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The aircraft, owned by the German operator Himmelsschreiber Azur GmbH, was planned to make a sightseeing tour over Hamburg. This was a present from a father for his son aged 12. Less than 2 minutes after takeoff from the Hamburg-Norderelbe Seaplane Base, in the city center, the engine lost power and caught fire. The pilot elected to make an emergency landing when the aircraft lost height, collided with a wagon and crashed on a railway road located in a marshalling yard about 2 km south from the departure point, bursting into flames. The aircraft was totally destroyed by a post crash fire. Four passengers were killed while the pilot and a fifth passenger were seriously injured. The pilot died the following day.

Shortly after takeoff from runway 05 at Cuenca-Mariscal La Mar Airport, while climbing to a height of 300 feet, the engine failed. The airplane lost height, causing the nose wheel to struck the roof of a building. Out of control, the aircraft crashed onto a building occupied by a rubber company. Five passengers were killed while nine other occupants were seriously injured. There were no injuries on the ground. The aircraft was destroyed.

The four engine aircraft departed Tehran-Mehrabad Airport on a flight to Bandar Abbas, carrying 84 passengers and a crew of 10, among them several journalists from local newspapers and the Iranian National TV who were flying to Bandar Abbas to cover important military manoeuvres. Some eight minutes after takeoff, while climbing, the captain informed ATC about technical problems with the engine n°4 and elected to return to Tehran for an emergency landing. After being cleared to return, the crew started the descent when the aircraft stalled and crashed in a residential area located in the district of Yaft Abad, about 2 km south of runway 29L threshold. All 94 occupants were killed as well as 12 people leaving in a 9-floor building that was struck by the airplane. At the time of the accident, the visibility was reduced to 1,500 metres due to haze.

According to the pilot, the airplane took off with a flaps setting of 25 percent, per the operator’s procedures at the time. He stated that, immediately after raising the landing gear after takeoff, he heard an explosion and saw that all gauges for the left engine, a Pratt & Whitney Canada (P&WC) PT6A-34, pointed to zero, indicating a loss of power to the left engine. He also noted that the left propeller had completely stopped so he added full power to the right engine, left the flaps at 25 percent, and left the landing gear up. He further stated that, although he “stood on the right rudder,” he could not stop the airplane’s left turning descent. The pilot later noted that, after the left engine lost power, he “couldn’t hold V speeds” and “the stall warning horn was going off the whole time.” Post accident examination of the accident airplane’s left engine revealed that that it had failed and that the propeller had been feathered. Examination of the trim positions revealed that the rudder was at neutral trim and the aileron was at full left trim. Although these trim positions could have been altered when the wings separated from the fuselage during ground impact, the pilot’s comment that he “stood on the rudder” suggests that he either had not trimmed the airplane after the engine failure or had applied trim opposite the desired direction. The activation of the stall warning horn and the pilot’s statement that he “couldn’t hold V speeds” indicate that he also did not lower the nose sufficiently to maintain best single-engine rate of climb or best single-engine angle of climb airspeed. In addition, a performance calculation conducted during the National Transportation Safety Board’s investigation revealed that the airplane, with flaps set at 25 degrees, would have been able to climb at more than 400 feet per minute if the pilot had maintained best single-engine rate of climb airspeed and if the airplane had been properly trimmed. Post accident examination of the accident airplane’s left engine revealed fatigue fracturing of the first-stage sun gear.[1] According to the airplane’s maintenance records, during an October 1998 engine overhaul, the first-stage planet gear assembly was replaced due to “frosted and pitted gear teeth.” The planet gear assembly’s mating sun gear was also examined during overhaul but was found to be serviceable and was reinstalled with the new planet gear assembly, which was an accepted practice at the time. However, since then, the engine manufacturer determined that if either the sun gear or planet gear assembly needed to be replaced with a zero-time component, the corresponding mating gear/assembly must also be replaced with a zero-time component; otherwise, the different wear patterns on the gears could potentially cause “distress” to one or both of the components. Review of maintenance records showed that the engines were maintained, in part, under a Federal Aviation Administration (FAA)-approved “on-condition” maintenance program;[2] Business Air’s maintenance program was approved in May 1995. In April 2002, P&WC, the engine manufacturer, issued Service Bulletin (SB) 1403 Revision 7, which no longer mentioned on-condition maintenance programs and required, for the first time for other time between overhaul extension options, the replacement of a number of PT6A-34, -35, and -36 life-limited engine components, including the first-stage sun gear at 12,000 hours total time since new. The first-stage sun gear on the accident airplane failed at 22,064.8 hours. In November 2005 (when the Manchester accident occurred), Business Air was operating under an engine on-condition maintenance program that did not incorporate the up-to-date PT6A 34, -35, and -36 reliability standards for the life-limited parts listed in SB 1403R7 because the SB did not address previously approved on-condition maintenance programs. Three months later, in an e-mail message to Business Air, P&WC stated that it would continue to “endorse” Business Air’s engine on-condition maintenance program. Although SB 1403R7 improves PT6A-34, -35, and -36 engine reliability standards, allowing grandfathered on condition maintenance programs for these engines is less restrictive and does not offer the same level of reliability. The National Transportation Safety Board’s review of maintenance records further revealed numerous deficiencies in Business Air’s on-condition engine maintenance program that appear to have gone undetected by the Portland, Maine, Flight Standards District Office (FSDO), which is in charge of monitoring Business Air’s operations. For example, one infraction was that Business Air did not specify which parts were included in its on-condition maintenance program and which would have been removed by other means, such as hard-time scheduling.[3] Also, the operator used engine condition trend monitoring as part of determining engine health; however, review of records revealed missing data, inaccurate data input, a lack of regular trend analyses, and a failure to update trends or reestablish baselines when certain maintenance was performed. Another example showed that, although Business Air had an engine-oil analysis program in place, the time it took to send samples for testing and receive results was lengthy. According to maintenance records, the operator took an oil sample from the accident engine more than 2 weeks before the accident and sent it for testing. The oil sample, which revealed increased iron levels, would have provided valuable information about the engine’s health. However, the results, which indicated a decline in engine health, were not received until days after the accident. If the FAA had been properly monitoring Business Air’s maintenance program, it may have been aware of the operator’s inadequate maintenance practices that allowed, among other things, an engine with a sun gear well beyond what the manufacturer considered to be a reliable operating timeframe to continue operation. It also took more than 2 1/2 years after the accident for the FAA to finally present a consent order[4] to the operator, in which both parties not only acknowledged the operator’s ongoing maintenance inadequacies but also the required corrective actions. [1] A sun gear is the center gear around which an engine’s planet gear assembly revolves; together, the sun gear and planet gear assembly provide a means of reducing the engine’s rpm to the propeller’s rpm. [2] According to FAA Advisory Circular (AC) 120-17A, “Maintenance Control by Reliability Methods,” under on-condition maintenance programs, components are required to be periodically inspected or checked against some appropriate physical standard to determine whether they can continue in service. [3] According to FAA AC 120-17A, “Maintenance Control by Reliability Methods,” under hard time maintenance programs, components are required to be periodically overhauled or be removed from service. [4] A consent order is a voluntary agreement worked out between two or more parties to a dispute. It generally has the same effect as a court order and can be enforced by the court if anyone does not comply with the orders. [4] A consent order is a voluntary agreement worked out between two or more parties to a dispute. It generally has the same effect as a court order and can be enforced by the court if anyone does not comply with the orders.

The pilot purchased the multiengine airplane about 18 months prior to the accident, and was conducting his first flight in the airplane, as he flew it from Georgia to Massachusetts. While en route, the airplane experienced a failure of the left engine. The airplane began maneuvering near an airport, as its groundspeed decreased from 173 miles per hour (mph) to 90 mph, 13 mph below the minimum single engine control speed. A witness reported that the airplane appeared to be attempting to land, when it banked to the left, and descended to the ground. The airplane impacted on a road, about 3 miles east-southeast of the airport. A 3-inch, by 2.5- inch hole was observed on the top of the left engine crankcase, and streaks of oil were present on the left gear door, left flap, and the left side of the fuselage. The number two connecting rod was fractured and heat distressed. The number 2 piston assembly was seized in the cylinder barrel. The airplane had been operated about 30 hours, during the 6 years prior to the accident, and it had not been flown since its most recent annual inspection, which was performed about 16 months prior to the accident. In addition, both engines were being operated beyond the manufacturer's recommended time between overhaul limits. The pilot did not possess a multiengine airplane rating. He attended an airplane type specific training course about 20 months prior to the accident. At that time, he reported 452 hours of total flight experience, with 0 hours of multiengine flight experience.

The airplane was fueled with 65-gallons of jet-A in preparation for the evening's flight. The 6,600-hour pilot stated that no abnormalities were noted during the engine start, and takeoff. However; shortly after departure, and after the pilot had leveled off at 7,000-feet, he reported to air traffic control that he had an engine failure and a total power loss. During the descent, the pilot attempted both an air and battery engine restart, but was not successful. The inspection on the engine was conducted on November 30, 2005. The accessory gearbox had a reddish-brown stain visible beneath the fuel pump/fuel control unit. The accessory gearbox was turned; rotation of the drive splines in the fuel pump (splines for the fuel control unit) was not observed. The fuel pump unit was then removed, the area between the fuel pump and accessory gearbox was stained with a reddish brown color. The fuel pump drive splines were worn. Additionally, the internal splines on the fuel pump drive coupling were worn. The wear on the spline drive and coupling prevented full engagement of the spline drives. Both pieces had evidence of fretting, with a reddish brown material present. The airplane had approximately 130 hours since a maintenance inspection (which included inspection of the fuel pump). The engine had accumulated approximately a total time of 9,852 hours, with 5,574 hours since overhaul.

On 5 September 2005, at 03:15 UTC, Mandala Airlines registered PK-RIM, operating as flight number MDL 091, a Boeing 737-200 departing for Soekarno-Hatta Airport, Jakarta from Medan. The previous flight was from Jakarta and arrived at Medan uneventfully. The same crew have flight schedule on the same day and returned to Jakarta. The flight was a regular scheduled passenger flight and was attempted to take-off from Polonia Airport, Medan, North Sumatra to Jakarta and it was the second trip of the day for the crew. At 02.40 UTC information from dispatcher, those embarking passengers, cargo process and all flight documents were ready. At 02.52 UTC, Mandala/MDL 091 asked for push back and start up clearance bound for Jakarta from the Air Traffic Controller/ATC, after received the approval from the ATC they began starting the engines. At 02.56 UTC, the controller cleared MDL 091 taxi into position on runway 23 via Alpha. At 03.02 UTC, MDL 091 received clearance for take off with additional clearance from ATC to turn left heading 120º and maintain 1500 ft. The MDL 091 read back the clearance heading 120º and maintains 1000 ft. The ATC corrected the clearance one thousand five hundred feet. The MDL 091 reread back as 1500 ft. Some of the passengers and other witnesses stated that the aircraft has lifted its nose in an up attitude and take off roll was longer than that normally made by similar airplanes. Most of them stated that the aircraft nose began to lift-off about few meters from the end of the runway. The ATC tower controller recalled that after rotation the plane began to “roll” or veer to the left and to the right. Some witnesses on the ground recalled that the airplane left wing struck a building before it struck in the busy road, then heard two big explosions and saw the flames. Persons on board in MDL 091, 5 crew and 95 passengers were killed, 15 passengers seriously injured and 2 passengers (a mother and child) were reported survived without any injuries; and other 49 persons on ground were killed and 26 grounds were serious injured.

The pilot accompanied by five passengers took off from Manzengwenya Aerodrome on a chartered flight to Virginia Aerodrome, (FAVG). The pilot reported that although it was drizzling, visibility was good. He reported his position to the FAVG Air Traffic Controller and requested joining instructions to FAVG. The ATC cleared the pilot to land on Runway 05. When he was on short finals, the tower noticed that the aircraft was drifting away from the runway centerline and called the pilot. The pilot stated that he is experiencing an engine problems and he is initiating a go around. The aircraft turned out to the left and away from the runway centerline, and the pilot allowed the aircraft to continue flying over the nearby “M4” highway and then towards a residential area. The aircraft then impacted the roof of a private residential property, (house) with its left wing first and the nose section. It came to rest in a tail high and inverted position. Although the wreckage was still fairly intact, both the aircraft and the residential property were extensively damaged. The aircraft’s left wing failed outboard of the engine on impact. The nose of the aircraft as well as the cabin instrumentation area was crushed towards the front seated passengers. Both main wing spars, the nose wheel, the engine mounts, the propellers, and the fuselage were also damaged. The aircraft had a valid Certificate of Airworthiness which was issued on 17 September 2004 with an expiry date of 16 September 2005. The last Mandatory Periodic Inspection was certified on 03 September 2004 at 7594.2 airframe hours and he aircraft had accumulated a further 75.8 hours since the last MPI was certified. The aircraft was recovered to an Approved AMO for further investigation. Both flight and engine controls were found satisfactory. Ground run test were conducted with both engines still installed to the aircraft, and both engines performed satisfactorily during these performance tests. The Aircraft Maintenance Organisation was audited in the last two years and the last audit was on 01 July 2005.

The crew stated the airplane was hire by a private individual and had 220 gallons of fuel onboard, and was carrying 6 pieces of granite, weighing 3,200 lbs. The passenger was responsible for the granite during the flight. During takeoff, about 400 feet above the ground, a discrepancy with the left engine manifold pressure was noted, followed by a slight hesitation and mild backfire. Oil was seen leaking from the front nose section of the engine followed by an engine manifold pressure and rpm decrease. Smoke coming from the left engine was observed and reported by the airport controllers. The left engine's propeller failed to feather and the airplane wouldn't maintain altitude. The airplane impacted trees, vehicles, and the right wing struck a home before coming to a stop on the road. A fire ensued immediately after ground impact, all onboard exited without assistance. The fuselage from the cockpit to the tail section melted from the fire. The right wing was damaged by impact and fire, and the right engine remained intact on the wing. The left wing was separated 12 feet from the outboard and the engine separated from the firewall. Both engine's propellers were in the low pitch position. The flaps were full up and the landing gear were retracted. A weight and balance sheet was never furnished. The pieces of granite and limited cargo recovered from the wreckage weighed 3,140 lb. Examination of the airplane revealed all flight controls surface were present and flight control continuity was accounted for and established. No evidence of any pre-impact mechanical discrepancies with the airframe or its systems was found that wound have prevented normal operation of airplane. On December 09, 2004, the left engine's nose section assembly was found with six out of the ten retaining bolts broken. The section was inspected and all ten bolts were replaced with serviceable ones. The assembly of the dose dome section and installation to the engine was performed by the repair station mechanic. The remaining assembling of the engine was completed by the operator's mechanic/pilot. During the left engine post accident examination, the ten bolts securing the nose dome section flange to the stationary reduction gear were fractured with their respective safety wire still intact. The chamber for the propeller feathering oil system was not secured to the plate sections, producing a bypass of the oil for the propeller feathering process. Metal flakes and pieces were observed deposited in the oil breather screen, consistent with the master rod bearing in an advance stage of deterioration. The silver plated master rod bearing had a catastrophic failure. Silver like metal flakes and particles were observed throughout the nose section, reduction gear section, main oil screen, and oil filter housing of the engine. An indication of propeller shaft housing movement was evident. Metal flakes with carbon build up were observed in the propeller shaft support and sleeve assembly. A metallurgical examination of the ten bolts securing the nose dome assembly indicated all were fractured though the threaded section of the shanks. The fatigue zones propagated from the opposite sides toward the center of the bolts consistent with reversed bending of the bolt.

The crew departed Rome-Ciampino Airport in the afternoon on a fire fighting mission in Forte dei Marmi, north of Pisa. Following two successful missions, the crew was attacking the fire in hilly terrain and low altitude when the aircraft collided with power cables. A fire erupted on the right side of the aircraft and the crew lost control of the airplane that crashed in a residential area. Both pilots were killed while there were no injuries on the ground.