Crash of an Antonov AN-32B in Medellín: 5 killed

Date & Time: Dec 22, 1998 at 0014 LT
Type of aircraft:
Operator:
Registration:
HK-3930X
Flight Type:
Survivors:
No
Schedule:
Bogotá – Medellín
MSN:
3309
YOM:
1993
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
5554
Captain / Total hours on type:
1100.00
Copilot / Total flying hours:
2017
Copilot / Total hours on type:
1000
Aircraft flight hours:
3106
Circumstances:
The aircraft departed Bogotá-El Dorado Airport on a cargo flight to Medellín, carrying two passengers, three crew members and a load of newspapers. On approach to Medellín-José María Córdova Airport, the crew encountered poor weather conditions and reduced visibility due to thick fog. On short final, the aircraft was too low, struck trees and crashed one km short of runway 36. The aircraft was totally destroyed upon impact and all five occupants were killed.
Probable cause:
Controlled flight into terrain after the crew decided to continue the approach in below minima weather conditions due to thick fog until the aircraft impacted terrain. The crew failed to initiate a go-around procedure to divert to a suitable terrain.
Final Report:

Crash of a PZL-Mielec AN-2TP in Ayan

Date & Time: Dec 20, 1998
Type of aircraft:
Registration:
RA-02482
Flight Phase:
Survivors:
Yes
Schedule:
Ayan - Nelkan
MSN:
1G119-25
YOM:
1970
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following a poor flight preparation, the crew chose the wrong runway according to the wind component and elected to takeoff with a tailwind, and moreover with the flaps retracted. The captain started the takeoff roll from an intersection instead using all the runway length, causing the takeoff distance to be 660 metres. After a course of about 190 metres, the aircraft deviated to the right, veered off runway and came into soft ground. The crew continued to roll on a distance of 95 metres when the tail gear (tail ski) was torn off while contacting a 40 cm high earth mound. The aircraft continued, overran and came to rest 30 metres past the runway end. All 11 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Poor flight preparation on part of the crew who neglected several published procedures. It was determined that the pilot was intoxicated at the time of the accident.

Crash of an Antonov AN-12BP in Saurimo: 1 killed

Date & Time: Dec 17, 1998
Type of aircraft:
Operator:
Registration:
S9-CAT
Flight Type:
Survivors:
Yes
Schedule:
Luanda - Saurimo
MSN:
6 34 45 03
YOM:
1973
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
On final approach to Saurimo Airport, the captain initiated a go-around procedure after a vehicle entered the runway. The crew increased engine power but the aircraft continued to descend and struck the runway surface just past the threshold. Upon impact, the aircraft went out of control and came to rest, bursting into flames. The navigator was killed and nine other occupants were injured.

Crash of a Piper PA-31-310 Navajo B in Tegucigalpa: 2 killed

Date & Time: Dec 16, 1998 at 0730 LT
Type of aircraft:
Registration:
YS-14C
Flight Type:
Survivors:
No
Schedule:
Guatemala City – Tegucigalpa
MSN:
31-7300940
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
While approaching Tegucigalpa-Toncontin Airport runway 01 in IMC conditions, the aircraft descended too low and crashed 10 km short of runway at an altitude of 5,325 feet. The aircraft was destroyed and both occupants were killed. The minimum altitude for the approach at the crash site is 6,700 feet. After crossing the 5 DME fix, a flight can descend to 5,200 feet.
Probable cause:
Controlled flight into terrain after the crew continued the approach at an insufficient altitude until the aircraft impacted ground.

Crash of an Airbus A310-204 in Surat Thani: 101 killed

Date & Time: Dec 11, 1998 at 1910 LT
Type of aircraft:
Operator:
Registration:
HS-TIA
Survivors:
Yes
Schedule:
Bangkok - Surat Thani
MSN:
415
YOM:
1988
Flight number:
TG261
Country:
Region:
Crew on board:
14
Crew fatalities:
Pax on board:
132
Pax fatalities:
Other fatalities:
Total fatalities:
101
Aircraft flight hours:
23028
Aircraft flight cycles:
22031
Circumstances:
Thai Airways International flight 261, an Airbus A310, left Bangkok-Don Mueang International Airport, Thailand at 17:54 hours local time for a domestic flight to Surat Thani. At 18:26 hours, the copilot first established contact with the Surat Thani approach controller while the aircraft was 70 nautical miles away from Surat Thani Airport. The controller radioed that the crew could expect a VOR/DME instrument approach to runway 22. At that time surface wind was calm with a visibility of 1500 meters, light rain and a cloud base of 1800 feet. At 18:39 hours the copilot contacted Surat Thani aerodrome controller and reported over the Intermediate Fix (IF). The controller informed him that the precision approach path indicators (PAPI) on the right side of runway 22 were unserviceable while the left lights were in use. At 18:41 hours, the copilot reported passing final approach fix (FAF). The controller informed the pilot that the aircraft was not in sight but it was cleared to land on runway 22. The surface wind was blowing from 310 degrees at a velocity of 5 knots so the pilots should be careful or the slippery runway. At 18:42 hours, the copilot reported that the runway was in sight and later on the controller also had the aircraft in sight. The pilot decided to go-around. The controller asked the pilot about the distance where the runway could be seen. The copilot reported that it could be seen at 3 nautical miles and requested for the second approach. The controller requested to report over FAF . When the copilot reported that the flight was over the FAF again, the controller cleared the flight to land although he again could not see the runway. When the flight crew failed to observe the runway lights, the captain decided to go around again. Again the controller instructed the flight to report over the FAF and reported that visibility had decreased to 1,000 meters in light rain. At 19:05, after reporting over the FAF, the flight was cleared to land on runway 22. The flight maintained the Minimum Descent Altitude (MDA) but the crew were unable to see the runway. The autopilot was disconnected and a little later the captain decided to go around. The pitch attitude increased continuously. The pitch attitude reached approximately 40°, when the pilot applied the elevator decreasing the pitch attitude to 32-33°. When he discontinued applying elevator the pitch increased to 47-48°. Consequently the speed decreased to 100 knots. The captain was not aware of the attitude due to stress and the expectation that the go around was flown exactly like the first two go-arounds. The airplane lost altitude until it impacted terrain to the left of the runway. 45 people survived and 101 others were killed, including 11 crew members.
Probable cause:
After careful consideration. the Aircraft Accident Investigation Committee of the Kingdom of Thailand ultimately came to the conclusion that the accident occurred because the aircraft entered into stall condition which might be caused by the followings:
1. The pilot attempted to approach the airport in lower than minimum visibility with rain.
2. The pilot could not maintain the VOR course as set forth in the approach chart. The aircraft flew left of VOR course on every approach.
3. The pilots suffered from the accumulation of stress and were not aware of the situation until the aircraft emerged into the upset condition.
4. The pilots had not been informed of the document concerning the wide-body airplane upset recovery provided by Airbus Industrie for using in pilot training.
5. The lighting system and approach chart did not facilitate the low visibility approach.
6. Stall warning and pitch trim systems might not fully function as described in the FCOM and AMM.

Crash of a Beechcraft 350 Super King Air in Istanbul: 2 killed

Date & Time: Dec 5, 1998 at 1210 LT
Operator:
Registration:
TC-DHA
Flight Type:
Survivors:
No
Schedule:
Istanbul - Antalya
MSN:
FL-37
YOM:
1991
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
After takeoff from Istanbul-Atatürk Airport, on a positioning flight to Antalya, the crew reported technical problems and was cleared to return for an emergency landing. After touchdown, the twin engine aircraft went out of control, veered off runway and eventually collided with containers stored by the apron, bursting into flames. Both pilots were killed.

Crash of a Piper PA-31-350 Navajo Chieftain in Pontiac: 1 killed

Date & Time: Dec 4, 1998 at 2045 LT
Registration:
N59902
Flight Type:
Survivors:
No
Schedule:
Lansing - Troy
MSN:
31-7652125
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1866
Captain / Total hours on type:
129.00
Circumstances:
The airplane collided with the tops of trees during an ILS approach near the middle marke. Witnesses heard the airplane strike the trees and a '...whop, whop, whop sound...' it made as it continued its flight. Other witnesses observed the airplane flying a curved, descending, flight path until the aircraft impacted the ground. Visibility was reported as 1/2 mile at the airport. The on-scene examination revealed no airframe or engine anomalies that would prevent flight. A section of the right propeller and other pieces of airframe were found along the approach path after initial impact with trees. The trees along the flight path were about 30 to 60 feet high. The tops of the taller trees were broken or had fresh cut marks on their limbs. The pilot's blood alcohol level was 216 (mg/dL, mg/hg).
Probable cause:
The pilot's descent below the decision height for the instrument approach.
Final Report:

Crash of an Avro 748-335-2A in Iqaluit

Date & Time: Dec 3, 1998 at 1536 LT
Type of aircraft:
Operator:
Registration:
C-FBNW
Flight Phase:
Survivors:
Yes
Schedule:
Iqaluit - Igloolik
MSN:
1759
YOM:
1978
Flight number:
FAB802
Location:
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8000
Captain / Total hours on type:
800.00
Copilot / Total flying hours:
2143
Copilot / Total hours on type:
117
Circumstances:
At approximately 1536 eastern standard time, First Air flight 802, a Hawker Siddeley HS-748-2A, serial number 1759, was on a scheduled flight from Iqaluit to Igloolik, Nunavut. On board were two flight crew, one flight attendant, one loadmaster, and three passengers. During the take-off run on runway 36, at the rotation speed (VR), the captain rotated the aircraft; however, the aircraft did not get airborne. Approximately seven seconds after VR, the captain called for and initiated a rejected take-off. The aircraft could not be stopped on the runway, and the nose-wheel gear collapsed as the aircraft rolled through the soft ground beyond the end of the runway. The aircraft hit the localizer antenna and continued skidding approximately 700 feet. It came to rest in a ravine in a nose-down attitude, approximately 800 feet off the declared end of the runway. The flight attendant initiated an evacuation through the left, main, rear cabin door. The two pilots evacuated the aircraft through the cockpit windows and joined the passengers and the flight attendant at the rear of the aircraft. The flight attendant was slightly injured during the sudden deceleration of the aircraft. The aircraft was substantially damaged.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The captain rejected the take-off at a speed well above the engine-failure recognition speed (V1) with insufficient runway remaining to stop before the end of the runway.
2. The far-forward position of the centre of gravity contributed to the pilot not rotating the aircraft to the normal take-off attitude.
3. The aircraft never achieved the required pitch for take-off. The captain=s inability to accurately assess the pitch attitude was probably influenced by the heavier than normal elevator control forces and the limited nighttime visual references.
4. The loadmaster did not follow the company- and Transport Canada-approved procedures to evaluate the excess baggage added to the aircraft, which led to a discrepancy of 450 pounds and a C of G position further forward than expected.
5. The performance analysis suggested that the aircraft was under-rotated as a result of a forward C of G loading and the generated lift never exceeded the aircraft=s weight during the take-off attempt.
Findings as to Risk:
1. The aircraft was approximately 200 pounds over maximum gross take-off weight.
2. The aircraft accelerated more slowly than normal, probably because of the snow on the runway.
3. Although atmospheric conditions were conducive to contamination and the aircraft was not de-iced, it could not be determined if contamination was present or if it degraded the aircraft performance during the attempted take-off.
4. Water methanol was not used for the occurrence take-off. Use of water methanol may have reduced the consequences of the rejected take-off.
5. The captain did not call for the overrun drill, and none of the items on the checklist were covered by the crew.
6. The co-pilot did not follow the emergency checklist and call air traffic control to advise of the rejected take-off or call over the public address system to advise the passengers to brace.
7. The aircraft lost all its electrical systems during the impact with the large rocks, rendering the radios unserviceable.
8. No HS-748 simulator exists that could be used to train pilots on the various take-off and rejected take-off scenarios.
9. There was confusion regarding the aircraft=s location. The flight service station, fire trucks, and intervening teams were not using an available grid map for orientation.
10. There is a risk associated with not de-icing aircraft before take-off in weather conditions such as those on the day of the accident.
11. There is a risk associated with not calculating the WAT limit and performance of an aircraft during an engine-out procedure in an environment with obstacles.
Other Findings
1. The aircraft=s brakes, anti-skid system, and tires functioned properly throughout the rejected take-off.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Point Lay

Date & Time: Dec 3, 1998 at 1038 LT
Operator:
Registration:
N3542H
Flight Type:
Survivors:
Yes
Schedule:
Kotzebue - Point Lay
MSN:
31-7952233
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3069
Captain / Total hours on type:
311.00
Aircraft flight hours:
15638
Circumstances:
A witness observed the airplane circle to land at the completion of an NDB approach. The nighttime meteorological conditions were an 800 feet ceiling, 1 mile visibility in blowing snow, and 26 knot winds. The surrounding terrain was essentially flat, snow covered, and featureless. The witness saw the airplane on final approach misaligned for the runway, and then disappear below an 18 feet msl bluff. He transmitted on the radio to 'get out of there,' and heard no response. About 10 minutes later the accident pilot walked up to the witness' airplane. The pilot told the investigator-in-charge that he was 'beat around by the winds, ...it was snowing pretty hard, I always had the lights, and I was concentrating on the runway. The next thing I knew I was on the ground short of the runway.' The pilot's previous experience to this airport was during daytime, and during visual conditions. The airport, which was being transferred from the Air Force to the North Slope Borough, has medium intensity runway lights (MIRL), and runway end identifier lights (REILS). It does not have visual approach slope indicator (VASI) lights.
Probable cause:
Failure of the pilot to maintain a proper glidepath. Factors associated with this accident were the airport not having a VASI system installed, and the lack of visual perception for the pilot.
Final Report:

Crash of a Lockheed L-1329-25 JetStar II in Austin

Date & Time: Nov 27, 1998 at 1405 LT
Type of aircraft:
Operator:
Registration:
N787WB
Survivors:
Yes
Schedule:
Houston - Austin
MSN:
5210
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8350
Captain / Total hours on type:
750.00
Aircraft flight hours:
5938
Circumstances:
During the landing roll, the nose gear settled onto the runway, and the aircraft veered hard to the right. Application of the left brake had no effect. The airplane skidded, exited the runway, struck a runway marker, and collapsed the nose landing gear. The steering actuator had failed, the hydraulic fluid was lost from the steering actuator, and the fuselage received structural damage. The steering actuator assembly, p/n 1501-4, had accumulated 5,938.0 hours since new and had not been repaired or overhauled. Examination of the nose gear steering actuator cylinder by the metallurgist revealed that the cylinder fracture was the result of fatigue cracking initiated by an abrupt machining transition from the 45 degree thread ring chamfer to the straight wall of the cylinder. The engineering drawings appear to depict the radius at the fatigue origin as a continuation of the 0.03 inch to 0.06 inch radius adjacent to the fracture. However, the drawing is not clear on the specific intent of the transition between the nearby radius and the internal threads for the nut.
Probable cause:
The steering actuator fatigue failure resulting from inadequate procedure documentation for the manufacturing process.
Final Report: