Crash of a Cessna 208B Grand Caravan in Nakina

Date & Time: Jan 3, 1997 at 1110 LT
Type of aircraft:
Operator:
Registration:
C-FTZF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nakina - Fort Hope
MSN:
208B-0389
YOM:
1994
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3200
Captain / Total hours on type:
1300.00
Circumstances:
At approximately 1110 eastern standard time (EST , the pilot commenced a scheduled cargo flight from Nakina, Ontario, to Fort Hope in a Cessna 208B Caravan, serial number 208B0389. The pilot reported that he selected the flaps to 20°, lined up on runway 09, and set the power at around 1,600 to 1,700 foot-pounds of torque. The torque redline is 1,865 foot-pounds. About 3/4 of the way through the take-off run, the aircraft began to yaw to the right, which the pilot initially compensated for by applying left rudder. As the airspeed increased and the nosewheel lifted off the runway, the right yaw became more pronounced, and the aircraft became more difficult to control. The aircraft became airborne at about 85 knots indicated airspeed (KIAS), with the pilot using left rudder and left aileron in his attempt to compensate for the yaw; however, he was not able to gain control of the aircraft. The aircraft touched down briefly on the runway, then became airborne again as the take-off continued. While flying at less than 20 feet above ground level over a small, frozen lake immediately off the end of the runway, the aircraft descended and struck the snow-covered surface of the lake. The aircraft was in a nose-high, right-wing-low attitude when it struck the ice. The aircraft flipped over and came to rest in an inverted position, approximately 1,000 feet past the end of the runway and 200 feet to the right of the extended right edge of the runway. The pilot received only minor injuries. He exited the aircraft and walked back to the flight office.
Probable cause:
The pilot experienced directional control difficulties during the take-off run, probably because the rudder trim was set at the near full left position. Because the rudder trim indicator could be moved without affecting the actual rudder trim, it is probable that it did not reflect the actual position of the rudder trim.
Final Report:

Crash of a Short 330-300 in Liverpool

Date & Time: Jan 3, 1997 at 0042 LT
Type of aircraft:
Operator:
Registration:
G-ZAPC
Flight Type:
Survivors:
Yes
Schedule:
Exeter - East Midlands
MSN:
3023
YOM:
1978
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3015
Captain / Total hours on type:
900.00
Circumstances:
The aircraft departed Exeter at 2237 hrs where the weather was fair with scattered cloud at 1500 feet. After climbing uneventfully through cloud to FL 90 the aircraft cruisedin clear, smooth air. In the cruise the co-pilot noticed that his vertical speed indicator was displaying a slight rate of climb although the aircraft was in level flight but this and a spurious hydraulic warning were the only anomalies. As the aircraft approached East Midlands airport the runway visual range there was below the approach minima and several aircraft were holding awaiting an improvement in the visibility. G-ZAPC descended to 2,500 ft and held in clear air over the Lichfield NDB for about 45 minutes until the fuel state dictated a diversion to Liverpool. On diversion the aircraft was initially cleared direct to the Whitegate NDB and then Wallasey VOR at FL 40. At this level the crew could see ground features in good visibility until they entered cloudas they descended through 3,500 feet whilst being radar vectored for an approach to Liverpool Airport. The cloud was stratiform in character and did not appear to contain precipitation or significant turbulence. At Liverpool airport the cloud base was 6/8at 1,100 feet, the visibility 12 km, the air temperature +1°Cand the surface wind was 060°/8 kt. There is an ILS localiser on Runway 09 but no glidepath transmitter so a LOC DME approach is normally flown. Although the DME antenna is mid-way along the runway, the DMErange is set to read zero at the runway displaced threshold. The pilot flies the localiser in azimuth and adjusts his height according to his pressure altimeter; the 3° glidepath commences at 1,610 feet QNH from 5 nm DME with check heights at 4, 3, 2 and 1 nm DME. On the north side of the runway 329 metres from the threshold there are 4 PAPI (Precision Approach Path Indicator)lights which are set to a glidepath of 3°. During the approach to Runway 09 at Liverpool all the anti-icing services were switched on and operating except for the wing de-icing boots which, having seen no ice on the wings,the commander decided not to employ, and the ice detector which he considered unreliable. The approach proceeded normally andthe aircraft descended out of cloud at about 1,100 feet having been in cloud for about 10 minutes. When the commander viewed the PAPIs at 1 DME"all four lights had a pink tinge". Thinking he might be slightly low relative to the approach glidepath, he asked the co-pilot to specify the correct height at 1 DME which was 410feet. At the time the commander's pressure altimeter, which was set to the QNH of 1019 mb, indicated that the aircraft was slightly high and so he made a small correction to the flight path which resulted in three red PAPI lights and one white light. The commander also decided to touch down slightly beyond the runway identifier numbers which are a few metres beyond the 'piano keys' that identify the threshold. The aircraft was cleared to land with a wind of "Easterly at 10 kt" and on short finals the commander asked for full flap. He then allowed the speed to bleed back from the approach speed of between 110 and 120 KIAS towards the threshold speed of 90 KIAS without moving the throttles from their approach power setting. According to both crew members and the passenger who was seated in the 'jump seat', the aircraft crossed over the end of runway at between 88 and 90 KIAS. Some 20 to 30 feet above the runway the commander noticed that the flight controls felt 'sloppy' as if the aircraft's speed was unusually low but there was no hint of a stall warning or stick shaker activation. At much the same time all three persons on board felt the aircraft sink rapidly; the commander pulled back on the control column but he was unable to arrest the high rate of descent and the aircraft struck the runway very hard. The right wing dropped as the right main gear collapsed and the aircraft veered to the right off the runway onto the grass. The ground was frozen hard and the aircraft came to a halt without incurring further significant damage. The crew informed ATC that they were unhurt before securing the aircraft whilst ATC activated the airport's emergency services. On leaving the aircraft the commander inspected the wings for ice accretion. He noticed a thin layer of clear,watery ice along the leading edges across the pneumatic de-icing boots from top to bottom. The ice layer could be wiped off with one finger and was no more than one eight of an inch thick. Throughout the flight there had been no visible signs of ice accretion on the wings or the windscreen wiper. Consequently, the commander had not increased the threshold speed to compensate for ice accretion.
Probable cause:
From the available evidence it appears probable that the aircraft developed a high rate of descent from a height of 20 to 30 feet above the runway without producing a stall warning. The following causal factors were considered: wind shear; wake turbulence; pitot-static system errors; low airspeed during the final stages of the approach; and significant ice accretion on the airframe. Wind shear was discounted because numerous wind readings showed the normal slight variation in direction but a consistent wind speed, and there were no obstacles such as hangars upwind of the threshold. Wake turbulence was discounted because the preceding aircraft had landed 19 minutes before GZAPC. The pitot-static systems were checked to be leak free and all relevant instruments were shown to be accurate. It was also established that all pitot head, static plate and stall warning heaters were serviceable. A favourable comparison of the approach profile with those of the preceding four aircraft indicated that there was no evidence of static pressure errors. The calculated airspeeds from radar were consistent with thespeeds reported by the crew for the initial approach suggesting that itot errors were not significant. Thus, unless icing, for example, had affected these systems at a late stage of the approach,erroneous instrument readings were considered unlikely. The final approach was flown at about the correct airspeed but there was a trend within the radar data,for the last mile of the approach, for the airspeed to reduce towards the stalling speed. However the data was too coarse to provide exact speeds and the stall warning system did not activate. The likelihood of significant airframe icing was discounted for several reasons including: the commander's statement; photographs taken of the aircraft shortly after the accident which showed no signs of significant ice accretion; no lumps of ice were found on the runway; and the airframe was icefree when examined by the AAIB despite overnight sub-zero temperatures. There was, therefore, no positive conclusion as to the cause and it remains a possibility that some or all of the above factors, to a small extent, may have combined to produce a high rate of descent while the aircraft was some 20to 30 feet above the runway.
Final Report:

Crash of a Piper PA-61P Aerostar (Ted Smith 601P) in Chesapeake: 4 killed

Date & Time: Jan 2, 1997 at 1937 LT
Operator:
Registration:
N3CD
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Chesapeake – Atlanta
MSN:
61-0353-108
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2100
Aircraft flight hours:
1949
Circumstances:
The airplane departed the airport and crashed shortly thereafter. Before departure, the airplane was fueled with 120 gallons of 100LL aviation fuel. According to the refueler, the airplane had full fuel tanks. The refueler also indicated the pilot had stated he wanted to be airborne prior to the arrival of bad weather. After the accident, the engines and propellers were disassembled and examined. No engine or propeller discrepancies were noted, except (post impact) heat damage.
Probable cause:
Failure of the pilot to maintain proper altitude/clearance above the ground after takeoff. A related factor was the pilot's self-induced pressure to depart before the arrival of bad weather.
Final Report:

Crash of a Cessna 208B Grand Caravan in Edenton: 2 killed

Date & Time: Jan 2, 1997 at 1835 LT
Type of aircraft:
Operator:
Registration:
N802TH
Flight Type:
Survivors:
No
Schedule:
Manteo - Edenton
MSN:
208B-0179
YOM:
1989
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2980
Captain / Total hours on type:
850.00
Aircraft flight hours:
3520
Circumstances:
During his weather briefing, the pilot was told that his destination weather was not available, and was provided weather for an airport about 10 miles north. He was briefed that low visibility due to fog prevailed. The flight departed earlier then usual because the company business manager was concerned that the weather at the destination airport was deteriorating, and if the airplane was not there earlier they might not get into the airport. At the time of the accident there was a power failure, and lights around the destination airport went out. The airplane had struck power lines and a support tower located on the approach end of runway 1 and runway 5, about 1/2 mile southwest of the airport. The airport had one NDB approach which was not authorized at night. The nearest recorded weather, about 10 miles north of the crash site, at the time of the accident was; '...ceiling 100, [visibility] 1/2 mile, fog, [temperature] 46 degrees F, dew point, 42 degrees F, winds 220 degrees at 5 [knots], altimeter 29.90 inches Hg. Witnesses reported that there was heavy fog at the airport and the visibility was below 1/4 mile.
Probable cause:
The pilot's continued VFR flight into instrument meteorological conditions. Factors in this accident were: fog, the low ceiling, and the dark night.
Final Report:

Crash of a Cessna 441 Conquest II in Lakeland

Date & Time: Jan 2, 1997 at 1121 LT
Type of aircraft:
Registration:
N441MS
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lakeland - Lakeland
MSN:
441-0056
YOM:
1978
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6511
Captain / Total hours on type:
533.00
Aircraft flight hours:
4697
Circumstances:
During the takeoff roll the pilot stated the right engine had an over torque condition and he was unable to control the aircraft. The aircraft went off the runway to the left and crashed coming to rest upright. A post crash fire erupted and destroyed the aircraft. The mechanic rated passenger stated he was observing the right engine gauges during this maintenance test flight and did not observe any over torque indications. When he looked up from the instruments at about the time the aircraft should lift off, the aircraft was drifting to the left. The pilot, who was looking at the engine instruments, looked up, saw the aircraft was about to drift off the runway, and retarded both power levers. The passenger/mechanic (who was also a pilot) reported that the pilot placed the propellers in reverse. Six thousand feet of runway remained at the abort point. The aircraft pitched up and then crashed on the left wing and nose. Cessna Service Newsletter SLN99-15 and AlliedSignal Operating Information Letter OI 331-17 report an abnormality that may affect the model engine in which an uncommanded engine fuel flow increase or fluctuation may occur, resulting in an unexpected high torque and asymmetric thrust. The condition is associated with an open torque motor circuit within the engine fuel control. A system malfunction resulting in engine acceleration to maximum power would produce an overtorque of about 2,288 foot-pounds (ft-lb). This power output is restricted by a fuel flow stop in the engine fuel control. Normal takeoff power is 1,669 ft-lbs; therefore, one engine accelerating to the stop limit while one engine continued to operate normally would cause a torque differential of 619 ft-lbs. The total loss of power in one engine during takeoff while one engine continued to operate normally would result in a torque differential of 1,669 ft-lbs. The Cessna 441 Flight Manual states that at 91 knots indicated airspeed, the airplane is controllable with one engine inoperative (that is, with a torque differential between engines of up to 1,669 ft-lbs). However, if an electronic engine control failure occurs on one engine and the other engine is retarded to idle, the fuel flow to the failed engine will not be reduced, and a torque differential of about 2,288 ft-lbs will occur, at which point the airplane is uncontrollable by the pilot.
Probable cause:
Failure of the electronic engine control, which caused an overtorque condition in the right engine that made directional control of the airplane not possible by the pilot when the power to the left engine was retarded to idle during the takeoff roll.
Final Report:

Crash of an Antonov AN-72 in Nagurskoye

Date & Time: Dec 23, 1996 at 1200 LT
Type of aircraft:
Flight Type:
Survivors:
Yes
Schedule:
Vorkouta – Nagurskoye
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The approach to Nagurskoye Airport was completed by a polar night and in poor weather conditions with snow falls. After landing on an iced and snow covered runway, the aircraft overran, lost its undercarriage and came to rest. Nine occupants were injured, among them four seriously. The aircraft was damaged beyond repair.

Crash of an Antonov AN-32B in Medellín: 4 killed

Date & Time: Dec 21, 1996 at 2232 LT
Type of aircraft:
Operator:
Registration:
HK-4008X
Flight Type:
Survivors:
No
Schedule:
Bogotá – Medellín
MSN:
3402
YOM:
1993
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
8635
Captain / Total hours on type:
550.00
Copilot / Total flying hours:
1409
Copilot / Total hours on type:
90
Aircraft flight hours:
403
Circumstances:
The aircraft was completing a cargo flight from Bogotá to Medellín, carrying one passenger, three crew members and a load of 18,300 newspapers for a total weight of 4,970 kilos. While descending to Medellín-Rionegro Airport, the crew encountered difficulties to intercept the ILS and made successives left and right turn when, on final approach, the aircraft went out of control and crashed 8 km short of runway 36. All four occupants were killed.
Probable cause:
Loss of control following the in-flight fracture of the right wing that induced the rupture of the left stabilizer exceeding the ultimate resistance of the structure. The exact cause of the structural failure could not be determined.
Final Report:

Crash of a Douglas DC-8-55F in Port Harcourt

Date & Time: Dec 17, 1996 at 0500 LT
Type of aircraft:
Operator:
Registration:
9G-MKD
Flight Type:
Survivors:
Yes
Schedule:
Luxembourg - Port Harcourt
MSN:
45965
YOM:
1968
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While descending to Port Harcourt Airport, the pilot-in-command established a visual contact with the runway lights at an altitude of 2,500 feet. The approach was continued when few seconds later, while the crew was thinking his altitude was 390 feet, the aircraft collided with trees. The captain decided to initiate a go-around procedure but all four engines failed to respond properly. The aircraft continued to descend and struck the ground 250 metres short of runway threshold. Upon impact, the undercarriage were torn off and the aircraft slid for few dozen metres before coming to rest. All four crew members escaped uninjured and the aircraft was damaged beyond repair. It was reported that the aircraft was unstable on final approach.

Crash of an Antonov AN-12RR in Andreapol: 17 killed

Date & Time: Dec 17, 1996
Type of aircraft:
Operator:
Registration:
21 red
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Saint-Petersburg – Andreapol – Krasnodar
MSN:
3 34 14 04
YOM:
1963
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
17
Circumstances:
The aircraft was completing a cargo flight from St Petersburg-Levashovo to Krasnodar with an intermediate stop in Andreapol, carrying 11 passengers, six crew members and a load of construction materials and the personal car of General Sergei Seleznyov who was building a private cottage in the region of Krasnodar. During initial climb, the aircraft became unstable and started to pitch up and down. When the crew retracted the flaps, the aircraft nosed down, entered an uncontrolled descent and crashed in a wooded area located some 8 km from the airport. All 17 occupants were killed, among them the General and his wife.
Probable cause:
It was determined that the aircraft weight was 1,5 ton above MTOW at the time of the accident. Also, it was reported that wings surfaces were contaminated with frost and snow, which was considered as a contributing factor.

Crash of a Cessna 425 Conquest in Ronkonkoma: 3 killed

Date & Time: Dec 16, 1996 at 1840 LT
Type of aircraft:
Registration:
N425EW
Survivors:
No
Schedule:
Macon – Ronkonkoma
MSN:
425-0150
YOM:
1983
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
10846
Captain / Total hours on type:
2089.00
Circumstances:
The pilot had received clearance for the ILS Runway 6 approach and was advised that the previous landing traffic reported '...breaking out at minimums.' Radar data revealed that the airplane descended in instrument meteorological conditions to the decision height altitude of 294 feet, approximately 3 miles from the missed approach point. The pilot did not perform the missed approach procedure. The airplane leveled off and continued at or below decision height altitude for approximately 28 seconds, traveling a distance of approximately 1 mile. Four low altitude alerts appeared on the tower controller's display. The controller stated he withheld the alert because '...it was a critical phase of flight and the aircraft appeared to be climbing...' The airplane collided with trees and terrain approximately 1.5 miles from the approach end of the landing runway.
Probable cause:
The pilot's early descent to decision height and his failure to perform the missed approach procedure. A factor was the failure of air traffic control to issue a safety advisory.
Final Report: