Crash of a Fletcher FU-24-950 in Ketapang: 2 killed

Date & Time: Dec 31, 2009 at 0826 LT
Type of aircraft:
Operator:
Registration:
PK-PNX
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Ujung Tanjung - Jambi - Pangkal Pinang - Ketapang - Tangar
MSN:
187
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2892
Captain / Total hours on type:
641.00
Circumstances:
The aircraft was completing a ferry flight from Ujung Tanjung/Pekanbaru home base to Tangar airstrip, Center of Kalimantan, with reference flight approval number D09-038960 and Security Clearance number AU05-033328, person on board was one pilot and one engineer. On 29 December 2009, the aircraft departed from Ujung Tanjung, transit at Jambi and stop overnight at Pangkal Pinang Airport, Bangka with total flight time was 3 hours. On the next day 30 December 2009, the aircraft continuing flight from Pangkal Pinang to Rahadi Oesman Airport, Ketapang, West Kalimantan and overnight at Ketapang with total flight time is 1:40 hours. On the next day 31 December 2009, the aircraft plan to continued flight to Tangar Airstrip. The aircraft was airworthy prior departure and dispatched from Ketapang with the following sequence:
a. The pilot requested for start the engine at 01:17 UTC4 (08:17 Local Time);
b. At 01:24 the pilot requested for taxi, and the ATC gave clearance via taxiway “A”. The pilot requested intersection runway 17 and approved by ATC
c. The ATC requested for reported when ready for departure, and the pilot reported ready for departure, then the ATC gave the departure clearance.
d. At 01:25, the aircraft was departed and crashed at 01:26 striking the roof of the hospital and broken down into pieces at the parking area in which have had approximate 1.5 Kilometer to the left side from the flight path centreline. The aircraft was substantially damage and the crew on board consist of one pilot in command and one aircraft maintenance engineer; both of them were fatally injured.
Probable cause:
The investigation concluded that the aircraft engine was not in power during impact with the hospital roof. There was a corroded fuel pump, that indicated of contaminated fuel.
Findings:
• The aircraft was airworthy prior departure.
• The pilot was fit for flight.
• The booster pump was found of an evident of surface corrosion on the spring, plate and van pump indicated that contaminated fuel.
• Referred to the Fletcher Flight Manual and Pilot Operating Handbook chapter 3.10. Fuel System Failure, the booster pump must have been operated prior to flight.
• The propeller blades were on fine pitch and no sign of rotating impact. The engine was not in powered when hit the ground.
• No evidence damage related to the engine prior to the occurrence.
Final Report:

Crash of a Douglas DC-3C in Manila: 4 killed

Date & Time: Oct 17, 2009 at 1214 LT
Type of aircraft:
Registration:
RP-C550
Flight Type:
Survivors:
No
Site:
Schedule:
Manila - Puerto Princesa
MSN:
14292/25737
YOM:
1944
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
On October 17, 2009at about 12:04 pm, RP-C550 a DC-3type of aircraft took off from Manila Domestic airport bound for Puerto Princesa, Palawan. Approximately 5 mins after airborne, the Pilot-in-Command (PIC) informed Manila Tower that they were turning back due to technical problem. The PIC was asked by the air controller whether he was declaring an “emergency” and the response was negative. The PIC was directed to proceed South Mall and wait for further instruction (a standard procedures for VFR arrivals for runway 13). At South Mall, RP-C550 was cleared to cross the end of runway 06, still without declaring an emergency. The tower controller sensed that something was wrong with the aircraft due to its very low altitude, immediately granted clearance to land runway 06. However, the aircraft was not able to make it to runway 06. At about 12:14, RP-C550 crashed at an abandoned warehouse in Villa Fidela Subd., Brgy. Elias Aldana Las Piñas City about 4 kms. from the threshold of runway 06. As a result, the aircraft was totally destroyed and all aboard suffered fatal injuries due to impact and post crash fire.
Probable cause:
The Aircraft Accident Investigation and Inquiry Board determine that the probable causes of this accident were the following:
- Non-procedural application of power during take-off and initial climb that led to left engine malfunction.
- The questionable qualifications of the flight crew.
- Low level of competence of the pilots.
- Not feathering the left engine.
- Turning towards the bad engine.
- Not declaring an emergency.
Final Report:

Crash of a Beechcraft 99 Airliner in Évora: 2 killed

Date & Time: Aug 14, 2009 at 1908 LT
Type of aircraft:
Operator:
Registration:
F-BTME
Survivors:
No
Site:
Schedule:
Évora - Évora
MSN:
U-79
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
22993
Aircraft flight cycles:
17449
Circumstances:
The aircraft, a Beechcraft model BE-99, s/n U79, with French registration F-BTME, belonging to the operator “Avioarte Serviços Aéreos, Lda”, was involved all that day, 14th of August, 2009, flying locally, carrying parachutists for skydiving exercises, in the vicinity of Évora aerodrome (LPEV), working for the enterprise “Skydive”. With twelve full equipped parachutists and one pilot on board, the aircraft took-off on runway 01 at 18:47, intending to climb to an altitude of 13000ft (4000m), at which altitude the jumping would take place. When passing about 9500ft (2900m), left engine (#1) flame-out and respective propeller was automatically feathered. The pilot stop climb at around 10500ft (3200m), informed the parachutists that one engine had stopped and they should jump a little lower than it was expected, while he would proceed for landing at same aerodrome, with one engine inoperative. All parachutists left the aircraft, on sequence, but one, who, after being next to the exit, returned to the cockpit and remained on board, with the pilot. The aircraft started a dive, turning around the field, and the pilot contacted the tower on left base leg for runway 01, but said nothing about the inoperative engine or any assistance required. He was told to report on final, which he never did. He continued the approach for runway 01, with landing gear down and flaps at initial setting (13º), but keeping high speed. The aircraft made a low pass, over all runway length, without the wheels touching the ground. Once passing runway end it continued flying, the pilot increased power on right engine (#2) and the aircraft started deviating to the left, with wings levelled and without showing significant climb tendency. Observers, at the aerodrome, lost the sight of the aircraft for some moments and saw it reappearing close to Almeirim residential quarter (in the outskirts of Évora). One testimony, sited at the aerodrome, referred seeing the aircraft executing a sudden manoeuvre, like a left roll, pointing the wheels up to the sky. Moments later a collision sound was heard, the engine became silent and some flames and a black smoke cloud appeared. The aircraft collided with a residential building, in Maria Auxiliadora street, Almeirim residential quarter, sited about 1160m far from runway end, on track 330º. After the collision with the building, the aircraft fell to the ground, upside-down, a fire sparked immediately and the plane was engulfed by flames. Fire brigades from Évora, Viana do Alentejo, Montemor-o-Novo and Arraiolos arrived at the scene, promptly, but it took some time for the fire to be extinguished (after burning all aircraft fuel) and the burned bodies recovered from the wreckage.
Probable cause:
Primary Cause:
Primary cause for this accident was pilot inability, as he was not qualified to fly this class of aircraft, to carry a single engine landing or maintain directional control during go-around with one engine inoperative.
Contributory Factors:
The following were considered as Contributory factors:
- The pilot was not qualified to operate multi-engine aircrafts and had no knowledge and training to fly this kind of aircraft;
- Unsuitable fuel monitoring and omission on manufacturer recommended procedures accomplishment;
- Inadequate flying technique, without consideration to the airplane special flying characteristics;
- Inadequate supervision, by the competent authorities, on flying activities carried by pilots and aircrafts with foreign licenses and registrations, inside Portuguese territory.
Final Report:

Crash of a Partenavia P.68 Observer II in Sant Pere de Vilamajor: 2 killed

Date & Time: Jun 23, 2009 at 1045 LT
Type of aircraft:
Operator:
Registration:
EC-IPG
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Sabadell - Sabadell
MSN:
421-21-OB2
YOM:
2003
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5686
Captain / Total hours on type:
155.00
Copilot / Total flying hours:
6689
Copilot / Total hours on type:
9
Circumstances:
The airplane, a Vulcan Air PA68 Observer 2, registration EC-IPG, had taken off from Sabadell airport to conduct a local flight. Onboard were the instructor and a pilot who was being tested for a CRI (SPA) (Class Rating Instructor). As they were flying over the town of Sant Pere de Vilamajor (Barcelona), the aircraft plunged to the ground, falling within the property limit of a private dwelling (a chalet). Several eyewitnesses reported that they stopped hearing the engine noise and that they then saw the airplane spinning in a nose down attitude. The front part of the airplane (cockpit) impacted the ground first. The crash resulted in a fire, the flames from which reached a part of the aircraft and an arbor next to the house, but not the house itself, though it was affected by the smoke. The two occupants perished immediately and were trapped inside the airplane. They were extracted by emergency personnel. The aircraft was destroyed by the impact and subsequent fire. The post-accident inspection did not reveal any signs of a fault or malfunction of any aircraft component. It has been determined that the accident resulted from a stall caused by flying the aircraft at a low speed. It has also been concluded that there were three contributing factors: the low altitude, the very likely possibility that the crew did not establish guidelines for action prior to the flight and the absence of an authority gradient between the crew members.
Probable cause:
The accident was caused when the aircraft stalled during the performance of a slow flying maneuver with the right engine stopped. Factors that contributed to the accident were the low altitude, the possibility that the crew did not define the responsibilities of each prior to the flight and which may have resulted in a lack of coordination when faced with the circumstances in the final moments of the flight, and the lack of an authority gradient between the crew members.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Fort Lauderdale: 1 killed

Date & Time: Apr 17, 2009 at 1115 LT
Operator:
Registration:
N1935G
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Fort Lauderdale - Fernandina Beach
MSN:
421B-0836
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
23000
Captain / Total hours on type:
5000.00
Circumstances:
Prior to the accident flight witnesses observed the pilot "haphazardly" pouring oil into the right engine. The pilot then ran the engines at mid-range power for approximately 20 minutes. The airplane subsequently taxied out of the ramp area and departed. Fire was observed emanating from the right engine after rotation. The airplane continued in a shallow climb from the runway, flying low, with the right engine on fire. The airplane then banked right to return to the airport and descended into a residential area. Examination of the right engine revealed an exhaust leak at the No. 4 cylinder exhaust riser flange. Additionally, one of the flange boltholes was elongated, most likely from the resulting vibration. The fuel nozzle and B-nut were secure in the No. 4 cylinder; however, its respective fuel line was separated about 8 inches from the nozzle. No determination could be made as to when the fuel line separated (preimpact or postimpact) due to the impact and postcrash fire damage. Examination of the right engine turbocharger revealed that the compressor wheel exhibited uniform deposits of an aluminum alloy mixture, consistent with ingestion during operation, and most likely from the melting of the aluminum fresh air duct. Additionally, the right propeller was found near the low pitch position, which was contrary to the owner's manual emergency procedure to secure the engine and feather the propeller in the event of an engine fire.
Probable cause:
The pilot's failure to maintain aircraft control and secure the right engine during an emergency return to the airport after takeoff. Contributing to the accident was an in-flight fire of the right engine for undetermined reasons.
Final Report:

Crash of a Beechcraft 200 Super King Air in Quito: 7 killed

Date & Time: Mar 19, 2009 at 1725 LT
Operator:
Registration:
AEE-101
Flight Type:
Survivors:
No
Site:
Schedule:
San Vicente - Quito
MSN:
BB-811
YOM:
1981
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The crew (four pilots under supervision and one instructor) departed San Vicente on a training flight to Quito-Mariscal Sucre Airport. On approach in foggy conditions, the twin engine aircraft descended too low, collided with a 4-floor building and crashed 4 km short of runway. All five occupants as well as two people on the ground were killed and four other people on the ground were seriously injured.

Crash of a De Havilland Dash-8-Q402 in Buffalo: 50 killed

Date & Time: Feb 12, 2009 at 2217 LT
Operator:
Registration:
N200WQ
Survivors:
No
Site:
Schedule:
Newark - Buffalo
MSN:
4200
YOM:
2008
Flight number:
CO3407
Crew on board:
4
Crew fatalities:
Pax on board:
45
Pax fatalities:
Other fatalities:
Total fatalities:
50
Captain / Total flying hours:
3379
Captain / Total hours on type:
111.00
Copilot / Total flying hours:
2244
Copilot / Total hours on type:
774
Aircraft flight hours:
1819
Aircraft flight cycles:
1809
Circumstances:
On February 12, 2009, about 2217 eastern standard time, a Colgan Air, Inc., Bombardier DHC-8-400, N200WQ, operating as Continental Connection flight 3407, was on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport. The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground was killed, and the airplane was destroyed by impact forces and a post crash fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121. Night visual meteorological conditions prevailed at the time of the accident.
Probable cause:
The captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover.
Contributing to the accident were:
1) The flight crew’s failure to monitor airspeed in relation to the rising position of the low speed cue,
2) The flight crew’s failure to adhere to sterile cockpit procedures,
3) The captain’s failure to effectively manage the flight,
4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.
Final Report:

Crash of a Beechcraft 200 Super King Air in Recife: 2 killed

Date & Time: Nov 23, 2008 at 1115 LT
Operator:
Registration:
PT-OSR
Survivors:
Yes
Site:
Schedule:
Teresina - Recife
MSN:
BB-784
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
10000
Circumstances:
Following an uneventful flight from Teresina, the crew started the approach to Recife-Guararapes Airport runway 18. On final, both engines failed simultaneously. The aircraft stalled and crashed in a residential area located 5 km from the runway threshold. A passenger and a pilot were killed while eight others occupants were injured. There were no victims on the ground while the aircraft was destroyed.
Probable cause:
Double engine failure caused by a fuel exhaustion. The following contributing factors were identified:
- Poor flight planning,
- The crew failed to add sufficient fuel prior to departure from Teresina Airport,
- The fuel quantity was insufficient for the required distance,
- The crew failed to follow the published procedures,
- Overconfidence from the crew,
- Poor organisational culture on part of the operator,
- Lack of discipline and poor judgment on part of the crew,
- Lack of supervision.
Final Report:

Crash of a Learjet 45 in Mexico City: 16 killed

Date & Time: Nov 4, 2008 at 1846 LT
Type of aircraft:
Registration:
XC-VMC
Flight Type:
Survivors:
No
Site:
Schedule:
San Luis Potosí – Mexico City
MSN:
45-028
YOM:
1999
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
16
Captain / Total flying hours:
4000
Captain / Total hours on type:
180.00
Copilot / Total flying hours:
11809
Copilot / Total hours on type:
57
Aircraft flight hours:
2486
Aircraft flight cycles:
2215
Circumstances:
Following an uneventful flight from San Luis Potosí, the crew was cleared to the MATEO VOR and for an ILS/DME approach to runway 05R at Mexico-Benito Juarez Intl Airport, then was instructed by ATC to increase their speed to 220 knots. The Learjet was trailing a Boeing 767-300 (Mexicana Flight 1692 from Buenos Aires), which was instructed to decrease speed to 160 knots to maintain separation with a preceding Airbus A318. At 18:41 a further instruction was given to slow down to an indicated airspeed of 150 knots. At 18:42 the Boeing 767 crossed MATEO VOR at a ground speed of 224 knots. The Learjet was following at 8 nautical miles (NM) at a ground speed of 272 knots. At 18:44 the controller instructed Mexicana Flight 1692 to slow down to the minimum approach speed. At that time, the Learjet 45 was crossing the MATEO VOR with a ground speed of 262 knots, approximately 5.7 NM behind. The controller then instructed the Learjet crew to reduce their airspeed to 180 knots. This was acknowledged but it took 16 seconds for the crew to take action. Separation between the Boeing 767 and Learjet had decreased to 3.8 NM and the Learjet entered the wake turbulence of the 767. Control was lost and the aircraft entered an uncontrolled descent, crashing on the Monte Pelvoux and Ferrocarril de Cuernavaca Avenues. The aircraft disintegrated on impact and all 9 occupants were killed as well as 7 people on the ground. Some buildings were damaged, about 20 cars were destroyed and 40 people on the ground were injured, some seriously. Among the passengers were:
Juan Camilo Mouriño Terrazo, Interior Minister,
José Luis Santiago Vasconcelos, General Attorney,
Miguel Monterrubio Cubas, Director for Social Communication.
Probable cause:
Loss of control at low altitude and subsequent impact of the aircraft with the ground after it encountered wake turbulence caused by a preceding aircraft.
The following contributing factors were identified:
- Lack of adequate crew training on Learjet 45,
- Delay of the crew to reduce the approach speed,
- Lack of Air Traffic Control to correct the excessive approach speed of the aircraft,
- Fatigue accumulated by ATC,
- Grant of flight capacity, administrative problems and probable corruption,
- Insufficient monitoring of the aircraft operator to provide maintenance and operation.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in North Las Vegas: 1 killed

Date & Time: Aug 28, 2008 at 1238 LT
Operator:
Registration:
N212HB
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
North Las Vegas - Palo Alto
MSN:
31-8152072
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3195
Captain / Total hours on type:
100.00
Aircraft flight hours:
6373
Circumstances:
During climb a few minutes after takeoff, a fire erupted in the airplane's right engine compartment. About 7 miles from the departure airport, the pilot reversed course and notified the air traffic controller that he was declaring an emergency. As the pilot was proceeding back toward the departure airport witnesses observed fire beneath, and smoke trailing from, the right engine and heard boom sounds or explosions as the airplane descended. Although the pilot feathered the right engine's propeller, the airplane's descent continued. The 12-minute flight ended about 1.25 miles from the runway when the airplane impacted trees and power lines before coming to rest upside down adjacent to a private residence. A fuel-fed fire consumed the airframe and damaged nearby private residences. The airplane was owned and operated by an airplane broker that intended to have it ferried to Korea. In preparation for the overseas ferry flight, the airplane's engines were overhauled. Maintenance was also performed on various components including the engine-driven fuel pumps, turbochargers, and propellers. Nacelle fuel tanks were installed and the airplane received an annual inspection. Thereafter, the broker had a ferry pilot fly the airplane from the maintenance facility in Ohio to the pilot's Nevada-based facility, where the ferry pilot had additional maintenance performed related to the air conditioner, gear door, vacuum pump, and idle adjustment. Upon completion of this maintenance, the right engine was test run for at least 20 minutes and the airplane was returned to the ferry pilot. During the following month, the ferry pilot modified the airplane's fuel system by installing four custom-made ferry fuel tanks in the fuselage, and associated plumbing in the wings, to supplement the existing six certificated fuel tanks. The ferry pilot held an airframe and powerplant mechanic certificate with inspection authorization. He reinspected the airplane, purportedly in accordance with the Piper Aircraft Company's annual inspection protocol, signed the maintenance logbook, and requested Federal Aviation Administration (FAA) approval for his ferry flight. The FAA reported that it did not process the first ferry pilot's ferry permit application because of issues related to the applicant's forms and the FAA inspector's workload. The airplane broker discharged the pilot and contracted with a new ferry pilot (the accident pilot) to immediately pick up the airplane in Nevada and fly it to California, the second ferry pilot's base. The contract specified that the airplane be airworthy. In California, the accident pilot planned to complete any necessary modifications, acquire FAA approval, and then ferry the airplane overseas. The discharged ferry pilot stated to the National Transportation Safety Board (NTSB) investigator that none of his airplane modifications had involved maintenance in the right engine compartment. He also stated that when he presented the airplane to the replacement ferry pilot (at most 3 hours before takeoff) he told him that fuel lines and fittings in the wings related to the ferry tanks needed to be disconnected prior to flight. During the Safety Board's examination of the airplane, physical evidence was found indicating that the custom-made ferry tank plumbing in the wings had not been disconnected. The airplane wreckage was examined by the NTSB investigation team while on scene and following its recovery. Regarding both engines, no evidence was found of any internal engine component malfunction. Notably, the localized area surrounding and including the right engine-driven fuel pump and its outlet port had sustained significantly greater fire damage than was observed elsewhere. According to the Lycoming engine participant, the damage was consistent with a fuel-fed fire originating in this vicinity, which may have resulted from the engine's fuel supply line "B" nut being loose, a failed fuel line, or an engine-driven fuel pumprelated leak. The fuel supply line and its connecting components were not located. The engine-driven fuel pump was subsequently examined by staff from the NTSB's Materials Laboratory. Noted evidence consisted of globules of resolidified metal and areas of missing material consistent with the pump having been engulfed in fire. The staff also examined the airplane. Evidence was found indicating that the fire's area of origin was not within the wings or fuselage, but rather emanated from a localized area within the right engine compartment, where the engine-driven fuel pump and its fuel supply line and fittings were located. However, due to the extensive pre- and post-impact fires, the point of origin and the initiating event that precipitated the fuel leak could not be ascertained. The airplane's "Pilot Operator's Handbook" (POH), provides the procedures for responding to an in-flight fire and securing an engine. It also provides single-engine climb performance data. The POH indicates that the pilot should move the firewall fuel shutoff valve of the affected engine to the "off" position, feather the propeller, close the engine's cowl flaps to reduce drag, turn off the magneto switches, turn off the emergency fuel pump switch and the fuel selector, and pull out the fuel boost pump circuit breaker. It further notes that unless the boost pump's circuit breaker is pulled, the pump will continuously operate. During the wreckage examination, the Safety Board investigators found evidence indicating that the right engine's propeller was feathered. However, contrary to the POH's guidance, the right engine's firewall fuel shutoff valve was not in the "off" position, the cowl flaps were open, the magneto switches were on, the emergency fuel pump switches and the fuel selector were on, and the landing gear was down. Due to fire damage, the position of the fuel boost pump circuit breaker could not be ascertained. Calculations based upon POH data indicate that an undamaged and appropriately configured airplane flying on one engine should have had the capability to climb between 100 and 200 feet per minute and, at a minimum, maintain altitude. Recorded Mode C altitude data indicates that during the last 5 minutes of flight, the airplane descended while slowing about 16 knots below the speed required to maintain altitude.
Probable cause:
A loss of power in the right engine due to an in-flight fuel-fed fire in the right engine compartment that, while the exact origin could not be determined, was likely related to the right engine-driven fuel pump, its fuel supply line, or fitting. Contributing to the accident was the pilot's failure to adhere to the POH's procedures for responding to the fire and configuring the airplane to reduce aerodynamic drag.
Final Report: