Crash of an Aviation Traders ATL-98 Carvair in Venetie

Date & Time: Jun 28, 1997 at 1618 LT
Registration:
N103
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Venetie - Fairbanks
MSN:
10273/4
YOM:
1943
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
20000
Captain / Total hours on type:
3000.00
Aircraft flight hours:
7145
Circumstances:
The air cargo flight had just off loaded its cargo at a remote site. Shortly after takeoff, the number two engine begin to run rough. The engine was shut down, and the propeller feathered. During the shutdown process, a fire warning light illuminated, and fire became visible near the number 2 engine. The crew activated both banks of engine fire extinguishers, but were unable to extinguish the fire. While on approach to an off-airport emergency landing site, the number two engine fell off and ignited a brush fire. The crew made a successful landing and ran away from the airplane. The airplane continued to burn and was destroyed by fire. The number 2 engine was not recovered or located.
Probable cause:
A fire associated with the number 2 engine for undetermined reasons.
Final Report:

Crash of a Cessna 207A Skywagon in Nome: 2 killed

Date & Time: Jun 27, 1997 at 1633 LT
Operator:
Registration:
N207SP
Survivors:
No
Schedule:
Brevig Mission - Nome
MSN:
207-0412
YOM:
1977
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1745
Captain / Total hours on type:
200.00
Aircraft flight hours:
12771
Circumstances:
The flight was landing under special VFR conditions. Special VFR operations are permitted with a visibility of 1 mile, and clear of clouds. The airport was the pilot's base of operations. The flight had held outside the airport surface area for 26 minutes, waiting for a special VFR clearance. While outside the airport surface area, the pilot was required to maintain 500 feet above the ground and 2 miles visibility. While holding, the weather at the airport was reported as 300 feet overcast. The visibility decreased from 4 miles to 1 mile in mist. The pilot was new to the area of operations, having worked at the company for 24 days, during which he accrued 69 hours of flight time. Four minutes after receiving clearance to enter the surface area for landing, the airplane collided with a 260 feet tall radio antenna tower at 222 feet above the ground. The tower was located 3.85 nautical miles east of the airport. The radio tower was not considered by the FAA to be an object affecting navigable airspace, but was depicted as an obstruction on the VFR sectional chart for the area. The tower was equipped with obstruction lighting for night illumination, and was painted alternating aviation orange and white for daytime marking. One minute after the collision, the overcast was reported at 200 feet, and the visibility was 5/8 mile.
Probable cause:
The pilot's continued VFR flight into instrument meteorological conditions, and his failure to maintain adequate clearance from an obstruction (antenna tower). Factors in the accident were low ceilings and visibility, and the pilot's lack of familiarity with the geographic area.
Final Report:

Crash of a Beechcraft D18S in Willow

Date & Time: Jun 25, 1997 at 1130 LT
Type of aircraft:
Operator:
Registration:
N765D
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Willow - Sleetmute
MSN:
A-818
YOM:
1952
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8000
Captain / Total hours on type:
35.00
Aircraft flight hours:
8600
Circumstances:
The pilot took off from a 4400-foot-long gravel airstrip with a near gross weight load of cargo. He said that shortly after lift-off the airplane felt 'sluggish', and he believes the left engine began to lose power. He said the airplane would not climb, and he elected to bring both engines to idle and land on the remaining runway. The airplane touched down a short distance from the end of the runway, and continued off the end and into the woods. A fire erupted, and the airplane was destroyed by fire. The pilot is unsure if the fire occurred in the air, or shortly after the airplane went off the end of the runway. The engines were extensively damaged by fire, and were not examined. FAA inspectors on scene said there was no obvious signs of catastrophic engine failure.
Probable cause:
The loss of engine power for an undetermined reason.
Final Report:

Crash of a Boeing 727-21F in Bogotá

Date & Time: Jun 25, 1997 at 0122 LT
Type of aircraft:
Operator:
Registration:
HK-1717
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Bogotá – Barranquilla
MSN:
18993/215
YOM:
1965
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
20067
Captain / Total hours on type:
8664.00
Copilot / Total flying hours:
4854
Copilot / Total hours on type:
292
Aircraft flight hours:
51014
Circumstances:
During the takeoff roll un runway 31 at Bogotá-El Dorado Airport, at a speed of 130 knots, the crew heard two explosions. As the aircraft started to vibrate, the captain decided to abandon the takeoff procedure and initiated an emergency braking manoeuvre. Unable to stop within the remaining distance, the aircraft overran, rolled for 497 metres then lost its nose gear and came to rest. All six occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
It was determined that the tread on the left front tyre (nose gear) deflated and broke off during takeoff, causing severe vibrations. This caused the antiskid system to be unserviceable and the aircraft could not be stopped on the remaining distance as the runway surface was humid. It was also reported that no information were available from both CVR and FDR systems. At the time of the accident, the total weight of the aircraft was 1,461 kilos above MTOW, making the decision speed (V1) to be higher by reducing the stopping distance, which was insufficient when discontinuing the pilot controls takeoff in wet runway conditions.
Final Report:

Crash of a Piper PA-31-310 Navajo Chieftain in San Diego: 3 killed

Date & Time: Jun 20, 1997 at 1231 LT
Type of aircraft:
Operator:
Registration:
N266MM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
San Diego - San Diego
MSN:
31-140
YOM:
1968
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
10041
Captain / Total hours on type:
1586.00
Aircraft flight hours:
8473
Circumstances:
The aircraft concluded an aerial survey and landed at Brown Field to clear U.S. Customs. On restart, as the left engine began running, a witness noticed two short, yellow flame bursts exit the exhaust. During taxi, the witness heard a popping sound coming from the aircraft. As power was applied to cross runway 26L, the sound went away. The aircraft stopped for a few seconds prior to pulling onto the runway; the witness did not observe or hear a run-up. Witnesses reported hearing a series of popping sounds similar to automatic gunfire and observed the aircraft between 600 and 1,000 feet above the ground with wings level and the landing gear up. The aircraft was observed to make an abrupt, 45-degree banked, left turn as the nose dipped down. Witnesses reported the nose of the aircraft then raised up toward the horizon. This was followed by the aircraft turning to the left and becoming inverted in an estimated 30-degree nose low attitude. With the nose still low, the aircraft continued around to an upright position and appeared to be in a shallow right bank. Witnesses then lost sight of the aircraft due to buildings and terrain. A May 20, 1997, work order indicated the left manifold pressure fluctuated in flight. Both wastegates were lubricated and a test flight revealed the left engine manifold pressure lagged behind the right engine manifold pressure. On June 18, 1997, the left engine differential pressure controller was noted to have been removed and replaced. This was the corrective action for a discrepancy write up that the left engine manifold pressure fluctuated up and down 2 inHg and the rpm varied by 100 in cruise. A test flight that afternoon by the accident pilot indicated the discrepancy still occurred at cruise power settings, but the engine operated normally at high and low power settings. Post accident functional checks were performed on various components. No discrepancies were noted for the left governor. The left engine differential pressure controller was damaged and results varied on each test. The left density controller was too damaged to test. The right engine density and differential pressure controllers tested satisfactory. The left and right fuel pumps operated within specifications. Both fuel servos were damaged. One injection nozzle on the left engine was partially plugged; all others flow tested within specifications.
Probable cause:
The loss of power in the left engine for undetermined reasons and the pilot's subsequent failure to maintain minimum single-engine control airspeed. A contributing factor was the pilot's decision to fly with known deficiencies in the equipment.
Final Report:

Crash of a PZL-Mielec AN-2R in Tula: 4 killed

Date & Time: Jun 17, 1997
Type of aircraft:
Registration:
RA-84700
Flight Phase:
Survivors:
Yes
Schedule:
Tula - Shakhty
MSN:
1G192-18
YOM:
1981
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
After takeoff from Tula Airport, while climbing, the crew noticed that the engine oil temperature increased while the engine pressure dropped. In such conditions, the captain decided to return to Tula Airport for an emergency landing and completed a turn when the engine failed. The aircraft lost speed and height then struck power cables and crashed. The captain and three passengers were killed while three other occupants were injured. The aircraft was destroyed.
Probable cause:
The following factors were identified:
- Engine failure as a result of the destruction of the bushing of the crankshaft of the main connecting rod due to a manufacturing defect in the absence of adhesion of bronze to the steel base of the bushing on a sufficiently large section,
- An unused chip-in-oil signaling system, due to the fact that the engine was not equipped with a chip signaling filter during repair, which deprived the crew of information about the beginning of the collapse of the sleeve and did not allow a timely decision to return to the departure point;
- Difficult terrain with the presence of various obstacles.

Crash of a Swearingen SA226TC Metro II in Ottawa

Date & Time: Jun 13, 1997 at 1248 LT
Type of aircraft:
Registration:
C-FEPW
Flight Type:
Survivors:
Yes
Schedule:
Hamilton - Ottawa
MSN:
TC-294
YOM:
1979
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2240
Captain / Total hours on type:
1930.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
55
Circumstances:
The flight crew were properly licensed and certified to conduct the flight. The pilot had a total flying time of approximately 2,240 hours, of which 1,930 were on the occurrence aircraft type. The co-pilot received his commercial pilots license in 1988 and had approximately 500 hours total flying time. He completed his instrument rating on 15 December 1996 and his initial training on the SA226-TC was completed in March 1997 in British Columbia with a different company. He had not flown for 44 days at the time his recurrent training was completed on 09 June 1997. This was the co-pilot=s third day of operational flying for the company; he had accumulated approximately 55 hours total time on the aircraft type. The co-pilot was flying the aircraft for a radar-vectored, localizer/back-course approach to runway 25 of the Ottawa/Macdonald-Cartier airport. Descending out of 10,000 feet above sea level, the crew completed a briefing for the approach. The weather conditions at the time did not necessitate a full instrument approach briefing because the crew expected to fly the approach in visual conditions. Air traffic control requested that the crew fly the aircraft at a speed of 180 knots or better to the Ottawa non-directional beacon (NDB), which is also the final approach fix (FAF) for the approach to runway 25. At approximately eight nautical miles from the airport the aircraft was clear of cloud and the crew could see the runway. In order to conduct some instrument approach practice, the pilot, who was also the company training pilot, placed a map against the co-pilot=s windscreen to temporarily restrict his forward view outside the aircraft. The approach briefing was not amended to reflect the simulated instrument conditions for the approach. The co-pilot accurately flew the aircraft on the localizer to the FAF, at which point, he began to slow the aircraft to approximately 140 knots and requested that the pilot set 2 flap, which he did. Once past the FAF, the copilot=s workload increased, and he had difficulty flying the simulated approach. On short final to runway 25, the pilot removed the map from the co-pilot=s windscreen. The co-pilot noted that the aircraft was faster and higher than normal and he tried to regain the proper approach profile. By the time the aircraft reached the threshold of the runway 25, it was approximately 500 feet above ground, and at a relatively high speed, so the pilot took control of the aircraft for the landing. The pilot attempted to descend and slow the aircraft as it proceeded down the length of the runway and stated that he had just initiated an overshoot when he heard the first sounds of impact. Runway 25 is 8,000 feet long. The first signs of impact on the runway were made by the propellers, with propeller marks beginning about 4,590 feet from the threshold of runway 25. The aircraft came to rest about 6,770 feet from the threshold, and a fire broke out in the area of the right engine. The co-pilot opened the main door of the aircraft while the pilot shut down the aircraft systems, and both exited the aircraft uninjured. The maximum speed for extending the landing gear on this aircraft is 176 knots, and the company standard operating procedures (SOPs) for a normal instrument approach stipulate that the aircraft should cross the final approach fix at a speed of 140 knots, with a 2-flap setting, and with the landing gear lowered. The company SOPs require that all checklist items, from the after start checks through to the after landing checks inclusive, be actioned through a challenge and response method with each item called individually. The first item of the before landing checks is a landing gear .....Down/3 greens@. The co-pilot did not recall being challenged for the landing gear check, and the pilot could not remember selecting the landing gear switch to the down position. Neither pilot checked for the three green lights prior to the occurrence. The pilot stated that it was his habit to check if the landing lights were on prior to landing because it was his habit to turn them on only after the landing gear had been extended. He remembered checking to see that the landing lights were on and so was satisfied that the gear was down. The co-pilot assumed that, because the aircraft had passed the NDB, the before landing checks had been completed; they are normally completed before or at that point during an approach. Neither pilot recalled hearing a gear warning horn prior to the impact. When the aircraft systems were inspected, the landing gear selector was found in the up position. Tests were conducted on the landing gear warning system which revealed that the gear warning horn did not function. A closer examination of the system revealed a faulty diode. The diode was replaced and when the warning system was checked again, it functioned properly. The pilot stated that the gear warning horn on the aircraft had functioned properly during the training for the co-pilot one week earlier.
Probable cause:
The aircraft was landed with the landing gear retracted because the flight crew did not follow the standard operating procedures and extend the landing gear. Contributing to the occurrence were the lack of planning, coordination, and communication on the part of the crew; and the failure of the landing gear warning system.
Final Report:

Crash of a Harbin Yunsunji Y-12 II in Mandalgov: 7 killed

Date & Time: Jun 10, 1997
Type of aircraft:
Operator:
Registration:
JU-1020
Survivors:
Yes
Schedule:
Ulan Bator - Mandalgov - Dalanzadgad
MSN:
0067
YOM:
1991
Flight number:
OM447
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
On final approach to Mandalgov Airport, at a height of 30 metres, the aircraft nosed down and crashed short of runway threshold. Seven passengers were killed while five other occupants were injured.
Probable cause:
Loss of control on final approach after the aircraft encountered windshear.

Crash of a BAc 111-525FT in Stockholm

Date & Time: Jun 7, 1997 at 1350 LT
Type of aircraft:
Operator:
Registration:
YR-BCM
Survivors:
Yes
Schedule:
Bucharest - Stockholm
MSN:
256
YOM:
1977
Flight number:
RO335
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12500
Captain / Total hours on type:
12000.00
Copilot / Total flying hours:
1866
Copilot / Total hours on type:
50
Aircraft flight hours:
23901
Aircraft flight cycles:
17888
Circumstances:
Flight ROT 335, a BAC 111 coming from Bucharest, was about to land on runway 26 at Stockholm/Arlanda airport. The pilots had visual contact with the field and the landing was performed according to visual flying rules (VFR). The commander, who was pilot flying (PF), has stated the following. The approach was normal with occasional turbulence and wind gusts from the south. When the aircraft was on 8 nautical miles1 final, the air-traffic controller in the tower reported the wind 160°/13 knots. To begin with the aircraft was somewhat above the glide slope but was on the glide slope when it passed the threshold. The touchdown on the runway was in the normal touchdown zone on the left main gear and nose up. Shortly thereafter came a strong wind gust whereupon the right main gear touched down and the nose gear heavily hit the runway. The commander controlled the aircraft with rudder, reversed the engines and braked lightly. He did not notice anything special in the behavior of the aircraft at that point. When - after the speed had become so low that rudder steering was no longer possible - he reverted to nose wheel steering he noticed that it was not functioning. He continued the light wheel braking but could not prevent the aircraft from veering to the right. He then braked fully but the aircraft continued towards the right runway edge. It left the runway at a speed of around 60 knots out onto the grass field. The retardation was soft and the passengers disembarked through ordinary exit. The airport rescue service was speedily on the scene but no action was necessary. The accident occurred on 7 June 1997 at 1350 hours in position 5939N 1755E; 121 feet (37 m) above sea level.
Probable cause:
The accident was caused by the collapse of the nose gear as a result of overload when the aircraft touched down with its nosewheel first after two bounces. A contributing factor was shortcomings in cockpit’s CRM (Cockpit Resource Management) during the flight.
Final Report:

Crash of a Boeing 727-227 in Newark

Date & Time: Jun 7, 1997
Type of aircraft:
Operator:
Registration:
N571PE
Flight Phase:
Survivors:
Yes
MSN:
21264
YOM:
1976
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was transferred from the maintenance facilities to the main terminal by a technical crew when control was lost. The airplane collided with the USAir Terminal and the cockpit was destroyed.