Crash of a Swearingen SA227AC Metro III in Santa Fe

Date & Time: Jun 3, 1998 at 0722 LT
Type of aircraft:
Operator:
Registration:
LV-WIL
Flight Type:
Survivors:
Yes
Schedule:
Buenos Aires – Santa Fe – Posadas
MSN:
AC-537
YOM:
1983
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While descending to Santa Fe-Sauce Viejo Airport by night, the crew was informed about poor weather conditions at destination. The visibility was estimated to be 30 metres in foggy conditions, well below minimums. As the crew elected to attempt an approach, he as cleared for and ILS approach to runway 03. On short final, the aircraft descended below the MDA and struck the ground 430 metres short of runway threshold. On impact, it lost its undercarriage and slid for another 180 metres before coming to rest. Both pilots escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
It was determined that the crew descended below the established minima during an instrument approach until the aircraft impacted terrain. The following contributing factors were identified:
- Inadequate flight planning, since there was reduced visibility at Sauce Viejo Airport from 01:00 hrs,
- Inappropriate request from the captain who attempted to make an approach in below minima weather conditions,
- Erroneous decision of the captain, knowing the meteorological conditions, to continue the approach below the decision height.

Crash of a Cessna 421A Golden Eagle I in Little Falls: 1 killed

Date & Time: Jun 1, 1998 at 1831 LT
Type of aircraft:
Registration:
N541N
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Little Falls - Little Falls
MSN:
421A-0161
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6000
Captain / Total hours on type:
1500.00
Circumstances:
A witness reported the airplane did not climb above 200 feet and reported seeing the airplane 'wobbling up and down' as it attempted to climb. He reported the airplane went into a sharp left bank and nose dived down. The airplane burned upon impact. The wreckage was located in a wooded area about 3/4 mile from the approach end of runway 30. Numerous open farm fields were located near the airplane's flight path. The winds were reported at 240 degrees at 22 knots gusting to 29 knots. The wreckage path was on a 040 heading and covered about 190 feet from initial tree impact to the location of the main wreckage. The engine inspection did not reveal any anomalies to either engine. The flight was the first maintenance check flight after the airplane had not been flown for 14 months. During maintenance the pilot had put about 100 gallons of water in the left main and left auxiliary fuel tanks to locate a fuel leak. A plug was installed in the left auxiliary fuel drain valve and the fuel tank could not be checked during preflight for fuel contamination without removing the plug.
Probable cause:
The pilot's continued operation with a known deficiency in equipment.
Final Report:

Crash of a Convair CV-240-17 in Aguadilla

Date & Time: Jun 1, 1998
Type of aircraft:
Registration:
N87949
Flight Type:
Survivors:
Yes
Schedule:
Aguadilla - Aguadilla
MSN:
202
YOM:
1950
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a local training flight at Aguadilla-Rafael Hernández Airport. Following several touch-and-go manoeuvres, the crew was approaching the airport when he inadvertently raised the landing gear prior to landing. The aircraft belly landed and came to rest. All three crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Belly landing after the crew mistakenly raised the landing gear.

Crash of a Cessna 414 Chancellor in North Platte

Date & Time: May 28, 1998 at 1300 LT
Type of aircraft:
Registration:
N888AA
Flight Phase:
Survivors:
Yes
Schedule:
North Platte - Kearney
MSN:
414-0468
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2353
Captain / Total hours on type:
312.00
Aircraft flight hours:
6159
Circumstances:
The airplane had just taken off and was at approximately 300 agl when the right engine 'had a sudden and catastrophic failure.' The right propeller stopped spinning with the blades in the low-pitch position. The pilot initiated a right turn back toward the airport, but the airplane would not maintain altitude. The pilot rolled out of the turn, but the descent continued until the airplane struck the trees. Examination of the airplane's right engine revealed that the crankshaft was broken at the number 3 short cheek, just forward of the number two cylinder piston rod. The number two crankshaft bearing was broken and melted. The oil feed line to the number two bearing was blocked by a piece of the broken bearing. The Single Engine Climb Data table in the Cessna 414 Pilot's Operating Handbook indicates that an airplane weighing 5,680 pounds, with gear and flaps retracted and the inoperative propeller in feather, operating at a density altitude of 5,055 feet, will have a best climb indicated airspeed of 115 knots. The rate of climb will be 308 feet per minute.
Probable cause:
The slipped number two bearing in the airplane's right engine, which blocked the bearing's oil feed line, causing the bearing and the crankshaft to overheat and fracture. A factor contributing to this accident was the trees.
Final Report:

Crash of a Pilatus PC-12/45 in Brno: 2 killed

Date & Time: May 26, 1998 at 0615 LT
Type of aircraft:
Operator:
Registration:
HB-FOJ
Flight Type:
Survivors:
No
Schedule:
Brno - Altenburg
MSN:
158
YOM:
1996
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
651
Captain / Total hours on type:
397.00
Circumstances:
After takeoff from runway 28 at Brno-Tuřany Airport, the pilot reported on the tower frequency that she needs to land. She received instruction to continue a southern (left-hand) circuit and to report final for runway 28. At this time the first contact was made with the aeroplane by secondary radar at a height of about 520 feet AAL and 560 metres north from runway 28. The pilot did not confirm the instruction, did not turn for the southern (left-hand) circuit, but continued to turn for the northern (right-hand) one. Since she did not confirm repeated approval for the left-hand circuit and continued the right-hand one, she received information from tower that it is possible to continue the northern circuit, clearance to land to runway 28 ans was offered assistance after landing. Without any confirmation. At this time the height was approximately 930 feet AAL and position 2,8 km north from the aerodrome. The aeroplane started gradually to descend and to turn as the pilot probably intended to accomplish approach for runway 28. However it did not happen and the aeroplane hit the ground at 0615,28 approximately 600 metres north from the runway 28 threshold. The aeroplane was flying very low in the last phase of flight according to statements of witnesses. The last height recorded by the secondary radar was approximately 120 feet AAL 13 seconds prior to the impact onto ground. Witnesses described the attitude of the aeroplane prior to strike to ground as very unusual. Both occupants were killed.
Probable cause:
The following factors were identified:
- The critical situation was caused by flap asymmetry. It occurred as a result of shear in torsion of the left-hand inner flexible shaft.
- Loss of controllability caused by reduction of airspeed with use of Beta range in the final phase of the flight was the direct cause of the accident.
- Incorrect application of emergency procedures for flap retraction listed in the Pilot's Operating Handbook was the main cause of the accident.
Final Report:

Crash of a Douglas C-47A-90-DL in Point McKenzie

Date & Time: May 24, 1998 at 0024 LT
Registration:
N67588
Flight Type:
Survivors:
Yes
Schedule:
Unalakleet - Anchorage
MSN:
20536
YOM:
1944
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14000
Captain / Total hours on type:
7000.00
Aircraft flight hours:
34232
Circumstances:
The captain/operator, the first officer and one passenger, departed on a cross-country positioning flight. The airplane contained about 300 gallons of fuel. After 3.9 hours en route, the flight was cleared for a visual approach to the destination airport. During the approach, both engines lost power about 2,000 feet mean sea level. The pilot stated the right fuel tank was empty. He estimated that 50 to 60 gallons of fuel remained in the left fuel tank. While the airplane was descending toward an area of open water, he attempted to restart the engines without success. He then lowered the landing gear, and made a right turn toward a small airstrip, located about 5 miles northwest of the destination airport. The airplane touched down in an area of soft, marsh covered, terrain. During the landing roll, the airplane nosed down and received damage to the forward, lower portion of the fuselage. An inspection of the airplane by an FAA inspector revealed the left fuel tank contained about 1 inch of fuel. The right fuel selector was positioned on the right auxiliary fuel tank. The left fuel selector was positioned between the left main, and the left auxiliary fuel tanks.
Probable cause:
The pilot's inadequate in-flight planning/decision which resulted in fuel exhaustion and subsequent loss of engine power. A related factor was the soft, marshy terrain at the forced landing area.
Final Report:

Crash of a Learjet 24B in Orlando

Date & Time: May 23, 1998 at 0330 LT
Type of aircraft:
Registration:
N100DL
Flight Type:
Survivors:
Yes
Schedule:
Miami - Orlando
MSN:
24-201
YOM:
1969
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18395
Captain / Total hours on type:
318.00
Aircraft flight hours:
8138
Circumstances:
During landing roll, the airplanes normal braking system failed as a result of hydraulic fluid leak(s). At the pilot's request, deployment of the drag chute and application of the emergency braking system was performed by the first officer. According to the first officer, application of the emergency brakes caused the airplane to yaw. The first officer then pulled up on the emergency brakes handle followed by re-application of braking pressure. This action took place several times during the landing roll. Gates' Learjet Flight Training Manual (Page 105) states, 'In using the emergency brake lever, slow steady downward pressure is required. Each time the lever is allowed to return upward to the normal position, nitrogen is evacuated overboard. Brace your hand so you will not allow the lever to move up and down inadvertently on a bumpy runway.' The airplane overran the end of the runway and collided with the Instrument Landing System back course antennae.
Probable cause:
The first officer's failure to perform proper emergency braking procedures.
Final Report:

Crash of an Embraer EMB-820C Navajo in Guanambi: 3 killed

Date & Time: May 20, 1998 at 1442 LT
Operator:
Registration:
PT-ENP
Flight Type:
Survivors:
No
Schedule:
Salvador - Guanambi
MSN:
820-075
YOM:
1978
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
9850
Captain / Total hours on type:
4940.00
Copilot / Total flying hours:
867
Copilot / Total hours on type:
218
Circumstances:
The twin engine aircraft was completing a cargo flight from Salvador to Guanambi, carrying one passenger, two pilots and a load consisting of briefcases containing valuables. On final approach to Guanambi Airport, following a 1 hour and 42 minutes of flight, both engines lost power. The crew lost control of the airplane that crashed few hundred metres short of runway. All three occupants were killed.
Probable cause:
The following findings were identified:
- Failure of the left engine on final approach,
- Possible over-correction on part of the pilot-in-command, causing a loss of control after a full rudder compensation,
- The aircraft was in a flaps and landing gear down configuration and it is believed that the copilot failed to assist the pilot during an emergency situation,
- The distance between the aircraft and the ground was insufficient to expect recovery,
- The crew used the auxiliary fuel tanks during all flight without paying attention to the potential danger of such procedure,
- Lack of crew support and crew training on part of the operator,
- Lack of crew resources management.
Final Report:

Crash of a Piper PA-31T Cheyenne I in Great Falls: 2 killed

Date & Time: May 19, 1998 at 1536 LT
Type of aircraft:
Registration:
N121BE
Flight Type:
Survivors:
No
Schedule:
Great Falls - Great Falls
MSN:
31-8004036
YOM:
1980
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2347
Aircraft flight hours:
2226
Circumstances:
The flight was on a practice nondirectional beacon (NDB) approach to Great Falls runway 34 in visual conditions. Abeam the final approach fix, the aircraft was 4 miles right of course. Upon being advised of this by ATC, the pilot corrected back to final with a 60-degree intercept angle, rolling out on course 3 miles from the runway. When the pilot called missed approach, the local controller (a trainee) instructed the pilot to make a 360-degree right turn to enter right downwind for runway 3, and the pilot acknowledged. The controller trainee then amended this instruction to a 180-degree right turn to enter right downwind for runway 21, then to a 180- degree right turn to enter right downwind for runway 3. The crew did not acknowledge the amended instruction. Controllers then observed the airplane had crashed. Witnesses reported the airplane entered a steep descent from a right turn and impacted the ground at a steep angle. The flight was described as recurrent training required by the owner's insurance; however, the second aircraft occupant's airline transport pilot and flight instructor certificates had been revoked, and he held only a private pilot certificate. Investigators found no evidence of aircraft malfunctions.
Probable cause:
The flight crew's failure to maintain aircraft control.
Final Report:

Crash of a Pilatus PC-12/45 in Clarenville

Date & Time: May 18, 1998 at 1741 LT
Type of aircraft:
Registration:
C-FKAL
Survivors:
Yes
Schedule:
Saint John’s – Goose Bay
MSN:
151
YOM:
1996
Flight number:
FKL151
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4700
Captain / Total hours on type:
800.00
Aircraft flight hours:
3913
Circumstances:
The aircraft, a Pilatus PC-12, serial number 151, was on a scheduled domestic flight from St. John's, Newfoundland, to Goose Bay, Labrador, with the pilot, a company observer, and eight passengers on board. Twenty-three minutes into the flight, the aircraft turned back towards St. John's because of a low oil pressure indication. Eight minutes later, the engine(Pratt & Whitney PT6A-67B) had to be shut down because of a severe vibration. The pilot then turned towards Clarenville Airport, but was unable to reach the airfield. The aircraft was destroyed during the forced landing in a bog one and a half miles from the Clarenville Airport. The pilot, the company observer, and one passenger sustained serious injuries. The Board determined that the pilot did not follow the prescribed emergency procedure for low oil pressure, and the engine failed before he could land safely. The pilot's decision making was influenced by his belief that the low oil pressure indications were not valid. The engine failed as a result of an interruption of oil flow to the first-stage planet gear assembly; the cause of the oil flow interruption could not be determined.
Probable cause:
The pilot did not follow the prescribed emergency procedure for low oil pressure, and the engine failed before he could land safely. The pilot's decision making was influenced by his belief that the low oil pressure indications were not valid. The engine failed as a result of an interruption of oil flow to the first-stage planet gear assembly; the cause of the oil flow interruption could not be determined.
Final Report: