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:

Crash of a Cessna 402B in Ocean Ridge

Date & Time: Jul 22, 2008 at 1350 LT
Type of aircraft:
Registration:
N3990C
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Lantana - Pompano Beach
MSN:
402B-0857
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1565
Aircraft flight hours:
7222
Circumstances:
The commercial pilot, who was also the former owner of the twin-engine airplane, stated that the purpose of the flight was to reposition the airplane to an airport approximately 22 miles south of the departure airport. Just prior to the flight, he purchased 10 gallons of fuel for each of the two main tanks. The pilot reported that about 5 minutes after takeoff, at an altitude of approximately 1,000 feet, he experienced a "loss of engine power." However, his three separate accounts of the event were inconsistent with respect to which engine had a problem, or the specific nature of the problem. The pilot reported that the airplane started to lose altitude "rapidly," and that he attempted to "wag the wings" in order to "get all the fuel to be useable." The airplane struck a building and terrain approximately 8 miles south of the departure airport. The pilot sustained serious injuries, but there was no fire. Damage to the left engine and propeller was consistent with the engine running at impact, and precluded an attempt to run the left engine in a test cell. Damage to the right engine and propeller was consistent with low or no power at impact. The right engine was subsequently successfully run in a test cell. No evidence of any pre-accident anomalies that could have contributed to the accident was noted with the airframe, engines, or propellers. The fuel selector valve placards did not accurately depict the fuel system configuration. The fuel quantity and its distribution in the tanks, either at the beginning of the flight or at the time of the accident, could not be determined.
Probable cause:
A partial loss of engine power due to fuel starvation. Contributing to the accident was the pilot’s decision to add only a limited amount of fuel prior to the flight, and the fuel selector valve placards' inaccurate depiction of the airplane fuel tank configuration.
Final Report:

Crash of a Piper PA-31-310 Navajo in Caracas: 6 killed

Date & Time: Apr 28, 2008 at 0955 LT
Type of aircraft:
Registration:
N6463L
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Caracas – Willemstad
MSN:
31-421
YOM:
1969
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The twin engine aircraft departed Caracas-Maiquetía-Simón Bolívar Airport on a private flight to Willemstad-Hato Airport, Curaçao, with two passengers and one pilot on board. During initial climb, the pilot reported engine problems and was cleared for an immediate return when he lost control of the airplane that crashed onto several buildings located in the district of Catia La Mar, about 6 km short of runway 09 threshold. The aircraft burst into flames and was totally destroyed. All three occupants as well as three people on the ground were killed. Five other people were injured.

Crash of a Douglas DC-9-51 in Goma: 40 killed

Date & Time: Apr 15, 2008 at 1430 LT
Type of aircraft:
Operator:
Registration:
9Q-CHN
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Goma – Kisangani
MSN:
47731/860
YOM:
1977
Location:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
86
Pax fatalities:
Other fatalities:
Total fatalities:
40
Circumstances:
During the takeoff roll from runway 18 at Goma Airport, the crew started the rotation but the aircraft failed to respond. The aircraft continued, overran and crashed in the Birere District, about 100 metres past the runway end, bursting into flames. Three passengers were killed as well as 37 people on the ground. All other occupants were injured. The aircraft was totally destroyed by impact forces and a post crash fire.
Probable cause:
It is possible that one of the engine or maybe both suffered a loss of power during takeoff after the aircraft passed through a puddle.

Crash of a Cessna 500 Citation I in Biggin Hill: 5 killed

Date & Time: Mar 30, 2008 at 1438 LT
Type of aircraft:
Registration:
VP-BGE
Flight Phase:
Survivors:
No
Site:
Schedule:
Biggin Hill – Pau
MSN:
500-0287
YOM:
1975
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
8278
Captain / Total hours on type:
18.00
Copilot / Total flying hours:
4533
Copilot / Total hours on type:
70
Aircraft flight hours:
5844
Aircraft flight cycles:
5352
Circumstances:
Pilot B arrived at Biggin Hill Airport, Kent, at about 1100 hrs for the planned flight to Pau, France. At about 1130 hrs he helped tow the aircraft from its overnight parking position on the Southern Apron to a nearby handling agent whose services were being used for the flight. A member of staff employed by the handling agent saw Pilot B carry out what was believed to be an external pre-flight check of the aircraft. Pilot B also asked another member of staff to provide a print out of the weather information for the flight. Pilot A arrived at about 1145 hrs and joined Pilot B at the aircraft. Witnesses described nothing unusual in either pilots’ demeanour. Three passengers arrived at the handling agent at about 1300 hrs and waited in a lounge whilst their bags were taken to the aircraft and loaded into the baggage hold in the nose. A member of the handling agency, who later took the passengers to the aircraft, reported that Pilot B met them outside the aircraft. After they had all boarded, the agent heard Pilot B say that he would give them a safety brief. Pilot B then closed the aircraft door. Pilot A called for start at 1317 hrs. He called for taxi at 1320 hrs and the aircraft was cleared to taxi to the holding point A1. No one could be identified as a witness to the aircraft’s start or subsequent taxi to the holding point. At 1331 hrs ATC cleared the aircraft to line up on Runway 21 and at 1332 hrs cleared it to take off. Both clearances were acknowledged by Pilot A. The takeoff was observed by the tower controller who stated that everything appeared normal. No transmissions were made between the aircraft and ATC until one minute after takeoff when, at 1334 hrs, the following exchange was made. Numerous witnesses reported seeing the aircraft at around this time flying over a built-up area, about 2 nm north-north-east of Biggin Hill Airport, where it was observed flying low, passing over playing fields and nearby houses. Witnesses reported that the aircraft was maintaining a normal flying attitude with some reporting that the landing gear was up and others that it was down. Some described seeing it adopt a nose-high attitude and banking away from the houses just before it crashed. Some witnesses stated that there was no engine noise coming from the aircraft whilst others stated that they became aware of the aircraft as it flew low overhead due to the loud noise it was making, as if the engines were at high thrust. Two witnesses described hearing the aircraft make a pulsing, intermittent noise. The location of witnesses and the description of the aircraft noise they heard are also shown in Figure 1. Having flown over several houses at an extremely low height the aircraft’s left wing clipped a house which bordered a small area of woodland. The aircraft then impacted the ground between this and another house and caught fire. There were no injuries to anyone on the ground but all those on board the aircraft were fatally injured.
Probable cause:
The following contributory factors were identified:
1. It is probable that a mechanical failure within the air cycle machine caused the vibration which led to the crew attempting to return to the departure airfield.
2. A missing rivet head on the left engine fuel shut-off lever may have led to an inadvertent shut-down of that engine.
3. Approximately 70 seconds prior to impact neither engine was producing any thrust.
4. A relight attempt on the second engine was probably started before the relit first engine had reached idle speed, resulting in insufficient time for enough thrust to be developed to arrest the aircraft’s rate of descent before ground impact.
Final Report: