Crash of a Swearingen SA226TC Metro II in Des Moines

Date & Time: Aug 19, 1997 at 2221 LT
Type of aircraft:
Operator:
Registration:
N224AM
Flight Type:
Survivors:
Yes
Schedule:
Wichita - Des Moines
MSN:
TC-227
YOM:
1977
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2436
Captain / Total hours on type:
93.00
Aircraft flight hours:
51119
Circumstances:
During a landing approach, the pilot noted that the right engine remained at a high power setting, when he moved the power levers to reduce power. He executed a missed approach and had difficulty keeping the airplane straight and level. The pilot maneuvered for a second approach to land. After landing, he could not maintain directional control of the airplane and tried to go around, but the airplane went off the end of the runway and impacted the localizer antenna. The pilot did not advise ATC of the problem nor did he declare an emergency. The Pilot's Operating Handbook stated that for a power plant control malfunction, the affected engine should be shut down, and a single engine landing should be made. The power control cable was found disconnected from the anchoring point. A safety tab was broken off the housing, allowing it to unscrew. About one month before the accident, maintenance had been performed on the right engine to correct a discrepancy about the right engine power lever being stiff. The mechanic re-rigged the right engine power cable.
Probable cause:
The pilot's improper in-flight planning/decision and failure to perform the emergency procedure for shut-down of the right engine. Factors relating to the accident were: the power lever cable became disconnected from the fuel control unit, due to improper maintenance; and reduced directional control of the airplane, when one engine remained at a high power setting.
Final Report:

Crash of a Boeing 727-23F in Lucapa

Date & Time: Aug 19, 1997
Type of aircraft:
Operator:
Registration:
D2-TJC
Flight Type:
Survivors:
Yes
MSN:
19180
YOM:
1966
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Damaged beyond repair following a hard landing at Lucapa Airport. All four crew members escaped uninjured.

Crash of a Beriev Be-103 in Moscow: 1 killed

Date & Time: Aug 18, 1997
Type of aircraft:
Registration:
RA-37019
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Moscow - Moscow
MSN:
30 01
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The pilot, sole on board, was completing a demonstration flight while taking part to the MAKS-97 Airshow at Moscow-Zhukovsky Airport. On takeoff, he lost control of the airplane that crashed by the runway. The pilot was killed.

Crash of a Beechcraft 200 Super King Air in Dalton: 1 killed

Date & Time: Aug 14, 1997 at 0611 LT
Operator:
Registration:
N74EJ
Flight Type:
Survivors:
No
Schedule:
Athens - Dalton
MSN:
BB-340
YOM:
1978
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2398
Captain / Total hours on type:
103.00
Aircraft flight hours:
6328
Circumstances:
The pilot was cleared for a localizer approach by Atlanta Center and told to maintain 5,000 feet until crossing the final approach fix (FAF). Normal altitude at the FAF was 2,700 feet. The pilot was unable to land from this approach and performed a missed approach. He was handed off to Chattanooga Approach, then was cleared to cross the FAF at 3,000 feet and perform another localizer approach. About one mile from the FAF, the pilot was told to change to the airport advisory frequency. The pilot acknowledged, then there was no further communication with the aircraft. A short time later, witnesses heard the aircraft crash near the approach end of the runway. Examination of the crash site showed the aircraft had touched down in a grass area about 1,100 feet from the end of the runway, while on the localizer. Propeller slash marks showed both engines were operating at approach power and the aircraft was at approach speed. No evidence of precrash mechanical failure or malfunction of the aircraft structure, flight controls, systems, engines, or propellers was found. The 0621 weather was in part: 300 feet overcast and 1/2 mile visibility with fog. Minimum descent altitude (MDA) for the localizer approach was 1,180 feet msl; airport elevation was 710 feet. The pilot had flown 8 flight hours, was on duty for 13.6 hours the day before the accident, was off duty for about 6 hrs, and had about 4 hours of sleep before the accident flight.
Probable cause:
The pilot's improper IFR procedure, by failing to maintain the minimum descent altitude (MDA) during the ILS localizer approach, until the runway environment was in sight, which resulted in a collision with terrain short of the runway. Factors relating to the accident were: darkness, low ceiling, fog, pilot fatigue, and improper scheduling by the aircraft operator.
Final Report:

Crash of a Beechcraft 1900C in Seattle

Date & Time: Aug 13, 1997 at 1913 LT
Type of aircraft:
Operator:
Registration:
N3172A
Flight Type:
Survivors:
Yes
Schedule:
Portland - Seattle
MSN:
UB-47
YOM:
1985
Flight number:
AMF262
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6370
Captain / Total hours on type:
106.00
Aircraft flight hours:
23892
Circumstances:
The Beech 1900C cargo aircraft was loaded with more than 4,962 pounds of cargo during an approximate 20 minute period. No scale was available at the aircraft, forcing loaders to rely on tallying either waybill weights or estimates of total cargo weight and center of gravity (CG) during the brief loading period. Additionally, a strike had shut down a major cargo competitor at the time with substantial cargo overflow to the operator. Post-crash examination determined the cargo load was 656 pounds greater than that documented on the pilot's load manifest, and the CG was between 6.8 and 11.3 inches aft of the aft limit. The airplane behaved normally, according to the pilot, until he initiated full flaps for landing approaching the threshold of runway 34L at the Seattle-Tacoma International airport. At this time, the aircraft's airspeed began to decay rapidly and a high sink rate developed as the aircraft entered into a stall/mush condition. The aircraft then landed hard, overloading the nose and left-main landing gear which collapsed. A post-impact fuel system leak during the ground slide led to a post-crash fire.
Probable cause:
A stall/mush condition resulting from an aft center of gravity which was inaccurately provided to the pilot-in-command by contractual cargo-loading personnel. Additional causes were overloading of the aircraft's landing gear and fuel leakage resulting in a post-crash fire. Factors contributing to the accident were the pilot's improper lowering of flaps in an aft CG situation and the inadequate company procedures for cargo loading.
Final Report:

Crash of a Boeing 727-230A in Thessaloniki

Date & Time: Aug 12, 1997 at 1741 LT
Type of aircraft:
Operator:
Registration:
SX-CBI
Survivors:
Yes
Schedule:
Athens - Thessaloniki - Frankfurt
MSN:
20791
YOM:
1974
Flight number:
OA171
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
26
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The approach to Thessaloniki Airport was completed in poor weather conditions. The aircraft landed too far down the runway and after touchdown, the crew realized he could not stop the aircraft within the remaining distance so he decided to veer off runway to the right. While contacting soft ground, the undercarriage were torn off and the aircraft came to rest. All 35 occupants escaped uninjured and the aircraft was damaged beyond repair. At the time of the accident, the wind was from 360° at 18 knots gusting to 28 knots with thunderstorm activity, rain falls and a visibility of 5 km.
Probable cause:
The following findings were reported:
- Poor weather conditions,
- The runway surface was wet and the braking action was considered as moderate to low,
- The flying crew consisted of two highly experienced captains,
- The crew was under stress during the final approach due to poor weather conditions,
- Wrong approach configuration as the aircraft was too high on the glide,
- The crew failed to follow the approach checklist,
- The aircraft landed too far down the runway, about a third past its threshold, reducing the landing distance available,
- Lack of crew coordination,
- The crew failed to initiate a go-around procedure.

Crash of a Beechcraft A90 King Air in Alice: 4 killed

Date & Time: Aug 12, 1997 at 1153 LT
Type of aircraft:
Registration:
N41VC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Alice - Alice
MSN:
LJ-242
YOM:
1967
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
17710
Aircraft flight hours:
7250
Circumstances:
The flight was part of a pre-buy inspection of the airplane. Witnesses reported the airplane did not climb more than 200 feet above ground level (agl) after takeoff. The airplane entered a shallow left turn and completed about 210 degrees of heading change before it impacted a flat field near the approach end of runway 26. Witnesses reported that the landing gear were retracted and that the engines sounded like they running at high power, but the airplane did not accelerate or climb normally. The airspeed was slow and 'mushy.' The engines' gas generator sections exhibited strong rotational scoring. The engines' power sections exhibited light rotational signatures. The left and right propellers exhibited minimal leading edge damage. Both propellers exhibited high blade angles. The secondary low pitch stops (SLPS) had been installed on the aircraft four days prior to the accident. A ground check, but no flight check, had been conducted. The SLPS sensors were found in the full aft position on the mounting bracket, not in the normal mid-range position. The SLPS control box installed on the aircraft was an updated box and was incompatible with the existing wiring.
Probable cause:
Loss of control due to the pilot's improper in-flight decision. A factor was the improper installation of the secondary low pitch stop system by the mechanic.
Final Report:

Crash of a Dornier DO228-212 in Matsu Nangan: 16 killed

Date & Time: Aug 10, 1997 at 0833 LT
Type of aircraft:
Operator:
Registration:
B-12256
Survivors:
No
Schedule:
Taipei - Matsu Nangan
MSN:
8220
YOM:
1993
Flight number:
VY7601
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
16
Circumstances:
On final approach to Matsu Nangan Airport, the twin engine aircraft struck the top of the Jade Hill located about one km short of runway and disintegrated on impact. A female passenger was seriously injured while 15 other occupants were killed. The only survivor died from his injuries few hours later. At the time of the accident, the visibility was reduced to six km in rain. It was reported that the crew was initiating a go-around procedure when the aircraft struck the hill. Few hours after the accident, a man in charge to transmit weather conditions to the crew committed suicide at the airport.

Crash of a Britten-Norman BN-2A-Islander in Fajardo

Date & Time: Aug 7, 1997 at 1248 LT
Type of aircraft:
Operator:
Registration:
N1202S
Flight Type:
Survivors:
Yes
Schedule:
Vieques - Fajardo
MSN:
193
YOM:
1970
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6200
Aircraft flight hours:
16942
Circumstances:
On August 7, 1997, about 1248 Atlantic Standard Time, two Britten-Norman BN-2 airplanes, collided in flight, over the landing threshold of runway 08, at the Diego Jimenez Airport, Fajardo, Puerto Rico (PR). Both airplanes were conducting a visual approach at the uncontrolled airport. The pilot of N1202S, was executing a non-standard right traffic pattern approach to landing, while the pilot of N26JA was executing a standard left traffic pattern approach to landing. The airplanes collided over the approach threshold of runway 08, about 100 feet agl. Passengers on N26JA, stated that the other airplane was coming from the right much lower then their airplane and disappeared under them. The next time they saw the other airplane they were colliding into its tail section. Examination of both airplanes revealed no mechanical discrepancies.
Probable cause:
The pilot's failure to maintain adequate visual lookout.
Final Report:

Crash of a Boeing 747-3B5 in Agana: 228 killed

Date & Time: Aug 6, 1997 at 0142 LT
Type of aircraft:
Operator:
Registration:
HL7468
Survivors:
Yes
Schedule:
Seoul - Agana
MSN:
22487
YOM:
1984
Flight number:
KE801
Country:
Region:
Crew on board:
17
Crew fatalities:
Pax on board:
237
Pax fatalities:
Other fatalities:
Total fatalities:
228
Captain / Total flying hours:
8932
Captain / Total hours on type:
1718.00
Copilot / Total flying hours:
4066
Copilot / Total hours on type:
1560
Aircraft flight hours:
50105
Aircraft flight cycles:
8552
Circumstances:
Korean Air Flight 801 was a regular flight from Seoul to Guam. The Boeing 747-300 departed the gate about 21:27 and was airborne about 21:53. The captain was pilot-flying. Upon arrival to the Guam area, the first officer made initial contact with the Guam Combined Center/Radar Approach Control (CERAP) controller about 01:03, when the airplane was level at 41,000 feet and about 240 nm northwest of the NIMITZ VOR/DME. The CERAP controller told flight 801 to expect to land on runway 06L. About 01:10, the controller instructed flight 801 to "...descend at your discretion maintain two thousand six hundred." The first officer responded, "...descend two thousand six hundred pilot discretion." The captain then began briefing the first officer and the flight engineer about the approach and landing at Guam: "I will give you a short briefing...ILS is one one zero three...NIMITZ VOR is one one five three, the course zero six three, since the visibility is six, when we are in the visual approach, as I said before, set the VOR on number two and maintain the VOR for the TOD [top of descent], I will add three miles from the VOR, and start descent when we're about one hundred fifty five miles out. I will add some more speed above the target speed. Well, everything else is all right. In case of go-around, since it is VFR, while staying visual and turning to the right...request a radar vector...if not, we have to go to FLAKE...since the localizer glideslope is out, MDA is five hundred sixty feet and HAT [height above touchdown] is three hundred four feet...." About 01:13 the captain said, "we better start descent;" shortly thereafter, the first officer advised the controller that flight 801 was "leaving four one zero for two thousand six hundred." During the descent it appeared that the weather at Guam was worsening. At 01:24 requested a deviation 10 miles to the left to avoid severe weather. At 01:31 the first officer reported to the CERAP controller that the airplane was clear of cumulonimbus clouds and requested "radar vectors for runway six left." The controller instructed the flight crew to fly a heading of 120°. After this transmission, the flight crew performed the approach checklist and verified the radio frequency for the ILS to runway 06L. About 01:38 the CERAP controller instructed flight 801 to "...turn left heading zero nine zero join localizer;" the first officer acknowledged this transmission. At that time, flight 801 was descending through 2,800 feet msl with the flaps extended 10° and the landing gear up. One minute later the controller stated, "Korean Air eight zero one cleared for ILS runway six left approach...glideslope unusable." The first officer responded, "Korean eight zero one roger...cleared ILS runway six left;" his response did not acknowledge that the glideslope was unusable. The flight engineer asked, "is the glideslope working? glideslope? yeh?" One second later, the captain responded, "yes, yes, it's working." About 01:40, an unidentified voice in the cockpit stated, "check the glideslope if working?" This statement was followed 1 second later by an unidentified voice in the cockpit asking, "why is it working?" The first officer responded, "not useable." The altitude alert system chime sounded and the airplane began to descend from an altitude of 2,640 feet msl at a point approximately 9 nm from the runway 06L threshold. About 01:40:22, an unidentified voice in the cockpit said, "glideslope is incorrect." As the airplane was descending through 2,400 feet msl, the first officer stated, "approaching fourteen hundred." About 4 seconds later, when the airplane was about 8 nm from the runway 06L threshold, the captain stated, "since today's glideslope condition is not good, we need to maintain one thousand four hundred forty. please set it." An unidentified voice in the cockpit then responded, "yes." About 01:40:42, the CERAP controller instructed flight 801 to contact the Agana control tower. The first officer contacted the Agana tower: "Korean air eight zero one intercept the localizer six left." The airplane was descending below 2,000 feet msl at a point 6.8 nm from the runway threshold (3.5 nm from the VOR). About 01:41:01, the Agana tower controller cleared flight 801 to land. About 01:41:14, as the airplane was descending through 1,800 feet msl, the first officer acknowledged the landing clearance, and the captain requested 30° of flaps. The first officer called for the landing checklist and at 01:41:33, the captain said, "look carefully" and "set five hundred sixty feet" (the published MDA). The first officer replied "set," the captain called for the landing checklist, and the flight engineer began reading the landing checklist. About 01:41:42, as the airplane descended through 1,400 feet msl, the ground proximity warning system (GPWS) sounded with the radio altitude callout "one thousand [feet]." One second later, the captain stated, "no flags gear and flaps," to which the flight engineer responded, "no flags gear and flaps." About 01:41:46, the captain asked, "isn't glideslope working?" The captain then stated, "wiper on." About 01:41:53, the first officer again called for the landing checklist, and the flight engineer resumed reading the checklist items. About 01:41:59, when the airplane was descending through 1,100 feet msl at a point about 4.6 nm from the runway 06L threshold (approximately 1.3 nm from the VOR), the first officer stated "not in sight?" One second later, the GPWS radio altitude callout sounded: "five hundred [feet]." About 01:42:14, as the airplane was descending through 840 feet msl and the flight crew was performing the landing checklist, the GPWS issued a "minimums minimums" annunciation followed by a "sink rate" alert about 3 seconds later. The first officer responded, "sink rate okay". At that time the airplane was descending 1,400 feet per minute. About 01:42:19, as the airplane descended through 730 feet msl, the flight engineer stated, "two hundred [feet]," and the first officer said, "let's make a missed approach." About one second later, the flight engineer stated, "not in sight," and the first officer said, "not in sight, missed approach." About 01:42:22, as the airplane descended through approximately 680 feet msl, the nose began to pitch up and the flight engineer stated, "go around." When the captain stated "go around" power was added and airspeed began to increase. As the airplane descended through 670 feet msl, the autopilot disconnect warning sounded. The GPWS radio altitude callouts continued: "one hundred...fifty...forty...thirty...twenty [feet]." About 01:42:26, the airplane impacted hilly terrain at Nimitz Hill, Guam, about 660 feet msl and about 3.3 nm from the runway 06L -threshold. It struck trees and slid through dense vegetation before coming to rest. A post-impact fire broke out. It was established a.o. that the software fix for the Minimum Safe Altitude Warning (MSAW) system at Agana Center Radar Approach Control (CERAP) had rendered the program useless. A software patch had been installed since there had been complaints of the high rate of false MSAW alarms at Guam. This made KAL801's descent below MDA go undetected at the Agana CERAP.
Probable cause:
The captain's failure to adequately brief and execute the nonprecision approach and the first officer's and flight engineer's failure to effectively monitor and cross-check the captain's execution of the approach. Contributing to these failures were the captain's fatigue and Korean Air's inadequate flight crew training. Contributing to the accident was the Federal Aviation Administration's intentional inhibition of the minimum safe altitude warning system and the agency's failure to adequately to manage the system.
Final Report: