Crash of a Boeing 737-2P6 in Atlanta

Date & Time: Nov 1, 1998 at 1848 LT
Type of aircraft:
Operator:
Registration:
EI-CJW
Survivors:
Yes
Schedule:
Atlanta - Dallas
MSN:
21355
YOM:
1977
Flight number:
FL867
Crew on board:
5
Crew fatalities:
Pax on board:
100
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15000
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
4976
Copilot / Total hours on type:
167
Aircraft flight hours:
45856
Aircraft flight cycles:
49360
Circumstances:
The first officer of AirTran Airways flight 890, which preceded AirTran flight 867 in the accident airplane, identified and reported a leak from the right engine of the Boeing 737-200 during a postflight inspection at William B. Hartsfield Atlanta International Airport (ATL), Georgia. AirTran mechanics at ATL identified the source of the leak as a chafed hydraulic pressure line to the right thrust reverser. They found the part in the illustrated parts catalog (IPC), which was not designed as a troubleshooting document and does not contain sufficient detail for such use. One of the mechanics telephoned an AirTran maintenance controller in Orlando, Florida, for further instructions. The mechanics who initially identified the source of the leak had little experience working on the Boeing 737 because they had worked for ValuJet Airlines, which flew DC-9s only, until ValuJet and AirTran merged in September 1997. On the basis of the information provided by the mechanic, and without questioning his description of the line or verifying the part number that he had provided against the IPC or some other appropriate maintenance document, the maintenance controller instructed the mechanic to cap the leaking line and deactivate the right thrust reverser in accordance with AirTran's Minimum Equipment List procedures. However, instead of capping the hydraulic pressure line, the mechanics capped the right engine hydraulic pump case drain return line. The mechanics performed a leak check by starting the auxiliary power unit and turning on the electric hydraulic pumps to pressurize the airplane's hydraulic systems; no leaks were detected. Although the mechanics were not required by company procedures to test their repair by running the engines, this test would have alerted the mechanics that they had incorrectly capped the hydraulic pump case drain line, which would have overpressurized the hydraulic pump and caused the hydraulic pump case seal to rupture. However, because the mechanics did not perform this test, the overpressure and rupture occurred during the airplane's climb out, allowing depletion of system A hydraulic fluid. Depletion of system A hydraulic fluid activated the hydraulic low-pressure lights in the cockpit, which alerted the flight crew that the airplane had a hydraulic problem. The crew notified air traffic control that the airplane would be returning to ATL and subsequently declared an emergency. The flight crew's initial approach to the airport was high and fast because of the workload associated with performing AirTran's procedures for the loss of hydraulic system A and the limited amount of time available to perform the procedures. Nevertheless, the crew was able to configure and stabilize the airplane for landing. However, depletion of system A hydraulic fluid disabled the nosewheel steering, inboard flight spoilers, ground spoilers, and left and right inboard brakes. The flight crew was able to land the airplane using the left thrust reverser (the right thrust reverser was fully functional but intentionally deactivated by the mechanics), outboard brakes (powered by hydraulic system B), and rudder. The flight crew used the left thrust reverser and rudder in an attempt to control the direction of the airplane down the runway, but use of the rudder pedals in this manner had depleted the system A accumulator pressure, which would have allowed three emergency brake applications. The use of the right outboard brake without the right inboard brake at a higher-than-normal speed (Vref for 15-degree flaps is faster than Vref for normal landing flaps) and with heavy gross weight (the airplane had consumed only 4,650 pounds of the 28,500 pounds of fuel on board at takeoff) used up the remaining friction material on the right outboard brake, causing it to fail. (The left outboard brake was still functional at this point.) The lack of brake friction material on the right outboard brake caused one of the right outboard brake pistons to overtravel and unport its o-ring, allowing system B hydraulic fluid to leak out; as a result, the left outboard brake also failed. Loss of the left and right inboard and outboard brakes, loss of nosewheel steering, and use of asymmetric thrust reverse caused the flight crew to lose control of the airplane, which departed the left side of the runway and came to rest in a ditch.
Probable cause:
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
(1) the capping of the incorrect hydraulic line by mechanics, which led to the failure of hydraulic system A;
(2) the mechanics' lack of experience working with the Boeing 737 hydraulic system; and
(3) the maintenance controller's failure to ascertain more information regarding the leaking hydraulic line before instructing the mechanics to cap the line and deactivate the right thrust reverser.
Contributing to the cause of the accident were:
(1) the asymmetric directional control resulting from the deactivation of the right thrust reverser;
(2) the depletion of the left and right inboard brake accumulator pressure because of the flight crew's use of the rudder pedals with only the left thrust reverser to control the direction of the airplane down the runway;
(3) the failure of the right outboard brake because the airplane was slowed without the use of the left and right inboard brakes and was traveling at a higher-than-normal speed and with heavy gross weight;
(4) the failure of the right outboard brake after one of the right outboard pistons overtraveled and unported its o-ring, allowing system B hydraulic fluid to deplete and the left outboard brake to fail; and
(5) the mechanics' improper use of the illustrated parts catalog for maintenance and troubleshooting and the maintenance controller's failure to use the appropriate documents for maintenance and troubleshooting.
Final Report:

Crash of a Douglas C-47A-90-DL in Quetzaltenango: 11 killed

Date & Time: Nov 1, 1998 at 1430 LT
Operator:
Registration:
N3FY
Flight Type:
Survivors:
Yes
Schedule:
Playa Grande - Quetzaltenango
MSN:
20562
YOM:
1944
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The aircraft was completing a humanitarian flight from Playa Grande to Quetzaltenango on behalf of the Living Water Teaching Ministries owned by Jim and Marion Zirkle. On board were 16 passengers and two pilots, among them doctors and a load of medicines and first aid kits for the victims of hurricane Mitch. The approach was completed in poor weather conditions with heavy rain falls and thick fog when the aircraft struck the ground few km from the airport. Seven people were rescued while 11 others were killed, among them Jim Zirkle and his son.
Probable cause:
The crew was approaching the airport under VFR mode in IMC conditions.

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

Date & Time: Oct 28, 1998 at 0858 LT
Operator:
Registration:
N35533
Flight Type:
Survivors:
No
Schedule:
Colorado Springs - Hayden
MSN:
31-8052047
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1800
Captain / Total hours on type:
375.00
Aircraft flight hours:
12411
Circumstances:
The Part 135 cargo flight was approaching its destination on an IFR flight plan. The pilot had requested the ILS-DME approach to runway 10, but 2 minutes later, he changed his request to the VOR-B approach to runway 28. ARTCC cleared him for the approach to the non-towered airport. The pilot contacted the airport's Unicom, and requested that the ramp personnel be standing by with fuel and oxygen. The airplane was found 5.8 nm from the approach end of runway 28, at 7,900 feet. The approach minimums for the VOR-B was 7,900 feet, which the pilot could descend to at 8.7 nm. The VOR was located 285 degrees at 13.6 nm from the accident site, and the ILS-DME transmitter was located 285 degrees at 5.6 nm from the accident site. The airplane was equipped with a single DME display head, and it had a Nav 1/Nav 2 selector switch.
Probable cause:
The pilot not following instrument procedures and subsequently descended to minimums prematurely. Factors were the mountainous terrain and the falling snow.
Final Report:

Crash of a Learjet 45 in Wallops Flight Facility

Date & Time: Oct 27, 1998 at 1456 LT
Type of aircraft:
Operator:
Registration:
N454LJ
Flight Type:
Survivors:
Yes
Schedule:
Wallops Flight Facility - Wallops Flight Facility
MSN:
45-004
YOM:
1998
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13073
Captain / Total hours on type:
767.00
Aircraft flight hours:
339
Circumstances:
The Learjet was participating in water ingestion tests, which required multiple landing rolls through a diked pool on the runway. On one of the landing rolls, the airplane's left main landing gear and nose landing gear tracked through the pool, while the right main landing gear tracked outside the pool. The airplane veered to the left, departed the left side of the runway, and struck a pickup truck parked adjacent to the runway. The airplane came to rest inverted and on fire. Formal hazard identification and risk management procedures were not employed and no alignment cues were in place on the runway to facilitate pool entry alignment. Further, the accident truck, other vehicles, heavy equipment, and personnel were placed hundreds of feet inside the FAA recommended runway-safe and object-free areas during the test.
Probable cause:
The failure of the pilot to obtain/maintain alignment with the water pool, which resulted in the loss of control. Factors in the accident were the inadequate preflight planning of the flight test facility and the airplane manufacturer which resulted in hazards in the test area and the subsequent collision of the airplane with a vehicle.
Final Report:

Crash of a Yakovlev Yak-40 in Yerevan: 4 killed

Date & Time: Oct 21, 1998 at 1315 LT
Type of aircraft:
Operator:
Registration:
EK-88272
Flight Phase:
Survivors:
Yes
Schedule:
Yerevan - Krasnodar
MSN:
9 72 10 53
YOM:
1977
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
33
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
During the takeoff roll at Yerevan-Erebuni Airport, at a speed of 95 km/h, the captain saw a military bus entering the runway. He made a first turn to the right then a second to the left to avoid the collision when the right wing struck the minibus while the aircraft was at a speed of 110 km/h. Upon impact, the minibus was destroyed and the aircraft came to a halt 300 metres further with its right wing partially torn off. All 37 occupants on board the aircraft escaped uninjured. Among the 10 people on the bus, four were killed and six were seriously injured.
Probable cause:
It was determined that the crew was cleared for takeoff while the bus driver did to establish any contact with the tower and elected to cross the runway without prior permission or traffic check. It was reported that ATC was not aware of the presence of the minibus at this time.

Crash of a Piper PA-31-350 Navajo Chieftain in Johannesburg

Date & Time: Oct 21, 1998 at 0310 LT
Operator:
Registration:
ZS-NHM
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Johannesburg - Windhoek
MSN:
31-8052035
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1020
Captain / Total hours on type:
350.00
Circumstances:
The aircraft was loaded with cargo intended for Namibia, early the morning of the accident. The pilot reported that the right-hand engine suffered a loss of power at the point where he rotated the aircraft for take-off. During the attempt to abort the take-off the aircraft skidded over the end of the runway and crashed down an embankment. The pilot and his passenger escaped with minor injuries, but the aircraft was subsequently destroyed by the post impact fire.
Probable cause:
During the investigation it was found that the aircraft was overloaded.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Eagle Pass

Date & Time: Oct 18, 1998 at 0600 LT
Operator:
Registration:
N19MH
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Eagle Pass - San Antonio
MSN:
421C-1008
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2095
Captain / Total hours on type:
120.00
Aircraft flight hours:
4071
Circumstances:
During takeoff climb, the twin-engine airplane encountered a strong downdraft and impacted trees and terrain. The pilot reported that while taxiing to the runway, he scanned the sky with the monochrome weather radar, which was set at the 40-mile range. 'No weather was shown behind the runway and a cell was shown 15 miles from the runway.' The takeoff roll was 'uneventful,' and the airplane was rotated at 95 knots. Climb out was accomplished at 110 knots, the engines were at maximum power, the propellers at maximum RPM, and the manifold pressure was indicating maximum. A 10-degree turn towards the Cotulla VOR was being made when at 1,500 feet msl, a sharp descent was felt with the VSI indicating an 800 ft/min rate of descent. The wings were leveled and the airspeed was slowed to 85 knots. 'The rate of descent slowed to 400 ft/min and then finally to 300 ft/min until impact...' The airplane was destroyed by fire that erupted on impact. A review of doppler weather radar images showed thunderstorms in the vicinity of the airport.
Probable cause:
A downdraft, which exceeded the aircraft's climb performance. A factor was the thunderstorms in the vicinity of the airport.
Final Report:

Crash of a Short SC.7 Skyvan 3M Variant 400 in Zell am See

Date & Time: Oct 17, 1998 at 1502 LT
Type of aircraft:
Operator:
Registration:
OE-FDF
Flight Phase:
Survivors:
Yes
Schedule:
Zell am See - Zell am See
MSN:
1958
YOM:
1978
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
6007
Aircraft flight cycles:
5409
Circumstances:
After takeoff from runway 25 at Zell am See Airport, the aircraft started to roll left and right. It banked right to an angle of 40° then stalled and crashed in an open field near the airport. All 21 occupants were rescued, among them eight were injured. The aircraft was damaged beyond repair after the undercarriage and both wings were torn off upon impact.
Probable cause:
The takeoff was initiated at an insufficient speed of 65 knots. It was determined that the friction locks of the throttles were not or not properly set prior to takeoff. Due to the vibration of the airplane, the throttles slowly retarded during the takeoff roll.

Crash of a Beechcraft 99A Airliner in Missoula

Date & Time: Oct 17, 1998 at 0230 LT
Type of aircraft:
Operator:
Registration:
N299GL
Flight Type:
Survivors:
Yes
Schedule:
Billings - Missoula
MSN:
U-102
YOM:
1969
Flight number:
AIP5010
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4567
Captain / Total hours on type:
667.00
Aircraft flight hours:
39685
Circumstances:
While flying a night visual approach, the co-pilot flared too high above the runway. As the aircraft floated down the runway, the speed decreased, and the pilot-in-command took control. Because he felt the aircraft was approaching a stall, he initiated a go-around. During the attempted go-around, the pilot-in-command found it necessary to keep both hands on the control wheel due to the fact that the aircraft had been trimmed to the full nose-up position during the landing flare. Even with both hands on the control wheel, the aircraft became very difficult to control. Although the co-pilot moved the throttles to maximum power and began retraction of the flaps, the pilot-in-command's remedial action had occurred too late to successfully execute the go-around. It was later discovered that during the operator's initial training, both crew members had been taught to apply full nose-up trim after crossing the runway threshold and reducing the power to idle. This action, which the operator eliminated from the landing sequence procedure after this accident, was inconsistent with the instructions in the Beech 99 Pilots Operating Manual.
Probable cause:
The pilot-in-command's delayed remedial action in response to the co-pilot's improper landing flare, and the co-pilot's application of excessive (full nose-up) trim during the landing flare as taught in the operator's initial aircrew training program. Factors include the co-pilot's improper flare and his lack of total experience in this type of aircraft.
Final Report:

Crash of a Beechcraft 65-B80 Queen Air in Brainerd

Date & Time: Oct 17, 1998 at 0033 LT
Type of aircraft:
Operator:
Registration:
N138BA
Flight Type:
Survivors:
Yes
Schedule:
Minneapolis - Brainerd
MSN:
LD-361
YOM:
1967
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4738
Captain / Total hours on type:
1813.00
Aircraft flight hours:
8119
Circumstances:
The pilot said that during the ILS approach he reached a point where he thought he should be seeing the approach lights. He said that he checked the radio to determine if it was on the correct frequency. He said that he realized that the transmit switch was selected to the wrong radio and when he returned his attention to the instruments, he realized that he had allowed the airplane to descend low on the glide path. He said that before he could react, the airplane impacted the terrain.
Probable cause:
The pilot's failure to maintain the proper glidepath and his diversion of attention during a critical phase of flight.
Final Report: