Airport (less than 10 km from airport)

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Schedule:

Port-Menier - Seven Islands

MSN:

UE-347

YOM:

1999

Flight number:

RH347

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

7065

Captain / Total hours on type:

606.00

Copilot / Total flying hours:

2600

Copilot / Total hours on type:

179

Aircraft flight hours:

373

Circumstances:

The RégionnAir flight took off from Port-Menier at 23:34 for an IFR flight to Seven Islands. The crew decided to carry out a straight-in GPS approach to runway 31. However, there is no published GPS approach for that runway. The descent from cruise flight into the airport was started late, and the aircraft was high and fast during the approach phase to the NDB. From an altitude of 10 000 feet at 9 nm from the NDB, the rate of descent generally exceeded 3000 fpm. The aircraft crossed the beacon at 600 feet asl. For the last 30 seconds of flight and from approximately 3 nm from the threshold, the aircraft descended steadily at approximately 850 fpm, at 140 to 150 knots indicated airspeed, with full flaps extended. The captain coached the first officer throughout the descent and called out altitudes and distances. The GPWS "Minimums" activation sounded, consistent with the decision height selection of 100 feet, to which the captain responded with directions to continue a slow descent. The last call was at 30 feet, 1.2 seconds before impact. Eight seconds before impact, the GPWS voice message "Minimums, Minimums" activated. The aircraft continued to descend and struck trees in a near-level attitude, in an area of rising terrain. A post-crash fire destroyed the wings, the right engine, and the right midside of the fuselage. The cabin area remained relatively intact, but the cockpit area separated and was crushed during the impact sequence. The Beechcraft in question was a brand new aircraft, registered just 2 months earlier. This accident was RégionnAir's second Beech 1900 loss in 1999; on January 4 an accident happened on approach to St. Augustin River. No one received fatal injuries in that accident however.

Probable cause:

Findings as to causes and contributing factors:
1. The pilot flying did not establish a maximum performance climb profile, although required by the company's standard operating procedures (SOPs), when the ground proximity warning system (GPWS) "Terrain, Terrain" warning sounded during the descent, in cloud, to the non-directional beacon (NDB).
2. The pilot flying did not fly a stabilized approach, although required by the company's SOPs. The crew did not carry out a go-around when it was clear that the approach was not stabilized.
3. The crew descended the aircraft well below safe minimum altitude while in instrument meteorological conditions.
4. Throughout the approach, even at 100 feet above ground level (agl), the captain asked the pilot flying to continue the descent without having established any visual contact with the runway environment.
5. After the GPWS "Minimums, Minimums" voice activation at 100 feet agl, the aircraft's rate of descent continued at 850 feet per minute until impact.
6. The crew planned and conducted, in cloud and low visibility, a user-defined global positioning system approach to Runway 31, contrary to regulations and safe practices.
Findings as to risk:
1. At the time of the approach, the reported ceiling and visibility were well below the minima published on the approach chart.
2. Because the runway was not equipped with a reporting runway visual range system, flying the NDB approach was allowable under the existing regulations.
3. The crew did not follow company SOPs for the approach and missed-approach briefings.
4. Both crew members had surpassed their maximum monthly and quarterly flight times and maximum daily flight duty times. They were thus at increased risk of fatigue, which leads to judgement and performance errors.
5. The first officer likely suffered from chronic fatigue, having worked an average of 14 hours a day for the last 30 days, with only 1 day of rest.
6. Transport Canada was not aware that the company's pilots were exceeding the flight and duty times.
7. The company operations manager did not effectively supervise the flight and duty times of company pilots.
8. The captain had not received the mandatory training in pilot decision making or crew resource management.
Other findings:
1. The emergency locator transmitter activated on initial impact but ceased to transmit shortly thereafter when its antenna cable was severed.

Final Report:

Crash of a Cessna 414 Chancellor in Monrovia: 6 killed

Date & Time: Aug 10, 1999 at 2005 LT

Type of aircraft:

Cessna 414 Chancellor

Operator:

Gibalco Air Services

Registration:

N373BC

Flight Phase:

Charter/Taxi (Non Scheduled Revenue Flight)

Flight Type:

Survivors:

Site:

Margibi (Gibi & Marshall)

Schedule:

Harper - Monrovia

MSN:

414-0411

YOM:

1973

Location:

Monrovia-Roberts

Country:

Liberia

Region:

Africa

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The twin engine aircraft departed Harper on a charter flight to Monrovia, carrying five police officers and one pilot. On a night approach to Monrovia-Roberts Airport, the aircraft crashed in unknown circumstances 4 km short of runway. The aircraft was destroyed and all six occupants were killed.

Crash of a Short SC.7 Skyvan 3 Variant 100 in Surkhet

Date & Time: Aug 7, 1999 at 0635 LT

Type of aircraft:

Short SC.7 Skyvan Variant

Operator:

Registration:

RAN-19

Flight Phase:

Flight Type:

Military

Survivors:

Site:

De Havilland DHC-6 Twin Otter

MSN:

1884

YOM:

1970

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

During the takeoff roll on runway 20, the aircraft started to skid. Halfway down, the crew decided to abandon the takeoff procedure but the aircraft was unable to stop within the remaining distance. It overran and came to rest in a ravine. Both pilots escaped uninjured and the aircraft was damaged beyond repair. Weather conditions were good at the time of the accident with an OAT of 18° C. and light wind. The Surkhet Airport runway 20/02 is grass and is 3,400 feet long. It was reported that at the time of the accident, the turf was quit high and wet due to the morning dew which was considered as a contributing factor.

Crash of a De Havilland DHC-6 Twin Otter 300 in Ilaga

Date & Time: Aug 6, 1999

Type of aircraft:

Operator:

Registration:

PK-NUU

Flight Phase:

Flight Type:

Positioning

Survivors:

Site:

Special Region of West Papua

MSN:

478

YOM:

1975

Location:

Ilaga

Country:

Indonesia

Region:

Asia

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The crew was completing a positioning flight to Ilaga Airport. After touchdown, the twin engine aircraft was unable to stop within the remaining distance. It overran, lost its nose gear and came to rest. Both pilots escaped uninjured and the aircraft was damaged beyond repair.

Crash of a Pilatus PC-6/B2-H2 Turbo Porter in Malargüe

Date & Time: Aug 2, 1999

Type of aircraft:

Pilatus PC-6 (Porter & Turbo Porter)

Operator:

Registration:

GN-808

Flight Phase:

Flight Type:

Government

Survivors:

Site:

MSN:

806

YOM:

1979

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The single engine aircraft crashed in unknown circumstances upon landing at Malargüe Airport. The aircraft was destroyed and all three occupants were seriously injured.

Crash of a Beechcraft C90 King Air in Marine City: 10 killed

Date & Time: Jul 31, 1999 at 0825 LT

Type of aircraft:

Beechcraft 90 King Air

Operator:

Registration:

N518DM

Flight Phase:

Flight Type:

Skydiving / Paratroopers

Survivors:

Site:

Schedule:

Marine City - Marine City

MSN:

LJ-251

YOM:

1967

Location:

Marine City

Michigan

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

9700

Aircraft flight hours:

8986

Circumstances:

The airplane impacted the terrain approximately 2,065 feet south of the departure end of runway 22. Damage to the cockpit section of the wreckage indicated a nose down crush angle of approximately 80 degrees. The wreckage path was on a 208 degree heading, and the distance from the initial impact to the location of the empennage was about 142 feet. The cockpit and cabin were destroyed by post impact fire. Examination of the engines and propellers revealed no preexisting failures or conditions that would have prevented normal operation. The engines exhibited indications of rotation, and the witness marks on both sets of propellers were consistent with the propellers operating in the governing range at impact. Control continuity was established from the right aileron, elevator, and rudder. Witnesses reported the airplane seem to be operating normally during taxi and takeoff, but that it entered a steep left bank after clearing a 100 foot powerline located about 1,800 feet from the departure end of runway 22. After entering the steep left turn, the nose of the airplane dropped and the airplane impacted the ground. There was no evidence in the airplane's maintenance records of any annual maintenance inspection since August, 1997, although an airframe and powerplant mechanic reported that he had completed an inspection on June 30, 1999. There was no record in the airplane's maintenance records of compliance with five airworthiness directives applicable to the airplane.

Probable cause:

The pilot's failure to maintain adequate airspeed, which resulted in a stall, inflight loss of control, and collision with the ground.

Final Report:

Crash of a Let L-410UVP-E9 in Arusha

Date & Time: Jul 26, 1999 at 1610 LT

Type of aircraft:

Let L-410

Operator:

Registration:

5H-PAB

Flight Phase:

Flight Type:

Training

Survivors:

Site:

Schedule:

Arusha - Arusha

MSN:

96 27 15

YOM:

1996

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

12000

Captain / Total hours on type:

700.00

Circumstances:

The aircraft took off from Arusha Airport (ARK) at 12:35 hours for a circuit training. It was carrying one instructor, a pilot trainee and three passengers. The aircraft was flying VFR. The instructor said that he intended to execute nine touch and go circuit operations, three of which were to be performed with 42° flaps, another three with 18° flaps and the rest with zero degree flaps. The first six circuits were performed uneventfully. Before initiating the first flapless landing the instructor ordered the trainee to extend his approach and establish a six-mile final to runway 09. When the aircraft was established on the final for runway 09 the instructor saw that the aircraft was a bit too low and ordered the trainee to adjust his approach. After 5H-PAB was established on the approach slope the instructor advised the trainee to call when he needed props fully forward (setting propellers into full coarse pitch). This he subsequently did and the instructor, aware of the relatively high aircraft speed for the configuration advised the trainee to be careful on the flare in order to avoid the possibility of the tail skid hitting the ground. When the aircraft was flared, the tail skid hit and scraped the ground followed by the belly and the nose underside section. After sliding for 164 metres the aircraft came to rest on the runway with the engines still running. The instructor carried out the emergency shut down checks and evacuated the aircraft. It was only after touchdown that the crew realised that they had belly landed. The commander then proceeded to select reverse thrust. There was no fire and none of the occupants was injured. The instructor said that he had forgotten to lower the landing gear because of his preoccupation with the rate of descent and the execution of the flapless flare. The pilot under instruction testified that he had concentrated too much an the technical side of flying to the point of forgetting to call for the gear down selection. There was only one checklist in use in the cockpit which was contained in a book and this was being used by the instructor. The instructor testified to have used the checklist for the first six landings. The checklist was not used for the accident landing. None pilot of the pilots reported to have heard the landing gear horn.

Probable cause:

Failure of the crew to follow the approach checklist and to lower the landing gear.

Crash of an Ilyushin II-76TD in Irkutsk

Date & Time: Jul 26, 1999 at 1346 LT

Type of aircraft:

Ilyushin II-76

Operator:

Elf Air

Registration:

RA-76819

Flight Phase:

Flight Type:

Cargo

Survivors:

Site:

Piper PA-61 Aerostar (Ted Smith 601)

Schedule:

Tianjin – Irkutsk – Perm – Moscow

MSN:

10134 09274

YOM:

1991

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Aircraft flight hours:

2882

Aircraft flight cycles:

1177

Circumstances:

The aircraft departed Tianjin on a cargo flight to Moscow with intermediate stops in Irkutsk and Perm, carrying a load of 49,750 kilos of various goods and seven crew members. At Irkutsk-Intl Airport, 38 tons of fuel were uplifted and the crew calculated 30,040 kilos for the cargo, giving a total weight of 170 tons, about 4 tons below the MTOW. During the takeoff roll, after a course of 2,000 metres, at a speed of 225 km/h, the captain started the rotation. The aircraft lifted up and flew for about 4 seconds when the captain requested gear up. At a speed of 250 km/h, the aircraft passed the runway end and adopted a 16° angle of attack. Then the aircraft' speed decreased when the flight engineer reduced the power on all four engines and activated the thrust reverser systems on both left engines n°1 and 2. The aircraft rolled to the left, collided with a building containing an electrical transformer and came to rest 1,476 metres past the runway end, bursting into flames. All seven occupants were injured, two seriously. The aircraft was destroyed.

Probable cause:

It was determined that the total weight of the aircraft at the time of the accident was 198-200 tons which means 24-26 tons above MTOW. The cargo manifest showed a total weight of 49,750 kilos of various goods upon departure from Tianjin Airport but only 30,040 kilos upon departure from Irkutsk Airport while no cargo was unloaded. The following contributing factors were identified:
- A miscalculation of the mass and balance,
- Poor flight planning,
- Poor crew coordination.

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

Date & Time: Jul 23, 1999 at 1113 LT

Type of aircraft:

Operator:

Mark H. Johnson

Registration:

N345LS

Flight Phase:

Flight Type:

Private

Survivors:

Site: