchdown, the aircraft was transferred to Hong Kong Tower and told to continue the approach. At 1041 hr, the crew were given a visibility at touchdown of 1600 metres (m) and touchdown wind of 320º at 25 kt gusting 33 kt, and cleared to land. The crew of flight CI642 followed China Airline’s standard procedures during the approach. Using the autoflight modes of the aircraft, involving full use of autopilot and autothrottle systems, the flight progressed along the ILS approach until 700 ft where the crew became visual with the runway and approach lights of RW 25L. Shortly after this point the commander disconnected the autopilot and flew the aircraft manually, leaving the autothrottle system engaged to control the aircraft’s speed. After autopilot disconnect, the aircraft continued to track the runway centreline but descended and stabilized slightly low (one dot) on the glideslope. Despite the gustiness of the wind, the flight continued relatively normally for the conditions until approximately 250 ft above the ground at which point the co-pilot noticed a significant decrease in indicated airspeed. Thrust was applied as the co-pilot called ‘Speed’ and, as a consequence, the indicated airspeed rose to a peak of 175 kt. In response to this speed in excess of the target approach speed, thrust was reduced and, in the process of accomplishing this, the aircraft passed the point (50 ft RA) at which the autothrottle system commands the thrust to idle for landing. Coincidentally with this, the speed decreased from 175 kt and the rate of descent began to increase in excess of the previous 750-800 feet per minute (fpm). Although an attempt was made to flare the aircraft, the high rate of descent was not arrested, resulting in an extremely hard impact with the runway in a slightly right wing down attitude (less than 4º), prior to the normal touchdown zone. The right mainwheels contacted the runway first, followed by the underside of the right engine cowling. The right main landing gear collapsed outward, causing damage to the right wing assembly, resulting in its failure. As the right wing separated, spilled fuel was ignited and the aircraft rolled inverted and came to rest upside-down alongside the runway facing in the direction of the approach. The cockpit crew were disorientated by the inverted position of the aircraft and found difficulty in locating the engine controls to carry out engine shut down drills. After extricating themselves, they went through the cockpit door into the cabin and exited the aircraft through L1 door and began helping passengers from the aircraft through a hole in the fuselage. Airport fire and rescue services were quickly on the scene, extinguishing the fuel fire and evacuating the passengers through the available aircraft exits and ruptures in the fuselage. As a result of the accident, two passengers were found dead on arrival at hospital, and six crew members and 45 passengers were seriously injured. One of the seriously injured passengers died five days later in hospital.
Probable cause:
The cause of the accident was the commander’s inability to arrest the high rate of descent existing at 50 feet RA. Probable contributory causes to the high rate of descent were:
- The commander’s failure to appreciate the combination of a reducing airspeed, increasing rate of descent, and with the thrust decreasing to flight idle.
- The commander’s failure to apply power to counteract the high rate of descent prior to touchdown.
- Probable variations in wind direction and speed below 50 feet RA may have resulted in a momentary loss of headwind component and, in combination with the early retardation of the thrust levers, and at a weight only just below the maximum landing weight, led to a 20 kt loss in indicated airspeed just prior to touchdown. A possible contributory cause may have been a reduction in peripheral vision as the aircraft entered the area of the landing flare, resulting in the commander not appreciating the high rate of descent prior to touchdown.
Final Report:

Crash of a Piper PA-46-310P Malibu in Paderborn: 3 killed

Date & Time: Aug 21, 1999 at 1017 LT
Operator:
Registration:
D-ELHB
Flight Type:
Survivors:
No
Schedule:
Niederstetten - Paderborn
MSN:
46-8608038
YOM:
1986
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
716
Captain / Total hours on type:
162.00
Aircraft flight hours:
2092
Circumstances:
The single engine aircraft departed Niederstetten Airport, Baden-Wurttemberg, at 0915LT with two passengers and one pilot on board. The flight was completed under VFR mode until Würzburg then the pilot was cleared to continue under IFR mode to the destination. On approach to Paderborn-Lippstadt Airport, after passing 5,000 feet, the pilot was cleared for an ILS approach to runway 24. At an altitude of 3,700 feet, while trying to establish on the ILS, the pilot momentarily lost control of the airplane. He elected to regain control when the aircraft climbed to 4'000 feet, entered a left turn then an uncontrolled descent until it crashed in a field located in Borchen, about 8 km short of runway 24. The aircraft was destroyed and all three occupants were killed.
Probable cause:
The pilot was trying to intercept the ILS runway 24 when he momentarily lost control of the airplane. While trying to regain control, the outer of the right wing broke off due to structural failure caused by aerodynamic forces that exceeded its certification. The pilot, despite holding an instrument license, was apparently unable to execute an instrument approach.
Final Report:

Crash of a BAe 125-600A in Las Vegas

Date & Time: Aug 17, 1999 at 1817 LT
Type of aircraft:
Operator:
Registration:
N454DP
Survivors:
Yes
Schedule:
Salina - Las Vegas
MSN:
256044
YOM:
1974
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10000
Captain / Total hours on type:
275.00
Copilot / Total flying hours:
5300
Copilot / Total hours on type:
700
Aircraft flight hours:
5753
Circumstances:
The pilot landed with the landing gear in the retracted position, when both the main and auxiliary hydraulic systems failed to extend the gear. The airplane caught fire as it skidded down the runway. The left inboard main tire had blown on takeoff and a 30-inch section of tread was loose. Black marks were along the length of the landing gear strut and up into the wheel well directly above the left inboard wheel. The normal and emergency hydraulic systems both connect to a common valve body on the landing gear actuator. This valve body also had black marks on it. A gap of 0.035 inch was measured between the valve body and actuator. When either the normal or auxiliary hydraulic system was pressurized, red fluid leaked from this gap. Examination revealed that one of two bolts holding the hydraulic control valve in place had fractured and separated. The fractured bolt experienced a shear load that was oriented along the longitudinal axis of the actuator in a plane consistent with impact forces from the flapping tire tread section.. Separation of only one bolt allowed the control valve to twist about the remaining bolt in response to the load along the actuator's longitudinal axis. This led to a loss of clamping force on that side of the actuator. Hydraulic line pressure lifted the control valve, which resulted in rupture of an o-ring that sealed the hydraulic fluid passage. 14 CFR 25.739 describes the requirement for protection of equipment in wheel wheels from the effects of tire debris. The revision of this regulation in effect at the time the airplane's type design was approved by the FAA requires that equipment and systems essential to safe operation of the airplane that is located in wheel wells must be protected by shields or other means from the damaging effects of a loose tire tread, unless it is shown that a loose tire tread cannot cause damage. Examination of the airplane and the FAA approved production drawings disclosed that no shields were installed to protect the hydraulic system components in the wheel well.
Probable cause:
The complete failure of all hydraulic systems due to the effects of a main gear tire disintegration on takeoff. Also causal was the manufacturer's inadequate design of the wheel wells, which did not comply with applicable certification regulations, and the FAA's failure to ensure that the airplane's design complied with standards mandated in certification regulations.
Final Report:

Crash of a Canadair CL-600 Challenger in Fort Lauderdale

Date & Time: Aug 16, 1999 at 2347 LT
Type of aircraft:
Operator:
Registration:
N63HJ
Flight Type:
Survivors:
Yes
Schedule:
Pueblo – Columbia
MSN:
1021
YOM:
1981
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10162
Captain / Total hours on type:
540.00
Aircraft flight hours:
9503
Circumstances:
While enroute from Pueblo, Colorado, to Columbia, South Carolina, the captain's windshield delaminated, and the flight diverted to Fort Lauderdale, Florida, for repairs. The flight crew stated the first officer was flying the airplane and had been instructed by the captain to make a firm landing at Fort Lauderdale to get the airplanes weight on the wheels, due to the airplane being light. The landing was firm and the first officer activated the engine thrust reversers. As the nose landing gear touched down, the airplane began veering to the left. Attempts to control the veer to the left were unsuccessful and the airplane ran off the left side of the runway. The airplane then ran over a taxiway and collided with a taxiway sign and the concrete base for the sign. The nose landing gear collapsed and the airplane came to rest. Examination of the runway showed alternating dark and light marks from the left main landing gear tire were present on the runway about 160 feet before marks from the right main landing gear tire are present. Post accident examination of the airplanes landing gear, tires, wheels, bakes, spoilers, and engine thrust reversers, showed no evidence of pre-accident failure or malfunction. At the time of the accident the flight crew had been on duty for about 17 hours 45 minutes.
Probable cause:
The failure of the flight crew to main directional control of the airplane after landing, resulting in the airplane going off the side of the runway and colliding with a taxiway sign, collapsing the nose landing gear, and causing substantial damage to the airplane. A factor in the accident was flight crew fatigue due to being on duty for about 17 hours 45 minutes.
Final Report:

Crash of a Swearingen SA227AC Metro III in San Antonio

Date & Time: Aug 16, 1999 at 1733 LT
Type of aircraft:
Operator:
Registration:
N2671V
Flight Type:
Survivors:
Yes
Schedule:
San Antonio - San Antonio
MSN:
AC-437
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3400
Captain / Total hours on type:
490.00
Aircraft flight hours:
19317
Circumstances:
The airplane landed wheels up after the instructor pilot failed to lower the landing gear. The instructor told the student to execute 'a no flap landing due to a simulated hydraulic pump failure.' The student established the airplane on the approach and called for the 'Emergency Gear Extension Checklist.' The instructor delayed extending the gear in accordance with the operator's flight standards manual, which stated that the landing gear should not be extended until the landing was assured. Later in the approach, when the gear warning horn stopped sounding, due to the student's movement of the power levers forward, the instructor removed his hand from the gear handle without extending the gear. The instructor stated that 'because [the student] had already called for the [Emergency Gear Extension] checklist once before, in a split second thought process, [he] mistakenly thought it had been completed.' Following the accident, the landing gear system was tested and found to operate normally. Review of the maintenance records revealed no uncorrected discrepancies. At the time of the accident, the instructor pilot was completing a 9-hour work day, and did not have a lunch break.
Probable cause:
The instructor pilot's failure to complete the Emergency Gear Extension Checklist, resulting in the inadvertent wheels-up landing. A factor was the instructor pilot's fatigued condition.
Final Report:

Crash of a Boeing 707-351C in Juba

Date & Time: Aug 14, 1999
Type of aircraft:
Operator:
Registration:
ST-ANP
Flight Type:
Survivors:
Yes
MSN:
19632
YOM:
1967
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following a wrong approach configuration, the aircraft was too high on the glide and landed too far down the runway. After touchdown, it was unable to stop within the remaining distance, overran and came to rest 150 metres further. All five crew members escaped uninjured while the aircraft was damaged beyond repair. The crew completed the landing procedure with a tailwind component of nine knots.
Probable cause:
Wrong approach configuration on part of the crew who continued the descent above the glide, causing the aircraft to land too far down the runway and reducing the landing distance available. The crew failed to initiate a go-around procedure.

Crash of an Antonov in Aden: 17 killed

Date & Time: Aug 14, 1999
Type of aircraft:
Operator:
Flight Type:
Survivors:
No
Schedule:
Hadibu - Aden
Country:
Region:
Crew on board:
17
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
17
Circumstances:
On approach to Aden-Khormaksar Airport following a flight from Hadibu, Socotra Islands, the aircraft crashed in unknown circumstances near the district of Bir Fadel. All 17 occupants were killed.