Crash of a Piper PA-31-325 Navajo C/R in Dayton: 1 killed

Date & Time: Jun 19, 1996 at 0810 LT
Type of aircraft:
Operator:
Registration:
N62852
Flight Type:
Survivors:
No
Schedule:
Berrien Springs - Dayton
MSN:
31-7612089
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1198
Captain / Total hours on type:
701.00
Aircraft flight hours:
3252
Circumstances:
The parents of the pilot/owner stated that he arrived late in the afternoon prior to the accident. They stayed up with their son until approximately 0100 the morning of the accident. They stated that their son was a doctor and kept a busy schedule. The son told the parents that he had to fly back in order to have new fuel cells installed in the airplane and to work at his clinic. The pilot was airborne by 0700. The weather at his destination had low ceilings and fog restricting the visibility. The pilot was cleared by ATC to fly the localizer approach to the runway. The pilot called his position at the outer marker on the unicom frequency and no further transmissions were heard. Witnesses on the airport heard and saw the bottom of the airplane and stated that the airplane's engines sounded normal as it went overhead. Radar data showed that the airplane's altitude fluctuated and ground speed decreased significantly during the missed approach flight path. The airplane impacted the ground in approximately 40- degree nose-low, right wing down attitude. The toxicology report revealed 0.005 ug/ml Tetrahydrocannabinol (Marihuana) in the blood, and 0.013 ug/ml and 0.017 ug/ml Tetrahydrocannabinol Carboxylic Acid (Marihuana) in the blood and kidney fluid respectively.
Probable cause:
The pilot's impairment of judgment and performance due to drugs which led to spatial disorientation and a loss of aircraft control. The weather was a factor.
Final Report:

Crash of a Short SC.7 Skyvan 3 Variant 400 in Hoogeveen

Date & Time: Jun 16, 1996
Type of aircraft:
Operator:
Registration:
OE-FDI
Survivors:
Yes
Schedule:
Hoogeveen - Hoogeveen
MSN:
1869
YOM:
1969
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was dispatched at Hoogeveen Airport to perform local skydiving missions. While cruising at an altitude of 8,000 feet, both engines failed simultaneously. The crew ordered the skydivers to bail out and decided to return for an emergency landing. On final, the crew realized he could not make it and eventually completed an emergency landing in a potato field located about 500 metres short of runway. Both pilots escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Double engine failure caused by a fuel exhaustion. It was determined that the crew miscalculated the necessary fuel quantity for the all mission as the accident occurred after 6 rotations.

Crash of a Douglas DC-10-30 in Fukuoka: 3 killed

Date & Time: Jun 13, 1996 at 1208 LT
Type of aircraft:
Operator:
Registration:
PK-GIE
Flight Phase:
Survivors:
Yes
Schedule:
Fukuoka – Denpasar – Jakarta
MSN:
46685
YOM:
1979
Flight number:
GA865
Country:
Region:
Crew on board:
15
Crew fatalities:
Pax on board:
260
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
10263
Captain / Total hours on type:
2641.00
Copilot / Total flying hours:
3910
Copilot / Total hours on type:
1437
Aircraft flight hours:
46325
Circumstances:
During the takeoff roll at Fukuoka-Itazuke Airport runway 16, at a speed of 158 knots, the captain started the rotation. During initial climb, at a height of about 3 metres, the right engine suffered a loss of power after a fan blade located on the 1st stage of the high pressure compressor disk separated. The N1 dropped to 23,7% and five seconds later, the flight engineer informed the crew about the failure of the engine n°1. The captain decided to abort the takeoff and landed back on runway. The aircraft contacted ground with a vertical acceleration of 2,1 g then thrust reversers were deployed and ground spoilers were extended. Unable to stop within the remaining distance, the aircraft overran, crossed a road, skidded for about 620 metres before coming to rest in an open field, bursting into flames. Three passengers were killed.
Probable cause:
Although the CAS was well in excess of V1 and the aircraft had already lifted off from the runway, the takeoff was aborted. Consequently the aircraft departed the end of the runway, came to rest and caught fire. It is estimated that contributing to the rejection of the takeoff under this circumstance was the fact that the CAP's judgement in the event of the engine failure was inadequate. Investigation revealed that the turbine blade that failed, had operated for 30913 hours and 6182 cycles. General Electric had advised customers to discard blades after about 6000 cycles.
Final Report:

Crash of a Beechcraft E90 King Air in Wiscasset: 2 killed

Date & Time: Jun 10, 1996 at 0600 LT
Type of aircraft:
Registration:
N916PA
Flight Phase:
Survivors:
No
Schedule:
Wiscasset - Philadelphia
MSN:
LW-313
YOM:
1979
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
10516
Captain / Total hours on type:
1138.00
Aircraft flight hours:
6230
Circumstances:
The pilot took off on runway 07 and was cleared direct to the Wiscasset NDB, east of the airport. Shortly after takeoff, the airplane began turning to the left. The pilot then asked the controller, '. . . can you tell if I'm in a turn? I have a problem here.' Soon thereafter, the airplane collided with terrain in an uncontrolled descent, about 1.6 miles north of the airport. Investigation revealed that three days before the accident, a refueler had fueled the airplane's left wing with 840 pounds of fuel, then the fuel farm ran out of fuel. No further fueling was accomplished, and the pilot was not advised of the uneven fuel load. Procedures in the Beech E90 Pilot's Operating Manual (POM) included a check of the fuel tanks during preflight. The Beech C90 POM specified a maximum fuel imbalance of 200 pounds, but the E90 POM did not specify a maximum fuel imbalance. During examination of the wreckage, no preimpact malfunction or failure was found.
Probable cause:
Failure of the pilot to maintain control of the airplane while climbing after takeoff, due to spatial disorientation, which resulted in an uncontrolled descent and subsequent collision with terrain. Factors relating to the accident were: the improper refueling (servicing of the aircraft) by FBO personnel, and failure of the pilot to note the excessive lateral imbalance of the airplane during preflight.
Final Report:

Crash of a Boeing 727-286 in Rasht: 4 killed

Date & Time: Jun 9, 1996 at 1455 LT
Type of aircraft:
Operator:
Registration:
EP-IRU
Flight Type:
Survivors:
Yes
Schedule:
Rasht - Rasht
MSN:
21079
YOM:
1975
Location:
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The crew departed Tehran-Mehrabad Airport at 1233LT on a training flight to Rasht. Following 14 touch-and-go manoeuvres completed successfully, the crew approached the airport but forgot to lower the landing gear. The aircraft landed on its belly and slid on runway 09 for a period of 30 seconds and on a distance of 2,100 metres. Despite the situation, the crew decided to take off again and continued to climb when the rear fuselage caught fire. The crew declared an emergency, extended the undercarriage manually and was cleared to land on runway 09. On final approach, the aircraft became unstable, lost height and crashed in a field located 5 km short of runway. Four crew members were killed while three others were injured. The aircraft was destroyed. §
Probable cause:
The following findings were reported:
- The crew failed to follow the approach checklist,
- The crew forgot to lower the landing gear,
- Poor crew coordination,
- Lack of crew resources management,
- Wrong decision on part of the crew to take off following a belly landing,
- Following the belly landing, the aircraft suffered a fire and was not fit to fly.

Crash of an Ilyushin II-76MD in Kinshasa: 10 killed

Date & Time: Jun 6, 1996
Type of aircraft:
Operator:
Registration:
UR-76539
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kinshasa - Athens
MSN:
00334 42234
YOM:
1983
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
10
Aircraft flight hours:
2134
Aircraft flight cycles:
1358
Circumstances:
While taxiing backwards at Kinshasa-N'Djili Airport, the crew used thrust reversers and failed to extend the flaps prior to takeoff. During the takeoff roll, the pilot-in-command started the rotation when the nose gear lifted off. Despite the aircraft failed to take off, the crew did not reject the takeoff procedure and continued. The aircraft adopted a high nose up attitude and a super critical angle of attack. It rolled for about 3,800 metres, overran, rolled for another 800 metres when it struck irregularities on the ground. On impact, the right wing was torn off and the aircraft crashed, bursting into flames. All 10 occupants were killed. The aircraft was on its way to Athens, carrying a load consisting of engine and spare parts.
Probable cause:
The crew failed to prepare the flight according to published procedures and failed to extend flaps prior to takeoff. The following contributing factors were reported:
- Poor flight preparation,
- Poor crew coordination,
- Misunderstanding by the crew about the aircraft configuration,
- The pilot-in-command failed to reject takeoff.
- Crew's fatigue,
- The aircraft was not equipped with an alarm in case of wrong flaps' position.

Crash of a Learjet 25C in Ribeirão Preto: 2 killed

Date & Time: Jun 4, 1996 at 1320 LT
Type of aircraft:
Registration:
PT-KBC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
São Paulo – Uberaba – Ribeirão Preto
MSN:
25-165
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3500
Captain / Total hours on type:
250.00
Copilot / Total flying hours:
2000
Copilot / Total hours on type:
420
Circumstances:
The crew departed São Paulo on a training flight to Ribeirão Preto with an intermediate stop in Uberaba. On approach to Ribeirão Preto-Leite Lopes Airport, the instructor decided to reduce power on the left engine to simulate a failure and to complete a touch-and-go manoeuvre. After touchdown, the left engine power lever remained in the idle position so the captain took over control and attempted to take off as he judged it impossible to stop on the remaining runway. The aircraft took off but landed back about 92 metres past the runway end. Out of control, it collided with a truck and a tree and came to rest, bursting into flames. A man in the truck as well as one pilot were killed while three other pilots were injured. The aircraft was destroyed.
Probable cause:
The following findings were reported:
- There are indications of the presence of psychological variables that may have influenced the instructor's decision to perform the touch-and-go manoeuvre.
- There was inadequate supervision, at the technical and operational level, by the aircraft operating company, due to the lack of training, inadequate instruction and absence of flight simulator training.
- There was an error made by the pilots due to the inadequate use of the crew resources in the cockpit intended for the operation of the aircraft, due to an ineffective fulfillment of the tasks assigned to each of the crew and the non-observance of the operational rules.
- Even though the crew was qualified for the type of flight, there was inadequate planning regarding the absence of a takeoff and landing briefing.
- There was an error made by the copilot, when the delay in reducing the power levers, as soon as the locking of the left engine lever was established during the dash on the ground, with an inadequate assessment of the situation in this regard.
- There was the participation of the training process received, due to quantitative and qualitative deficiency, which did not attribute to pilots the full technical conditions to be developed in the activity, regarding the lack of simulator training, lack of a company training program that included CRM and local flights, among others.
- There are indications that the difficulties reported by the pilots in relation to the throttle were caused by the rupture of fibers in the cable that transfers its control to the FCU. This cable slides inside a corrugated cover and can be jammed if any fiber in the cable breaks.
Final Report:

Crash of an Aeritalia G.222 in Pisa

Date & Time: May 31, 1996
Type of aircraft:
Operator:
Registration:
MM62108
Flight Type:
Survivors:
Yes
MSN:
4013
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
For unknown reasons, the aircraft landed on its belly, slid for few dozen metres then lost a wing and came to rest. all four crew members escaped uninjured.

Crash of a Cessna 340 in Halfpenny Green

Date & Time: May 30, 1996 at 1603 LT
Type of aircraft:
Operator:
Registration:
G-KINK
Flight Type:
Survivors:
Yes
Schedule:
Halfpenny Green - Halfpenny Green
MSN:
340-0045
YOM:
1972
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
605
Captain / Total hours on type:
289.00
Circumstances:
The pilot carried out extensive pre-flight checks of G-KINK which had been little used during the preceding six months. During these checks he established visually that the left main (tip) fuel tank was 30% full and the right main fuel tank was 40% full(the tanks can each hold 51 US gallons which equates to approximately 306 lb per side). Both wing (auxiliary) tanks were full but the locker tanks were empty. At 1539 hrs the aircraft departed Halfpenny Green in CAVOK weather conditions for a brief local flight to the west of the airfield. After climbing to an altitude of 2,500 feet and establishing cruise power conditions, the pilot changed the fuel valve selectors from main to auxiliary tanks on both engines. A few minutes later,he set course for a return to Halfpenny Green and changed the fuel selectors back to main tanks on both engines. At this stage the left tank indicated 50 lb remaining and the right tank indicated 70 lb remaining but the pilot had established during his pre-flight checks that these tank gauges were over-reading. About 13 nm from the airport the pilot lowered one stage of flapand obtained 'clearance' from Halfpenny Green Information foran overhead join for landing on Runway 16 from a left-hand circuit. The aircraft overflew the airport and after reducing engine power to 20 inches manifold pressure and 2,200 RPM, the pilot manoeuvred to the west of Runway 16 where he descended on the 'dead side' in preparation for the downwind leg. In his report to the AAIB, the pilot stated that on throttling back, both engines faltered whereupon he checked that all thethrottle, pitch and mixture levers were fully forward, the fuel pumps were switched on and that main tanks were selected on both engines. He then declared an emergency on the AFIS frequency and requested an immediate left orbit with the intention of landing on Runway 16. Initially power was restored on both engines and the pilot lowered the landing gear in preparation for a shortfield landing on Runway 16. However, at approximately 300 ft agl, whilst still travelling downwind, the left engine stopped. There was no time to feather the propeller but the pilot applied right rudder and, with the aircraft descending rapidly, he decided to force-land straight ahead into a field of standing crop to the north west of the airfield. Unfortunately, whilst manoeuvring to avoid farm buildings, the aircraft's left wing tip struck electricity power lines. During the subsequent crash landing the aircraft slid about 50 yards and latterly it 'cartwheeled' in the standing crop and came to rest upside down. There was no fire and all three occupants remained suspended by their seat harnesses. The pilot noticed a strong smell of fuel which was dripping from the region of the fuel valve selectors. He switched off the battery master and engine magneto switches; he also attempted to select both fuel valves to the OFF position but initially he was unsuccessful. After some difficulty, probably due to the weight of the now inverted boarding steps, the pilot succeeded in opening the main cabin door and together with his passengers, he vacated the aircraft and moved to a safe distance to await the arrival of the emergency services. However, before long, when he was convinced there was no longer any danger of fire, he returned to the aircraft to recover documents and valuables. At the same time he confirmed that the electrical switches were off and he succeeded in turning the left engine fuel valve selector to OFF. However, the right fuel valve selector could not be moved to the OFF position.
Probable cause:
Post accident checks of the wreckage revealed that both propellers were bent rearwards in a manner consistent with low power or windmilling. All the fuel tanks were disrupted and it was not possible to reconstruct the disposition of fuel in the various tanks. Nevertheless,there was fuel between the flow divider and the fuel injectors of the right engine but no fuel in the corresponding locations on the left engine indicating that it had stopped due to fuel starvation. The aircraft maintenance organisation which recovered the wreckage stated that the fuel valves on the Cessna 340 must be operated with great care. The selectors have indicating bands which maybe wider than the selectable range and the valves must be carefully placed in the correct detent by feel as well as by sight. Moreover,during an investigation into a similar accident to Cessna 340A,GXGBE reported in AAIB Bulletin 11/93, it was noted that both valve selectors are positioned athwartships whichever of the two main tanks is selected. Therefore, it is possible inadvertently to run both engines off the same main fuel tank resulting in near simultaneous engine failure when the fuel in the tank is exhausted. The senior fireman who attended the accident scene also attempted to move the right engine fuel valve selector to the OFF position without success. He reported that the selector was stuck and would not move in either direction. He remembered, although he could not be absolutely certain, that the selector was pointing to the "9 o'clock" position when viewed from the normal aspect which corresponds to selecting the right engine to feed from the left main tank. If this was indeed the case, and the left main tank ran dry, it is likely that the left engine would stop slightly before the right engine because its fuel lines from the left tank are shorter. This sequence of events is consistent with the sum of the evidence.
Final Report:

Crash of a Piper PA-31T Cheyenne II in Malvern: 5 killed

Date & Time: May 29, 1996 at 1835 LT
Type of aircraft:
Operator:
Registration:
N333LM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Malvern - Malvern
MSN:
31-792005
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
7500
Captain / Total hours on type:
700.00
Aircraft flight hours:
4483
Circumstances:
After the completion of scheduled maintenance and a normal ground run up, the airplane departed the airport for a local test flight. Witnesses observed the airplane in a nose high attitude, turn to the left, and then saw the nose drop toward the ground approximately 1 1/2 miles from the departure end of the runway. The airplane impacted hilly terrain and was consumed by a post impact fire. Detailed examination of the airframe, engines, and propellers revealed no defects or anomalies that would have contributed to the accident.
Probable cause:
The pilot's failure to maintain control of the airplane after takeoff.
Final Report: