Crash of a Boeing 737-230 in Medan: 149 killed

Date & Time: Sep 5, 2005 at 1015 LT
Type of aircraft:
Operator:
Registration:
PK-RIM
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Medan - Jakarta
MSN:
22136
YOM:
1981
Flight number:
RI091
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
112
Pax fatalities:
Other fatalities:
Total fatalities:
149
Captain / Total flying hours:
7522
Captain / Total hours on type:
7302.00
Copilot / Total flying hours:
2353
Copilot / Total hours on type:
685
Aircraft flight hours:
51599
Aircraft flight cycles:
51335
Circumstances:
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.
Probable cause:
The National Transportation Safety Committee determines that probable causes of this accident are:
• The aircraft took-off with improper take off configuration namely with retracted flaps and slats causing the aircraft failed to lift off.
• Improper checklist procedure execution had lead to failure to identify the flap in retract position.
• The aircraft’s take off warning horn was not heard on the CAM channel of the CVR. It is possible that the take-off configuration warning horn was not sounding.
Final Report:

Crash of a Britten-Norman BN-2B-27 Islander in Durban

Date & Time: Aug 21, 2005 at 1300 LT
Type of aircraft:
Operator:
Registration:
ZS-PCJ
Survivors:
Yes
Site:
Schedule:
Manzengwenya – Durban
MSN:
869
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
950
Captain / Total hours on type:
6.00
Aircraft flight hours:
7670
Circumstances:
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.
Probable cause:
The pilot employed a incorrect go-around technique and took inappropriate actions during the emergency situation, which aggravated the situation.
Contributory Factors:
- Prevalent carburettor icing probability conditions for any power setting.
- Lack of experience of the pilot on the aircraft type.
Final Report:

Crash of a Douglas R4D-8 in Fort Lauderdale

Date & Time: Jun 13, 2005 at 1550 LT
Type of aircraft:
Operator:
Registration:
N3906J
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Fort Lauderdale – Marsh Harbour
MSN:
43344
YOM:
1943
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18000
Copilot / Total flying hours:
8500
Aircraft flight hours:
19623
Circumstances:
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.
Probable cause:
The inadequate maintenance inspection by company maintenance personnel/pilot and other maintenance personnel of the left engine resulting in a total failure of the master rod bearing, and nose case partial separation, which prevented the left propeller from feathering. This resulted in the airplane not able to maintain altitude and a subsequent forced landing in a residential area.
Final Report:

Crash of a Canadair CL-415 in Forte dei Marmi: 2 killed

Date & Time: Mar 18, 2005 at 1805 LT
Type of aircraft:
Operator:
Registration:
I-DPCK
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Rome - Rome
MSN:
2051
YOM:
2001
Flight number:
Tanker 22
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2000
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
2000
Copilot / Total hours on type:
1232
Aircraft flight hours:
1733
Circumstances:
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.
Probable cause:
The accident was the consequence of an in-flight collision with a power line because the crew adopted a wrong approach configuration to the fire area. The following contributing factors were identified:
- Poor decision making in attacking the fire, causing the crew to focus their attention on obstacles (pylons) of power line n°500, without considering the presence of the cable guard line n°550,
- The reduced visibility of obstacles resulting from the smoke of the forest,
- The inadequate reporting of electricity pylons and associated overhead lines,
- Non-activation of the required radio links, so the crew could not receive reports on the presence of obstacles,
- Short and discontinuous experience of the captain in that role, coming from the institution of the "PIC Frozen",
- The combination of to similar qualified pilots ("PIC Frozen") in the cockpit for the operation of a flight, one just rehabilitated to a high command function, the other still employed in the role of co-pilot: This condition could have a negative impact in terms of crew integration, obscuring decision making,
- The existence of criticality in corporate manuals used at the date of the accident,
- Reduced operational capacity of the crew in the last phase of flight, resulting from the strong heat of the fire under the left wing which penetrated the airplane through an opening created by the separation of a porthole.
Final Report:

Crash of a Rockwell Aero Commander 685 in Toluca: 2 killed

Date & Time: Feb 11, 2005 at 2110 LT
Operator:
Registration:
XB-PRS
Survivors:
Yes
Site:
Schedule:
Cancún – Toluca
MSN:
685-12050
YOM:
1973
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
On February 12, 2005, at 2110 central standard time, a Twin Commander 685 twin-engine airplane, Mexican registration XB-PRS, was destroyed upon impact with the ground following a loss of control during approach near Toluca, State of Mexico, in the Republic of Mexico. The commercial pilot was seriously injured and the two passengers were fatally injured. Night visual meteorological conditions prevailed for the domestic business flight. The flight originated from Cancun, State of Quintana Roo, Mexico, approximately 1930, with the Toluca International Airport as its intended destination. According to local authorities, the 1973-model airplane, serial number 12050, destroyed one residence and damaged two others when it crashed in a residential area near the airport. There were no injuries to anyone on the ground.

Crash of an Embraer EMB-110 Bandeirante in Uberaba: 3 killed

Date & Time: Dec 11, 2004 at 0516 LT
Operator:
Registration:
PT-WAK
Flight Type:
Survivors:
No
Site:
Schedule:
São Paulo – Uberaba
MSN:
110-071
YOM:
1975
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4920
Captain / Total hours on type:
596.00
Copilot / Total flying hours:
659
Copilot / Total hours on type:
459
Aircraft flight hours:
11689
Circumstances:
When the crew departed São Paulo-Guarulhos Airport, weather conditions at destination were considered as good. These conditions deteriorated en route and when the crew started the approach to Uberaba Airport by night, the visibility was below IFR minimums. Nevertheless, the crew attempted to land, continued the approach, descended below the MDA by 240 feet when the aircraft struck two houses and crashed in the district of Conjunto Pontal, bursting into flames. The wreckage was found about 800 metres short of runway 17 threshold. Both pilots as well as one people in a house were killed.
Probable cause:
The decision of the crew to descend below MDA in below weather minimums. The following contributing factors were identified:
- Low visibility (night),
- Poor judgment on part of the crew,
- Poor approach planning,
- Lack of supervision,
- The pilot acted on the controls of the aircraft to allow it to stall during the approach, losing its control and colliding with the obstacles,
- Poor crew coordination,
- Lack of discipline.
Final Report:

Crash of a Beechcraft B60 Duke in Asheville: 4 killed

Date & Time: Oct 27, 2004 at 1050 LT
Type of aircraft:
Operator:
Registration:
N611JC
Flight Phase:
Survivors:
No
Site:
Schedule:
Asheville – Greensboro
MSN:
P-496
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
13400
Aircraft flight hours:
2144
Circumstances:
At about the 3,000-foot marker on the 8,000-foot long runway witnesses saw the airplane at about 100 to 150-feet above the ground with the landing gear retracted when they heard a loud "bang". They said the airplane made no attempt to land on the remaining 5,000 feet of runway after the noise. The airplane continued climbing and seemed to gain a little altitude before passing the end of the runway. At that point the airplane began a right descending turn and was in a 60 to 80 degree right bank, nose low attitude when they lost sight of it. The airplane collided with the ground about 8/10 of a mile from the departure end of runway 34 in a residential area. Examination of the critical left engine found no pre-impact mechanical malfunction. Examination of the right engine found galling on all of the connecting rods. Dirt and particular contaminants were found embedded on all of the bearings, and spalling was observed on all of the cam followers. The oil suction screen was found clean, The oil filter was found contaminated with ferrous and non-ferrous small particles. The number 3 cylinder connecting rod yoke was broken on one side of the rod cap and separated into two pieces. Heavy secondary damage was noted with no signs of heat distress. Examination of the engine logbooks revealed that both engine's had been overhauled in 1986. In 1992, the airplane was registered in the Dominican Republic and the last maintenance entry indicated that the left and right engines underwent an inspection 754.3 hours since major overhaul. There were no other maintenance entries in the logbooks until the airplane was sold and moved to the United States in 2002. All three blades of the right propeller were found in the low pitch position, confirming that the pilot did not feather the right propeller as outlined in the pilot's operating handbook, under emergency procedures following a loss of engine power during takeoff.
Probable cause:
The pilot's failure to follow emergency procedures and to maintain airspeed following a loss of engine power during takeoff, which resulted in an inadvertent stall/spin and subsequent uncontrolled impact with terrain. Contributing to the cause was inadequate maintenance which resulted in oil contamination.
Final Report:

Crash of a Canadair RegionalJet CRJ-200LR in Jefferson City: 2 killed

Date & Time: Oct 14, 2004 at 2215 LT
Operator:
Registration:
N8396A
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Little Rock – Minneapolis
MSN:
7396
YOM:
2000
Flight number:
NW3701
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6900
Captain / Total hours on type:
973.00
Copilot / Total flying hours:
761
Copilot / Total hours on type:
222
Aircraft flight hours:
10168
Aircraft flight cycles:
9613
Circumstances:
On October 14, 2004, about 2215:06 central daylight time, Pinnacle Airlines flight 3701 (doing business as Northwest Airlink), a Bombardier CL-600-2B19, N8396A, crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport, Jefferson City, Missouri. The airplane was on a repositioning flight from Little Rock National Airport, Little Rock, Arkansas, to Minneapolis-St. Paul International Airport, Minneapolis, Minnesota. During the flight, both engines flamed out after a pilot-induced aerodynamic stall and were unable to be restarted. The captain and the first officer were killed, and the airplane was destroyed. No one on the ground was injured.
Probable cause:
The National Transportation Safety Board determines that the probable causes of this accident were:
1) the pilots' unprofessional behavior, deviation from standard operating procedures, and poor airmanship, which resulted in an in-flight emergency from which they were unable to recover, in part because of the pilots' inadequate training;
2) the pilots' failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites; and
3) the pilots' failure to achieve and maintain the target airspeed in the double engine failure checklist, which caused the engine cores to stop rotating and resulted in the core lock engine condition.
Contributing to this accident were:
1) the engine core lock condition, which prevented at least one engine from being restarted, and
2) the airplane flight manuals that did not communicate to pilots the importance of maintaining a minimum airspeed to keep the engine cores rotating.
Final Report:

Crash of a Bushmaster 2000 in Fullerton

Date & Time: Sep 25, 2004 at 1523 LT
Type of aircraft:
Operator:
Registration:
N750RW
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Fullerton - Fullerton
MSN:
2
YOM:
1985
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3700
Captain / Total hours on type:
54.00
Aircraft flight hours:
1420
Circumstances:
The airplane crashed onto a street adjacent to the airport shortly after takeoff. As the airplane started its takeoff roll, it began to veer to the left off of the runway. About midway down the runway the airplane lifted off the ground and flew over a crowd of people assembled at the airport for an airport appreciation day. The airplane climbed to about 50 feet, made a steep roll to the left, flying in-between the control tower and a light pole, and crossed over the boundary fence where the left wing struck a moving vehicle before coming to rest against several parked cars. Numerous photographs (including video footage) were taken by witnesses on the airport of the airplane on the takeoff ground roll and throughout the accident sequence. The photographs clearly show a nylon strap connecting the left elevator and rudder. It was surmised that the use of the nylon strap was as a flight control/gust lock for the airplane. During the investigation, a nylon strap was observed hanging from an S-hook that was attached to the vertical stabilizer/rudder hinge attach point. The loop at the other end of the strap had come apart, and when investigators looked under the left stabilizer/elevator hinge attach area they noted a similar S-hook attached to the hinge attach area.
Probable cause:
The inadequate preflight inspection by the pilot-in-command, where the pilot failed to remove the makeshift gust lock attached to the rudder and left elevator of the airplane. As a result, the airplane veered off the runway surface during the takeoff roll, became airborne, and immediately began an uncontrolled descending left roll until impacting vehicles and the ground.
Final Report:

Crash of a Lisunov LI-2T in Moscow: 3 killed

Date & Time: Jun 26, 2004 at 1728 LT
Type of aircraft:
Operator:
Registration:
RA-1300K
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Moscow - Kaluga
MSN:
234 416 05
YOM:
1952
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
After takeoff from Moscow-Myashkovo Airport runway 06, while climbing, the left engine failed. The aircraft lost height then struck the roof of a house and crashed in the residential area of Zaozerye located 2,5 km from the airport, three minutes after takeoff. Two occupants were seriously injured while three others were killed. Few hours later, one of the survivor died from his injuries, thus a passenger was the only survivor. This model was the last LI-2 airworthy in the world.
Probable cause:
Failure of the left engine during initial climb due to fuel exhaustion. Investigations determined that the fuel selector for the left engine was positioned on an empty tank. Poor flight preparation on part of the crew. The flight engineer was intoxicated at the time of the accident.