Crash of a Boeing 737-247 in Loma Bonita

Date & Time: May 10, 1999
Type of aircraft:
Operator:
Registration:
B-12001
Flight Type:
Survivors:
Yes
Schedule:
Loma Bonita - Loma Bonita
MSN:
20127
YOM:
1969
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a local training flight at Loma Bonita Airport which has a 1,400 metres long 18/36 runway. After touchdown, the crew initiated the braking procedure but the aircraft was unable to stop within the remaining distance. It overran, rolled for about 100 metres then came to rest. All six occupants escaped uninjured. A fire erupted and destroyed the aircraft in few minutes as local firebombers were not sufficiently trained and well equipped.
Probable cause:
It was determined that following a wrong approach configuration, the crew landed too far down the runway, reducing the landing distance available. Brake marks were found on the last portion of the runway.

Crash of a Cessna T303 Crusader in San Diego

Date & Time: May 7, 1999 at 2230 LT
Type of aircraft:
Registration:
N3303S
Flight Type:
Survivors:
Yes
Schedule:
Houston – San Diego
MSN:
303-00018
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
25000
Captain / Total hours on type:
200.00
Aircraft flight hours:
1832
Circumstances:
The airplane departed Houston, Texas, for a VFR flight to San Diego, California. The pilot in the left seat said that they originally planned to purchase fuel at Gila Bend, Arizona, but were told that the fueling was closed. The left seat pilot said they elected to land at a private airstrip and made arrangements to have an individual drive to Casa Grande airport to purchase fuel for them. The left seat pilot said they were worried about adequate runway length, so they elected to only purchase 65 gallons of fuel for the remainder of the flight to San Diego. En route to San Diego, the right seat pilot obtained weather for the destination from FSS and was advised of 1,000-foot overcast ceiling. The right seat pilot then requested and received an instrument clearance. The TRACON controller advised the pilot of the accident airplane that he would have to keep speed up due to jet traffic or be given delay vectors for traffic spacing. The pilot told ATC that they were fuel critical and later said they had about 45 minutes to 1 hour of fuel. The right seat pilot was cleared for the localizer runway 27 approach. Approximately 18 minutes later, the pilot elected to do a missed approach because he was too high to land and moments later told San Diego radar that he was fuel critical and only had about 5 minutes of fuel left. San Diego radar began to give the pilot vectors to the closest airport and told the pilot not to descend any further. The right seat pilot replied that they were a glider and later told San Diego police that they had run out of fuel. There were no discrepancies noted with either the airframe or the engines during the postaccident aircraft examination.
Probable cause:
The pilot-in-command's inaccurate fuel consumption calculations that resulted in fuel exhaustion and the subsequent ditching.
Final Report:

Crash of a De Havilland DHC-5 Buffalo in Mandera: 1 killed

Date & Time: May 1, 1999
Type of aircraft:
Operator:
Registration:
KAF207
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
75
YOM:
1977
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
During the takeoff roll, the captain decided to abort for unknown reasons. Unable to stop within the remaining distance, the aircraft overran and collided with a building. All five occupants escaped uninjured while one people on the ground was killed.

Crash of a Beriev BE-103 in Straubing: 1 killed

Date & Time: Apr 29, 1999 at 1833 LT
Type of aircraft:
Registration:
RA-03002
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Straubing - Straubing
MSN:
30 02
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
A testflight for the purpose of vibration measurements on the propellers was to be carried out with the a.m. aircraft. The Beriev BE103 is the prototype of a 6 seater, twin engine amphibious aircraft of russian design. It was powered by two piston engines Teledyne Continental IO-360 E5 which operated hydraulic variable pitch propellers. In the course of the russian type certification the vibration behavior and the stiffness of the propeller blades had to be proven. Therefore a test propeller, fitted with wire strain gauges was attached to the L/H engine at the propeller manufacturer’s facilities in Straubing. The transducers and transmitters were fitted instead of the spinner by means of special brackets. The data recording system was installed in the aircraft’s cabin. As during the testflights a maximum of 105% of the maximum allowable rpm had to be achieved the L/H propeller governor was adjusted to 2940 rpm. Furthermore the R/H propeller and governor were changed from prototypes to the serial components. After these modifications several engine test runs were carried out for calibration of the test equipment and data recording. The testflight was recorded on a camcorder. The film showed that the pilot in command taxied to the far end of the 940 m long pavement runway, adjusted the engines while standing and thereafter commenced his take-off run which should have been approx. 300 m long with view to the aircraft weight according to information gained from the a/c manufacturer. The a/c, however, taxied far beyond the ½ marking of the runway, rotated fairly long and went airborne after approx. 700 m with a high angle of attack. After gaining 10 to 15 m of altitude the pilot in command retracted the landing gear. Right after that the a/c entered a shallow descend in a nose-up attitude and turned to the left before it left the camera view some seconds before the impact. During the entire flight a constant and normal engine noise was audible. Approx. 600 m behind the runway end the aircraft hit the bank of a street and caught fire. The pilot in command was fatally injured, the aircraft was destroyed by the impact and the post impact fire.
Probable cause:
The accident was caused by the pilot in command trying to depart at an extremely reduced power setting and not aborting the take-off in time. Technical causes were not determined. The wrong power setting was related to a misinterpretation of the function and procedures in connection with the constant speed propeller system. Although these are part of the basic knowledge of a pilot on aircraft of this category they were explained to him by employees of the propeller manufacturer and the aircraft manufacturer’s test flight engineer as part of the preflight briefing. With a high probability the pilot did not understand these explanations in all details. The service of an interpreter was refused by him. The planned testflights wouldn’t have led to a power reduction when accomplished properly.
Final Report:

Crash of a Pilatus PC-6/B1-H2 Turbo Porter in Haifa: 4 killed

Date & Time: Apr 24, 1999
Operator:
Registration:
4X-AIY
Flight Phase:
Survivors:
Yes
Schedule:
Haifa - Haifa
MSN:
729
YOM:
1971
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
After takeoff from Haifa Airport, while climbing to a height of about 300 feet, the engine lost power then failed. The aircraft lost height and crashed on the top of a hill near the airport. The pilot and three skydivers were killed while six other occupants were injured.
Probable cause:
Engine failure for unknown reasons.

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

Date & Time: Apr 23, 1999 at 1023 LT
Registration:
N48MD
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ruidoso – North Las Vegas
MSN:
61-0492-201
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3681
Captain / Total hours on type:
597.00
Aircraft flight hours:
4526
Circumstances:
The pilot departed on runway 06 with zero degrees of flaps. A witness said that she noticed that the airplane appeared to wobble and shudder, and immediately went into a steep right bank turn right after takeoff. The airplane then went into the clouds which were 200 to 400 feet agl. Radar data indicated that the airplane made several 90 degree turns prior to impacting the mountainous terrain 2.55 nm from the departure end of the runway. The pilot normally used 20 degrees of flaps for takeoff. A test pilot said that the airplane handles significantly different during takeoff if zero degrees of flaps are used verses 20 degrees of flaps. The upper cabin's entry door was found, with the locking handle and locking pins, in the closed position. No preimpact engine or airframe anomalies, which might have affected the airplane's performance, were identified.
Probable cause:
The pilot's failure to maintain aircraft control for undetermined reason. A factor was the low ceiling IMC weather condition.
Final Report:

Crash of a Cessna 402B in Fort Lauderdale

Date & Time: Apr 20, 1999 at 1910 LT
Type of aircraft:
Registration:
N744MA
Flight Type:
Survivors:
Yes
Schedule:
Fort Myers – Fort Lauderdale
MSN:
402B-0592
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2600
Captain / Total hours on type:
500.00
Aircraft flight hours:
2675
Circumstances:
While on approach to land the left engine surged and lost power. The pilot switched the left engine fuel selector to another fuel tank and the engine restarted. A short time later the left engine surged and lost power again. The pilot switched the left engine fuel selector to the right main fuel tank and the engine again restarted. A short time later the left engine quit again and he shutdown the engine and feathered the propeller. A short time later the right engine surged and lost power. He shut down the right engine and feathered the propeller. He then made a forced landing in a field and during landing rollout the aircraft's left wing collided with a tree. A fire erupted in the left wing area. Post crash examination showed the right main fuel tank was empty. The right auxiliary fuel tank contained 2.5 gallons. The left main fuel tank contained one half gallon of fuel and the left auxiliary tank was ruptured. The pilot operating handbook stated that the main fuel tanks had one gallon unusable fuel and the auxiliary fuel tanks had one half gallon of unusable fuel.
Probable cause:
A loss of engine power due to fuel exhaustion and the pilot in command's failure to ensure that the aircraft had adequate fuel to complete the flight.
Final Report:

Crash of a Beechcraft Beechjet 400A in Beckley

Date & Time: Apr 17, 1999 at 1451 LT
Type of aircraft:
Operator:
Registration:
N400VG
Survivors:
Yes
Schedule:
West Palm Beach – Beckley
MSN:
RK-113
YOM:
1996
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4719
Captain / Total hours on type:
107.00
Copilot / Total flying hours:
6250
Copilot / Total hours on type:
148
Aircraft flight hours:
1215
Circumstances:
The airplane touched down about 1/3 beyond the approach end of Runway 28, a 5,000 footlong, asphalt runway. The PIC stated, 'as usual,' he applied 'light' braking and attempted to actuated the airplane's thrust reverser (TR) system; however, the TR handles could not be moved beyond the 'Deploy-Reverse-Idle' position. After the PIC cycled the levers two or three times, he began to apply maximum braking. A passenger in the airplane stated he looked out of the cockpit window, saw the end of the runway, and the airplane seemed like it was still moving 'pretty fast.' As the airplane approached the end of the runway, he could see smoke, which he believed was coming from the airplane's tires. He then sensed the airplane was falling. The co-pilot stated he had no memory at all of the accident flight. Review of the CVR revealed the co-pilot said that the airplane was 'Vref plus about twenty,' when the airplane was 100 feet over the runway threshold. The PIC could not recall the airplane's touchdown speed, however, he stated that it seemed like the airplane was still traveling 50 to 60 knots when it departed the end of the runway. A pair of parallel tire marks were observed 3,200 feet beyond the approach end of the runway. The tire marks extended past the end of the runway and onto a 106 foot-long grass area. The airplane came to rest on a plateau about 90 feet below the runway elevation. Examination of the airplane, including the optional TR system did not reveal any pre-impact malfunctions. The airplane's estimated landing distance was calculated to be about 3,100 feet. The PIC reported about 4,700 hours of total flight experience, of which, 107 hours were in make and model. The PIC stated he had never performed a landing in the accident airplane without using the TR system. Winds reported at the time of the accident were from 290 degrees at 15 knots, with 21 knot gusts.
Probable cause:
The pilot-in-command misjudged his altitude and airspeed which resulted in an overrun. Contributing to the accident were the pilot's lack of total flight experience in make and model, the pilot's reliance on the airplane's optional thrust reverser system and his inability to engage the airplane's thrust reverser system for undetermined reasons.
Final Report:

Crash of a McDonnell Douglas MD-11F in Shanghai: 8 killed

Date & Time: Apr 15, 1999 at 1604 LT
Type of aircraft:
Operator:
Registration:
HL7373
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Shanghai - Seoul
MSN:
48409
YOM:
1992
Flight number:
KE6316
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
12898
Captain / Total hours on type:
4856.00
Copilot / Total flying hours:
1826
Copilot / Total hours on type:
1152
Aircraft flight hours:
28347
Aircraft flight cycles:
4463
Circumstances:
On April 15, 1999, Korean Air cargo flight KE6316, a McDonnell Douglas MD-11F, Korean registration HL7373, departed from runway 18 at Shanghai-Hongqiao International Airport, for Seoul, Korea with 2 pilots and 1 flight technician on board at 16:01:35 Beijing local time (08:01:35 UTC time). The autopilot was off 1 minute 7 seconds (at 16:02:42) after takeoff. The airplane maneuvered first to the right, and then kept level flight at approximately 200° track for more than 30 seconds, and maneuvered back to the left. The crew was subsequently cleared to climb to 1,500 meters (4,900 feet) during which the airplane turned to NHW** at 900 meters (3,000 feet). The airplane passed 1,310 meters at 16:04:15, the airplane suddenly executed a very rapid descent after reaching 1,370 meters (4,500 feet) at 16:04:19 and then the airplane disappeared from the airport SSR screen. The airplane crashed into the ground at 16:04:35 according to Shanghai Seismic Bureau's measurement. The distance from the accident site to the airport runway is 11.6 kilometers, the site azimuth is 165° from the center of the runway centerline. The aircraft was totally destroyed and all three crew members were killed as well as five people on the ground. Thirty-six other people were injured, four seriously.
Probable cause:
The joint investigative team determines that the probable cause of the Korean Air flight KE 6316 accident was the flight crew's loss of altitude situational awareness resulting from altitude clearance wrongly relayed by the first officer and the crew's overreaction with abrupt flight control inputs.
Final Report:

Crash of a Learjet 24D in Ribeirao Preto: 5 killed

Date & Time: Apr 7, 1999 at 1147 LT
Type of aircraft:
Registration:
PT-LEM
Flight Type:
Survivors:
No
Schedule:
São Paulo - Ribeirão Preto
MSN:
24-270
YOM:
1973
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
4000
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
6000
Copilot / Total hours on type:
100
Circumstances:
The aircraft departed São Paulo-Congonhas on a training flight to Ribeirão Preto-Leite Lopes Airport, carrying five crew members, instructor and pilots. On final approach to runway 18, during the last segment, just prior to touchdown, the aircraft rolled to the right, causing the right wing tip to struck the runway surface. The pilot-in-command overcorrected, the aircraft went out of control and crashed 420 metres past the first impact, bursting into flames. All five occupants were killed.
Probable cause:
Contributing Factors:
- There was the participation of individual psychological variables in the pilot-in-command's performance due to the excess of self-confidence and self-demand in his customary behavior, besides the dissimulation regarding his real qualification for the type of flight. The personality with traces of permissiveness and insecurity of the co-pilot also contributed to the occurrence, as it allowed the aircraft to be operated by an unqualified pilot, with no employment link with the company.
- There was a lack of adequate supervision by Manacá Táxi Aéreo, as it allowed a crew member who had not operated the type of aircraft for one year and had not made any type of flight for four months, besides not having any employment relationship with that company. It is also necessary to consider the failure of supervision at the organizational level due to the issue of an incorrect license by the DAC, giving rise to the possibility of its use for the revalidation of license in aircraft for which the pilot was not qualified to exercise the function of commander.
- The entire sequence of events began with pilot errors resulting from the pilot's lack of flight experience in the left-hand seat on the aircraft in question.
- The inadequate use of cockpit resources destined to the aircraft operation, due to an ineffective accomplishment of the tasks assigned to each crew member, besides the interpersonal conflict resulting from the co-pilot's intervention in the pilot in command operation, in the final approach phase, already close to the aircraft's touchdown, configure the collaboration of this factor to the accident.
- The inadequate use of the aircraft commands, by the pilot in command, making excessive aileron corrections in the final approach phase, near the landing.
- The pilot was qualified as a co-pilot on the equipment, but due to a typing error, he was issued a pilot license. Thus, the situation and operation of the pilot in question were totally irregular.
Final Report: