Crash of a De Havilland DHC-6 Twin Otter 200 in Palm Beach

Date & Time: Apr 5, 1999 at 0945 LT
Operator:
Registration:
N838MA
Survivors:
Yes
Schedule:
Palm Beach - Kissimmee
MSN:
188
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8000
Captain / Total hours on type:
200.00
Aircraft flight hours:
16659
Circumstances:
The pilot reported that prior to takeoff, he completed a preflight inspection of the airplane that included checking the engine oil quantity. The line personnel topped off the oil reservoirs, and reportedly secured the engine oil reservoir filler caps. Approximately two minutes into the flight, the right engine oil pressure warning light illuminated. The pilot informed Palm Beach Approach Control of the engine oil pressure problem, shut down the right engine, and returned to Lantana. As the flight approached runway 03, the pilot heard a radio transmission from another airplane taxiing for takeoff. As the pilot continued the approach, with full flaps extended, he elected to go-around 1500 feet from the approach end of the 3000-foot runway. The airplane collided with the ground during the go-around maneuver to runway 15. The wreckage examination also disclosed that the right cowling showed oil streaming back from behind the engine and onto the wing strut. Inspection of the oil filler cap revealed that it had not been properly installed.
Probable cause:
The pilot's failure to secure the engine oil filler cap during the preflight inspection that resulted the subsequent loss of engine power, and his in-flight decision to attempt a single engine go-around with full wing flaps extended.
Final Report:

Crash of a Grumman G-21A Goose in Fort Lauderdale: 1 killed

Date & Time: Mar 25, 1999 at 1139 LT
Type of aircraft:
Registration:
N5548A
Flight Type:
Survivors:
Yes
Schedule:
Watson Island - Fort Lauderdale
MSN:
1150
YOM:
1942
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10000
Captain / Total hours on type:
520.00
Aircraft flight hours:
13136
Circumstances:
The pilot was receiving a competency flight in the seaplane from an FAA inspector. The pilot was returning to their initial departure airport, descended to 1,000 feet, contacted the control tower for landing instructions, and was instructed to enter on a right base. Before he could acknowledge the landing instructions the engines started to make loud, rough, and unusual noises. The pilot informed the control tower that he was 2 miles south , declared an emergency, and stated he had a bad engine on the left side. The FAA inspector stated the pilot started the emergency procedure, the manifold pressure and rpm was fluctuating. The inspector could not determine the dead engine by the dead foot, dead engine method, because her rudder pedals were stowed. She pointed out a pasture and the pilot stated they were going to the water. She did not recall the pilot shutting down the engine or feathering the propeller. She could not recall the final seconds of the flight. The airplane collided with a tree, canal bank, and came to rest inverted in the canal. Examination of the airframe and flight control systems revealed no evidence of a precrash mechanical failure or malfunction. Examination of the left propeller revealed it was not feathered. The No. 6 front forward spark plug ignition lead was disconnected from the spark plug. The ignition lead shroud threaded coupling on the No. 4 front forward spark plug was unscrewed and the carbon wire was exposed. The left and right engines were removed from the airplane and transported to an authorized FAA approved repair station. The left engine was placed in an engine test cell. The engine was started, developed rated power, and achieved takeoff power. The spark plug lead was removed from the No.6 forward cylinder. The left magneto had a 125 rpm drop during the magneto check. The right magneto had a 75 rpm drop. The magneto drop exceeded the allowable drop indicated by the engine overhaul manual. The right engine was placed in a engine test cell. The engine was started, developed rated power, and achieved takeoff power. Review of the FAA inspectors FAA Form 4040.6 revealed she was not Event Based Current (EBC) for the 4th quarter of the Flight Standards EBC program, and she did not meet the EBC quarterly events required by the end of the 14-day grace period. FAA Order 4040.9 states for an FAA inspector to be eligible / assigned to perform flight certification job function they must be EBC current., and inspectors should not accept assignments without being in compliance with the FAA Order. Managers and supervisors should not assign inspectors who are not current. The FAA inspector's supervisor was aware that the inspector was not current. He contacted the FAA Safety Regulation Branch, FAA Southern Region Headquarters, and stated that FAA Southern Region indicated that the inspector could administer the checkride. FAA Southern Region stated at no time did they approve or agree to an operation outside the parameters of the FAR's, Inspector Handbook or FAA Order.
Probable cause:
The pilots failure to correctly identify an in-flight emergency (fluctuating manifold pressure and rpm due to a disconnected spark plug lead / unscrewed ignition lead shroud) and failure to complete the engine shutdown procedure once it was initiated (propeller not feathered). This resulted in a forced landing and subsequent in-flight collision with a tree, dirt bank and canal. Contributing to the accident was the FAA inspectors improper supervision of the pilot, and the improper supervision of the inspector by her supervisor, in his failure to follow written procedures / directives in assigning a non-current inspector to conduct a competency flight.
Final Report:

Crash of an Airbus A300C4-620 in Rhodes

Date & Time: Mar 24, 1999 at 1210 LT
Type of aircraft:
Operator:
Registration:
A6-PFD
Survivors:
Yes
Schedule:
Dubai - Rhodes
MSN:
374
YOM:
1985
Country:
Region:
Crew on board:
19
Crew fatalities:
Pax on board:
252
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Dubai, the crew completed the approach to Rhodes-Diagoras Airport in rain falls and strong winds. The aircraft landed at a speed of 166 knots, about 22 knots above Vref. After touchdown, the ground spoilers did not deploy automatically because they had not been armed. Consequently the auto brake system, which operates by the deployment of spoilers, did not activate. The crew attempted manual braking but this operation was too late and the aircraft was unable to stop within the remaining distance. It overran, lost its undercarriage and came to rest few dozen metres further. All 271 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a Beechcraft A90 King Air in Franca: 2 killed

Date & Time: Mar 23, 1999 at 1910 LT
Type of aircraft:
Registration:
PT-OUL
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Franca – Ribeirão Preto
MSN:
LJ-125
YOM:
1966
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3500
Captain / Total hours on type:
650.00
Copilot / Total flying hours:
206
Circumstances:
Less than a minute after takeoff from Franca Airport, while climbing in poor weather conditions, the twin engine aircraft nosed down and crashed in a huge explosion about 1,500 metres past the runway end. The aircraft was destroyed and both pilots were killed. They were completing a cargo flight to Ribeirão Preto, carrying documents on behalf of Banco do Brasil.
Probable cause:
The following findings were identified:
- The crew was in a hurry to take off in order to avoid poor weather approaching the airport,
- The crew took off from an intersection with a taxiway,
- Immediately after takeoff, the aircraft entered clouds,
- Approximately one minute after liftoff, the aircraft impacted ground,
- After the first impact, the aircraft flew for another 200 metres and again collided with the ground and exploded,
- The aircraft was totally destroyed by a post crash fire,
- The pilot had a hearing problem that was stabilized and was being researched by HASP. Considering the relationship between ear and ear balance, spatial disorientation in the pilot in
in the face of the adverse conditions it experienced: flight conditions by instruments associated with “windshear”. Since the search could not be completed above mentioned, this aspect remains undetermined,
- Individual characteristics contributed due to the habits acquired by the pilot and his eventual practice of taking off from the taxiway, delaying the point from which the aircraft would achieve the best characteristics flight performance,
- Poor weather conditions with CB's, sudden changes in wind, strong turbulence and rain, were conducive to the emergence of the phenomenon of “Windshear”, representing a real risk to the operation of any aircraft, being that voluntary entry or not, in this type of training, results almost always in the loss of control of the aircraft with unforeseeable consequences. The crew faced these conditions when the aircraft took off,
- It was evident from the witness statements that the pilot was in a hurry to take off, in addition to having used runway 23 from the intersection and towards the sector most affected by poor weather.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter in Davis Inlet: 1 killed

Date & Time: Mar 19, 1999 at 0945 LT
Operator:
Registration:
C-FWLQ
Flight Type:
Survivors:
Yes
Schedule:
Goose Bay - Davis Inlet
MSN:
724
YOM:
1980
Flight number:
PB960
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1600
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
70
Aircraft flight hours:
30490
Circumstances:
The flight was a pilot self-dispatched, non-scheduled cargo flight from Goose Bay to Davis Inlet, Newfoundland, and was operating as Speed Air 960 under a defence visual flight rules flight plan. Before the flight, the captain received weather information from the St. John's, Newfoundland, flight service station (FSS) via telephone and fax. The aircraft departed for Davis Inlet at 0815 Atlantic standard time (AST). The captain was the pilot flying (PF). During the first approach, the first officer (FO) had occasional visual glimpses of the snow on the surface. The captain descended the aircraft to the minimum descent altitude (MDA) of 1340 feet above sea level (asl). When the crew did not acquire the required visual references at the missed approach point, they executed a missed approach. On the second approach, the captain flew outbound from the beacon at 3000 feet asl until turning on the inbound track. It was decided that if visual contact of the surface was made at any time during the approach procedure, they would continue below the MDA in anticipation of the required visual references. The captain initiated a constant descent at approximately 1500 feet per minute with 10 degrees flap selected. The FO occasionally caught glimpses of the surface. At MDA, in whiteout conditions, the captain continued the descent. In the final stages of the descent, the FO acquired visual ground contact; 16 seconds before impact, the captain also acquired visual ground contact. At 8 seconds before impact, the crew selected maximum propeller revolutions per minute. The aircraft struck the ice in controlled flight two nautical miles (nm) from the airport (see Appendix B). During both approaches, the aircraft encountered airframe icing. The crew selected wing de-ice, which functioned normally by removing the ice.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The captain decided to descend below the minimum descent altitude (MDA) without the required visual references.
2. After descending below MDA, both pilots were preoccupied with acquiring and maintaining visual contact with the ground and did not adequately monitor the flight instruments; thus, the aircraft flew into the ice.
Findings as to Risk:
1. The flight crew did not follow company standard operating procedures.
2. Portions of the flight were conducted in areas where the minimum visual meteorological conditions required for visual flight rules flight were not present.
3. Although both pilots recently attended crew resource management (CRM) training, important CRM concepts were not applied during the flight.
4. The cargo was not adequately secured before departure, which increased the risk of injury to the crew.
5. The company manager and the pilot-in-command did not ensure that safe aircraft loading procedures were followed for the occurrence flight.
6. There were lapses in the company's management of the Goose Bay operation; these lapses were not detected by Transport Canada's safety oversight activities.
7. The aircraft was not equipped with a ground proximity warning system, nor was one required by regulation.
8. Records establish that the aircraft departed approximately 500 pounds overweight.
Other Findings:
1. The flight crew were certified, trained, and qualified to operate the flight in accordance with existing regulations and had recently attended CRM training.
2. During both instrument approaches, the aircraft was operating in instrument meteorological conditions and icing conditions.
3. There was no airframe failure or system malfunction prior to or during the flight. In particular, the airframe de-icing system was serviceable and in operation during both approaches.
4. It was determined that an ice-contaminated tailplane stall did not occur.
5. The fuel weight was not properly recorded in the journey logbook.
6. The wreckage pattern was consistent with a controlled, shallow descent.
7. The emergency locator transmitter was damaged due to impact forces during the accident, rendering it inoperable.
Final Report:

Ground fire of an ATR42-320 in Mucuri

Date & Time: Mar 16, 1999 at 1818 LT
Type of aircraft:
Operator:
Registration:
PT-MFI
Survivors:
Yes
Schedule:
São Paulo – Mucuri
MSN:
302
YOM:
1992
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10500
Captain / Total hours on type:
3550.00
Copilot / Total flying hours:
6500
Copilot / Total hours on type:
799
Circumstances:
On approach to Mucuri-Itabatã Airport runway 05, the right engine caught fire. The crew followed the checklist, continued the approach and completed a safe landing. After touchdown, the aircraft slightly deviated to the right and came to rest, bursting into flames. All 14 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
It is believed that the engine fire was the consequence of the failure of a fuel burner.
Final Report:

Crash of a Cessna 340A in Chesapeake: 2 killed

Date & Time: Mar 16, 1999 at 0950 LT
Type of aircraft:
Registration:
N13DT
Flight Type:
Survivors:
No
Schedule:
Chesapeake – Bunnell
MSN:
340A-0063
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4500
Captain / Total hours on type:
10.00
Aircraft flight hours:
3575
Circumstances:
After takeoff, the airplane returned to the departure airport for an emergency landing. The aircraft was observed in the vicinity of the runway threshold, about 500 feet above the ground, with it's left propeller feathered, when it entered a left bank which increased to about 90 degrees. The airplane then entered a spin, descended, and impacted the ground. Examination of wreckage revealed the camshaft of the left engine had failed as a result of a fatigue crack. No other abnormalities were observed of airframe or engine. The left engine had accumulated about 1,200 hours since overhaul. The pilot purchased the airplane about 1 month prior to the accident. At that time, he reported 700 hours of flight experience in multi-engine airplanes, of which, 10 hours were in the make and model of the accident airplane.
Probable cause:
The pilot's failure to maintain control of the airplane during a single engine emergency landing, after experiencing a failure of the left engine. A factor in this accident was the failure of the left engine's camshaft due to a fatigue crack.
Final Report:

Crash of a McDonnell Douglas MD-83 in Pohang

Date & Time: Mar 15, 1999 at 1155 LT
Type of aircraft:
Operator:
Registration:
HL7570
Survivors:
Yes
Schedule:
Seoul - Pohang
MSN:
53485
YOM:
1996
Flight number:
KE1533
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
150
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Pohang Airport, the crew encountered poor weather conditions with rain falls and strong winds. The captain decided to initiate a go-around procedure and started a second approach few minutes later. On approach to runway 10, the wind component changed and the crew continued the descent with a 20 knots tailwind. At an excessive speed of 158 knots, the aircraft landed 1,500 feet past the runway threshold. On a wet runway surface, the aircraft was unable to stop within the remaining distance (runway 10 is 7,000 feet long), overran, struck a 3 metres high embankment and came to rest in a ravine, broken in two. All 156 occupants were rescued, among them 60 passengers were injured, two seriously.
Probable cause:
The following findings were identified:
- Poor crew action during an approach in poor weather conditions,
- Excessive tailwind component,
- Misuse of brake and thrust reverser systems during the landing roll, about 27 seconds after touchdown only,
- The crew failed to initiate a go-around procedure as the landing was obviously missed,
- Poor ground assistance.

Crash of a Beechcraft C-45G Expeditor in Detroit: 1 killed

Date & Time: Mar 11, 1999 at 0051 LT
Type of aircraft:
Registration:
N234L
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Detroit - Detroit
MSN:
AF-447
YOM:
1958
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1305
Aircraft flight hours:
7073
Circumstances:
The aircraft declared an emergency following departure from runway 03R at Detroit Metropolitan Wayne County Airport, Romulus, Michigan. The aircraft was resting on a magnetic heading of 055 degrees located approximately 3,400 feet from and 1,900 feet to the left of the departure end and centerline of runway 03R at DTW. Inspection of the forward section of the fuselage door and surrounding fuselage, a circular impression with no exposure of the underlying metal was noted approximately 2 feet 6-1/2 inches from the door hinge line. The door was opened to a point nearly flush with the aircraft's fuselage. The door handle was found to match the circular impression in position and shape. There was no tearing or fracturing of the forward fuselage door pin tips or its door pin holes. Inspection of the door's latching mechanism revealed a brown colored nail connecting the handle and vertical latches. Both engine supercharger turbine wheels displayed scoring and deformation of the impeller blades in the plane of rotation. Aileron, elevator and rudder flight control continuity was established. The elevator trim was in the neutral position. The trailing edge flaps were in the retracted positions. Both engine oil screens showed no evidence of metal contamination.
Probable cause:
The aircraft control not maintained and the inadvertent stall by the pilot while maneuvering to the landing area. The open door was a contributing factor.
Final Report:

Crash of a Cessna 421B Golden Eagle II in North Bend: 2 killed

Date & Time: Mar 8, 1999 at 2145 LT
Operator:
Registration:
N41096
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
North Bend - Aurora
MSN:
421B-0446
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1200
Captain / Total hours on type:
135.00
Aircraft flight hours:
2342
Circumstances:
Witnesses reported hearing the engines start and shortly thereafter, the airplane taxied to the runway. The pilot then contacted ATC for an IFR clearance. The clearance was given with a short void time. The pilot acknowledged the clearance and began the takeoff ground roll. Witnesses reported that the night-time takeoff roll and engine sound appeared normal. Witnesses near the end of the runway reported that the airplane was observed at about 50 feet above the runway with about 1,000 feet of runway remaining when engine power was reduced on both engines. The airplane was heard to touch down, then engine power was reapplied. Shortly thereafter, the sound of the impact was heard. The airplane collided with the terrain about 600 feet from the end of the runway. During the post-accident inspection of the airplane and engines, no evidence was found to indicate a mechanical failure or malfunction. Documentation of the events indicated that from the time the aircraft began its taxi to the runway, to the time the takeoff roll began, was approximately six minutes in duration. Before the takeoff roll began, the pilot had accepted a clearance with a void time of four minutes. By the time the pilot correctly read back the clearance, less than two minutes remained before the void time. Post accident documentation of the accident site revealed that neither the pilot nor the passenger were wearing their lap belts or shoulder harnesses. It was also noted that the pilot had not yet selected the discrete transponder code as indicated by the clearance.
Probable cause:
A delayed aborted takeoff for an undetermined reason.
Final Report: