Crash of a Rockwell Shrike Commander 500S near Morón AFB: 2 killed

Date & Time: Feb 7, 2001
Operator:
Registration:
T-144
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Morón - Morón
MSN:
500-1771-54
YOM:
1968
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was completing a local training flight at Morón AFB. In unknown circumstances, the aircraft crashed in the swimming pool of a private residence located in the district of Moreno, west of the airbase. Both pilots (Cpt Reyna and Lt Pesci) were killed while there were no injuries on the ground.

Crash of a Rockwell 681BT Turbo Commander in São Paulo: 7 killed

Date & Time: Dec 16, 2000 at 2120 LT
Registration:
PT-IEE
Flight Phase:
Survivors:
No
Site:
Schedule:
São Paulo – Maringá
MSN:
681-6071
YOM:
1972
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
5000
Captain / Total hours on type:
600.00
Copilot / Total flying hours:
2500
Copilot / Total hours on type:
200
Circumstances:
After takeoff from runway 17 at São Paulo-Congonhas Airport, the crew was cleared to climb to 5,500 feet maintaining heading 270. Weather conditions were poor with clouds, atmospheric turbulences and strong winds. At an altitude of 5,300 feet, the aircraft lost height and descended to 4,700 feet, an altitude that was maintained for 17 seconds. Then the aircraft entered an uncontrolled descent and crashed in four houses located in the district of Vila Anhanguera, about 5,5 km southwest of the airport. The aircraft and all four houses were destroyed. All seven occupants were killed while on the ground, six people were injured, one seriously.
Probable cause:
The accident occurred in poor weather conditions. It was determined that during initial climb, the aircraft's attitude, speed and altitude varied suddenly and rapidly, causing the pilot flying a stressful situation insofar as he believed that artificial horizons presented technical problems. In such a situation, investigators consider probable the hypothesis that the pilot made inadequate corrections, exacerbating the abnormal situation in which he was operating. The following contributing factors were identified:
- The crew were suffered fatigue because they had been on duty for more than 15 hours and were unable to observe satisfactory rest time at Congonhas airport,
- This fatigue certainly affected the pilots in their decision-making,
- The urge to return home and distrust of instruments in difficult flight conditions seriously compromised the performance of pilots and their ability to make decisions,
- A direct contact with passengers was stressful as they were going through a period of mourning and were eager to return home to Maringá,
- Weather conditions were unfavorable and contributed to the anxiety of the crew,
- Poor assessment of these conditions by the pilots,
- The working time of the pilots exceeded the limitations and the operator did not take into account adequate rest conditions for the crew,
- The training of the captain in instrument flights in recent months was insufficient.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Burlington: 9 killed

Date & Time: Aug 9, 2000 at 0752 LT
Registration:
N27944
Flight Phase:
Survivors:
No
Site:
Schedule:
Lakehurst - Patuxent
MSN:
31-7952056
YOM:
1979
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
3968
Captain / Total hours on type:
1418.00
Circumstances:
A Piper PA-31-350 Navajo Chieftain, N27944, operated by Patuxent Airways, Inc., Hollywood, Maryland, and a Piper PA-44-180 Seminole, N2225G, operated by Hortman Aviation Services, Inc., Philadelphia, Pennsylvania, were destroyed when they collided in flight over Burlington Township, New Jersey. The airline transport pilot, commercial pilot, and seven passengers aboard the Navajo Chieftain were killed, as were the flight instructor and the private pilot aboard the Seminole. Day visual meteorological conditions existed at the time of the accident, and both airplanes were operating under visual flight rules when the collision occurred. The flight crews of both airplanes were properly certificated and qualified in accordance with applicable Federal regulations. None of these individuals was experiencing any personal problems or rest anomalies that would have affected their performance. The airplanes had undergone the required inspections. Examination of their maintenance documents revealed that both airplanes complied with all appropriate airworthiness directives. Evidence gathered from the wreckage indicated that neither airplane had experienced an in-flight fire, bird strike, or structural or mechanical failure. Tissue samples revealed that the pilot of the Seminole had taken doxylamine sometime before the accident. (Doxylamine is a sedating antihistamine that has substantial adverse effects on performance.) However, the amount of blood available for analysis was insufficient for determining exactly when the pilot may have ingested the medication or whether his performance was impaired by the effects of doxylamine. A partial cockpit visibility study revealed that the Seminole would have been visible to the pilots in the Chieftain for at least the 60 seconds before the collision. No stereo photographs from a Seminole cockpit were available to determine precise obstruction angles. However, because of the relative viewing angle, the Chieftain would have been visible to the pilots in the Seminole for most of the last 60 seconds. The study further revealed that about 4 seconds before impact, or about .11 nm separation, the angular width of each airplane in each pilot's field of vision would have been approximately 0.5 to 0.6 degrees or about 1/4 inch apparent size at the windscreen.
Probable cause:
The failure of the pilots of the two airplanes to see and avoid each other and maintain proper airspace separation during visual flight rules flight.
Final Report:

Crash of a Aérospatiale-BAC Concorde in Gonesse: 113 killed

Date & Time: Jul 25, 2000 at 1644 LT
Type of aircraft:
Operator:
Registration:
F-BTSC
Flight Phase:
Survivors:
No
Site:
Schedule:
Paris – New York
MSN:
203
YOM:
1975
Flight number:
AF4590
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
100
Pax fatalities:
Other fatalities:
Total fatalities:
113
Captain / Total flying hours:
13477
Captain / Total hours on type:
317.00
Copilot / Total flying hours:
10035
Copilot / Total hours on type:
2698
Aircraft flight hours:
11989
Aircraft flight cycles:
4873
Circumstances:
On Tuesday 25 July 2000 the Concorde registered F-BTSC, operated by Air France, took off from Paris Charles de Gaulle to undertake charter flight AF4590 to New York with nine crew members (3 FC, 6 CC) and 100 passengers on board. The Captain was Pilot Flying (PF), the First Officer was Pilot Not Flying (PNF). The total weights of the aircraft and of the fuel on board stated by the Flight Engineer (FE) at the time the aircraft started out were 186.9 t and 95 t respectively. The speeds selected by the crew were V1: 150 kt, VR: 198 kt, V2: 220 kt. At 13 h 58 min 27 s, the crew contacted ATC on the Flight data frequency and requested the whole length of runway 26 right for a takeoff at 14 h 30. At 14 h 07 min 22 s, the controller gave start-up clearance and confirmed runway 26 right for takeoff. At 14 h 34 min 38 s, the Ground controller cleared the aircraft to taxi towards the runway 26 right holding point via the Romeo taxiway. At 14 h 40 min 02 s, the Loc Sud controller cleared 4590 to line up. At 14 h 42 min 17 s, he gave it takeoff clearance, and announced a wind from 090° at 8kt. The crew read back the takeoff clearance. The FE stated that the aircraft had used eight hundred kilos of fuel during taxiing. At 14 h 42 min 31 s, the PF commenced takeoff. At 14 h 42 min 54.6 s, the PNF called one hundred knots, then V1 nine seconds later. A few seconds after that, tyre No 2 (right front) on the left main landing gear was destroyed after having run over a piece of metal lost by an aircraft that had taken off five minutes before. The destruction of the tyre in all probability resulted in large pieces of rubber being thrown against the underside of the left wing and the rupture of a part of tank 5. A severe fire broke out under the left wing and around the same time engines 1 and 2 suffered a loss of thrust, severe for engine 2, slight for engine 1. By 14 h 43 min 13 s, as the PF commenced the rotation, the controller informed the crew the presence of flames behind the aircraft. The PNF acknowledged this transmission and the FE announced the failure of engine 2. The recorded parameters show a transient loss of power on engine 1 that was not mentioned by the crew. At around 14 h 43 min 22 s the engine fire alarm sounded and the FE announced "shut down engine 2" then the Captain called for the "engine fire" procedure. A few seconds later, the engine 2 fire handle was pulled and the fire alarm stopped. The PNF drew the PF’s attention to the airspeed, which was 200 kt. At 14 h 43 min 30 s, the PF called for landing gear retraction. The controller confirmed the presence of large flames behind the aircraft. At 14 h 43 min 42 s the engine fire alarm sounded again for around 12 seconds. It sounded for the third time at about 14 h 43 58 s and continued until the end of the flight. At 14 h 43 min 56 s, the PNF commented that the landing gear had not retracted and made several callouts in relation to the airspeed. At 14 h 43 min 59 s, the GPWS alarm sounded several times. The FO informed ATC that they were trying for Le Bourget aerodrome. The recorded parameters then indicate a loss of power on engine 1. A few seconds later, the aircraft crashed onto a hotel at “La Patte d’Oie” in Gonesse at the intersection of the N17 and D902 roads. The aircraft was totally destroyed by impact forces and a post crash fire and all 109 occupants were killed as well as four people working in the hotel. Five other employees were injured. The aircraft was chartered by the German Operator Deilmann to carry German tourists to New York. On board were nine French citizens (all crew members), 96 Germans, two Danish, one American and one Austrian.
Probable cause:
The following findings were identified:
- High-speed passage of a tyre over a part lost by an aircraft that had taken off five minutes earlier and the destruction of the tyre.
- The ripping out of a large piece of tank in a complex process of transmission of the energy produced by the impact of a piece of tyre at another point on the tank, this transmission associating deformation of the tank skin and the movement of the fuel, with perhaps the contributory effect of other more minor shocks and /or a hydrodynamic pressure surge.
- Ignition of the leaking fuel by an electric arc in the landing gear bay or through contact with the hot parts of the engine with forward propagation of the flame causing a very large fire under the aircraft's wing and severe loss of thrust on engine 2 then engine 1.
- In addition, the impossibility of retracting the landing gear probably contributed to the retention and stabilisation of the flame throughout the flight.
Final Report:

Crash of a Boeing 737-2A8 in Patna: 60 killed

Date & Time: Jul 17, 2000 at 0734 LT
Type of aircraft:
Operator:
Registration:
VT-EGD
Survivors:
Yes
Site:
Schedule:
Calcutta – Patna – Lucknow – New Delhi
MSN:
22280
YOM:
1980
Flight number:
CD7412
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
52
Pax fatalities:
Other fatalities:
Total fatalities:
60
Captain / Total flying hours:
4361
Captain / Total hours on type:
1778.00
Copilot / Total flying hours:
4085
Copilot / Total hours on type:
3605
Aircraft flight hours:
44087
Aircraft flight cycles:
51278
Circumstances:
Alliance Air Flight No. CD-7412 departed Netaji Subhash Chandra Bose International Airport, Kolkata at 0651 hrs. on 17th July, 2000 bound for Patna-Lucknow-Delhi. After normal departure from Runway 01R, the aircraft climbed to FL260 on track to Patna via route W52. The aircraft was under the control of Kolkata Radar from 0652 hrs. to 0659 hrs. It changed over to Kolkata Area Control Centre. The aircraft reported position SAREK at FL 260 at 0712 hrs. and changed over to Patna Control with information that there was no reported traffic for descent. The aircraft contacted Patna ATC at 0713 hrs. and gave it’s ETA at Patna as 0736 hrs. Patna ATC cleared the aircraft to PPT VOR ILS/DME ARC Approach for R/W 25. The ATC Officer communicated that Patna METAR originated at 0650 hrs. stated “Wind calm, Visibility 4000 metres, Weather Haze, Clouds Broken 25000 feet, temp 29ºC, Dew Point 27º, QNH 996 hPa, No Sig”. The aircraft was cleared to descend to 7500’ and report 25 DME from PPT VOR. The aircraft reported 25 DME at 0726 hrs. The aircraft then descended to 4000’ on QNH 996 hPa and was asked to report 13 DME for ILS/DME ARC Approach R/W 25. The aircraft reported commencing the ARC at 0728 hrs. The aircraft reported crossing lead radial 080 at 0731 hrs. and coming on to the Localizer. The aircraft was then asked to descend to 1700’ on QNH 997 hPa with instructions to call established on Localizer. The aircraft informed Patna ATC at 0732 hrs. that it would like to do a 360º turn due to being high on approach. Patna ATC sought confirmation from the aircraft whether it had the airfield in sight and on receiving an affirmative reply, asked the aircraft to report on finals for R/W 25 after carrying out a 360º turn. This was acknowledged by the aircraft at 0732 hrs. This was the last communication from the aircraft. Immediately thereafter, the aircraft was spotted by the Air Traffic Controller in normal descent aligned with the R/W 25. It, however, appeared to be high on approach. The aircraft then turned steeply to the left losing height all of a sudden and disappeared from sight behind a row of trees. The Air Traffic Controller observed a huge column of smoke rising from the Gardani Bagh area outside the airfield perimeter and initiated crash action. All six crew members and 49 passengers were killed as well as five people on the ground. Three passengers escaped with serious injuries.
Probable cause:
The cause of the accident was loss of control of the aircraft due Human Error (air crew). The crew had not followed the correct approach procedure, which resulted in the aircraft being high on approach. They had kept the engines at idle thrust and allowed the air speed to reduce to a lower than normally permissible value on approach. They then maneuvered the aircraft with high pitch attitude and executed rapid roll reversals. This resulted in actuation of the stick shaker stall warning indicating an approaching stall. At this stage, the crew initiated a Go Around procedure instead of Approach to Stall Recovery procedure resulting in an actual stall of the aircraft, loss of control and subsequent impact with the ground.
Final Report:

Crash of a Learjet 55 Longhorn in Boca Raton: 3 killed

Date & Time: Jun 23, 2000 at 1141 LT
Type of aircraft:
Operator:
Registration:
N220JC
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Boca Raton - Fort Pierce
MSN:
55-050
YOM:
1982
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
15180
Aircraft flight hours:
8557
Circumstances:
The Learjet departed from an uncontrolled airport about 2 minutes before the accident on a on a VFR climb and was not talking to ATC. The Extra EA-300S departed VFR from a controlled airport and requested and received a frequency change from the control tower 2 minutes after departure. Review of radar data revealed that the Extra climbed to 2,500 feet on a heading of 346 degrees before descending to 2,400 at 1141:25. The Learjet was observed on radar in a right crosswind departure passing through 700 feet on a heading of 242 degrees at 1141:02. At 1141:16, the Learjet was at 1,400 feet heading 269. At 1141:30, the Extra is observed on radar at 2,400 feet, in a right turn heading 360 degrees. The Learjet is observed on radar at 1141:28 in a climbing left turn passing through 2,300 feet. The last radar return on both aircraft was at 1141:30.
Probable cause:
The failure of the pilot's of both airplanes to maintain a visual lookout (while climbing and maneuvering) resulting in an in-flight collision and subsequent collision with residences and terrain.
Final Report:

Crash of a Beechcraft 65-B80 Queen Air in Belo Horizonte: 3 killed

Date & Time: Apr 12, 2000 at 1328 LT
Type of aircraft:
Registration:
PT-KKI
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Belo Horizonte - Sorocaba
MSN:
LD-483
YOM:
1974
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2019
Circumstances:
Shortly after takeoff from Belo Horizonte-Pampulha Airport, while in initial climb, the left engine failed. The pilot lost control of the aircraft that rolled to the left, lost height and crashed onto four houses located in the district of São Bernardo near the airport. The aircraft and four houses were destroyed. All three occupants were killed and two other people on the ground were injured.
Probable cause:
Failure of the left engine that was not lubricated according to published procedures. Inappropriate engine maintenance on part of the operator. Also, it was reported that the pilot's experience on this type of aircraft was insufficient.
Final Report:

Crash of an Antonov AN-32 in Bangalore

Date & Time: Feb 23, 2000
Type of aircraft:
Operator:
Registration:
K2690
Flight Type:
Survivors:
Yes
Site:
MSN:
03 05
YOM:
1984
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was approaching Bangalore-Hindustan Airport when it crashed in unknown circumstances in the district of Vijayanagar, about 13 km short of runway 09 threshold. There were no casualties.

Crash of an Embraer EMB-110P2 Bandeirante in Maputo: 1 killed

Date & Time: Feb 8, 2000 at 1007 LT
Operator:
Registration:
C9-AUH
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Maputo - Manzini
MSN:
110-186
YOM:
1978
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Shortly after takeoff from Maputo Airport in excellent weather conditions, the aircraft lost height and crashed onto several houses located in the 25th June district near the airport. The aircraft was destroyed and all 18 occupants were rescued. Unfortunately, a woman in a house was killed. All passengers were students going back home.

Crash of a Let L-410UVP-E in San José: 5 killed

Date & Time: Jan 15, 2000 at 1304 LT
Type of aircraft:
Registration:
YS-09-C
Flight Phase:
Survivors:
Yes
Site:
Schedule:
San José - Tortuguero
MSN:
86 16 20
YOM:
1986
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
7801
Copilot / Total flying hours:
3000
Circumstances:
After takeoff from San José-Tobías Bolaños Airport, en route to the Tortuguero National Park, while in initial climb, the aircraft stalled and crashed onto a house located in the district of Rohrmoser, about 3 km southeast of the airport. Four passengers were killed while 14 other occupants were injured, some seriously. Three people in the house, a nurse and two little girls were uninjured. Fifteen days after the accident, on January 30, the captain died from his injuries.
Probable cause:
Possible loss of longitudinal control of the aircraft in flight, due to not reaching the minimum climb speed, due to a wrong takeoff configuration as the flaps were retracted (zero position).
The following contributing factors were identified:
- Inadequate weight distribution that affected the position of the aircraft.
- The CofG was beyond the rear limit, out of the envelope.
- The crew failed to follow the pre-takeoff checklist.
- The total weight of the aircraft was above the MTOW.
- The high density altitude.
- Lack of supervision of the dispatch of the flight by the operator. (Absence of procedures).
- Self-induced pressure from the crew for an expeditious operation.
Final Report: