Crash of an Antonov AN-32B in Kinshasa: 298 killed

Date & Time: Jan 8, 1996 at 1243 LT
Type of aircraft:
Operator:
Registration:
RA-26222
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Kinshasa - Kahemba
MSN:
2301
YOM:
1989
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
298
Circumstances:
The aircraft was completing a cargo flight from Kinshasa to Kahemba, carrying two passengers, four crew members and a load of food and basic necessities. During the takeoff roll, at a speed of 204 km/h, the pilot-in-command pulled up the control column to start the rotation but the aircraft failed to respond. The crew decided to abort the take off procedure but this decision was taken too late. Unable to stop within the remaining distance (the runway is 1,700 metres long), the aircraft overran, rolled for about 240 metres and came to rest in the district of Simbazikita, bursting into flames. A crew member was killed while five other occupants were injured. On ground, at least 297 people were killed while 253 others were injured, some seriously.
Probable cause:
It was determined that the aircraft was unable to take off because its total weight at the time of the accident was well above the MTOW. Due to lack of evidences, investigations were unable to determine the exact value of the excess mass, probably between 2 and 7 tons. Nevertheless, the decision of the crew to abort the takeoff procedure was taken too late and the runway length was insufficient. It was also reported that the aircraft was operated by African Air and leased from Moscow Airways. The flight was operated illegally on behalf of Scibe-Airlift which was not concerned about such operation. The certificate of airworthiness expired last December and the aircraft was not authorized to fly.

Crash of a Rockwell Grand Commander 690A in Warsaw

Date & Time: Nov 29, 1995 at 0220 LT
Registration:
EC-FFE
Survivors:
Yes
Site:
MSN:
690-11344
YOM:
1976
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Warsaw-Okecie Airport runway 33 by night, the pilot reported engine problems when the aircraft lost height and crashed in the district of Mysiadło, about six km short of runway threshold. All four occupants were injured and there were no victims on the ground. The aircraft was destroyed. It was reported that both engines lost power on approach, maybe after being taken over by frost. At the time of the accident, icing conditions were present in Warsaw.

Crash of a Beechcraft 65 Queen Air in West Point: 12 killed

Date & Time: Sep 10, 1995 at 1840 LT
Type of aircraft:
Registration:
N945PA
Flight Phase:
Survivors:
No
Site:
Schedule:
West Point - West Point
MSN:
LC-217
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
2980
Captain / Total hours on type:
462.00
Aircraft flight hours:
1530
Circumstances:
The airplane was loaded with 10 sport parachutists and one pilot. Later, investigators calculated that the maximum gross weight was exceeded by 149.6 pounds, and the center of gravity was 2.87 inches aft of the aft limit. The cabin door had been removed for parachuting operations; however, an altered Flight Manual Supplement had been used as authority for the door removal. The airplane was not on the FAA-approved eligible list for such removal. The airplane needed to be refueled before flight, but the quantity of fuel in the airport's underground storage tank was below the electric cutoff level. Fuel was pumped manually from the storage tank into plastic jugs, which were used to refuel the airplane. Before takeoff, samples of fuel were reported to have been drained from the airplane's fuel tanks (sumps). According to witnesses, they heard an engine misfiring during takeoff. They observed the airplane level off during the initial climb and start a shallow right turn. The bank angle gradually increased from shallow to steep as the nose dropped and the airplane descended. Other witnesses observed the airplane in a steep dive just before it crashed in the rear of a residence. One person in the residence was killed. A postaccident fire destroyed the accessory sections of both engines. Examination of the airplane disclosed evidence that the right engine had been shut down and the right propeller had been feathered; however, no preimpact mechanical failure was found. A sample of excess fuel was obtained from the tank that was used to refuel the airplane, but no observable quantity of water or contamination was found.
Probable cause:
The pilot's inadequate preflight/preparation, his failure to ensure proper weight and balance of the airplane, and his failure to obtain/maintain minimum control speed, which resulted in a loss of aircraft control after loss of power in one engine. A factor relating to the accident was: loss of power in the right engine for undetermined reason(s).
Final Report:

Crash of a Cessna 207A Skywagon in Santa Cruz: 10 killed

Date & Time: Mar 28, 1995
Registration:
CP-1947
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Santa Cruz – Santa Ana del Yacuma
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
10
Circumstances:
Shortly after takeoff from El Trompillo Airport, while in initial climb, the single engine aircraft entered an uncontrolled descent, struck a tree and crashed onto several houses located in a populated area by the airport. Debris were found on a large area and all seven occupants were killed as well as three people on the ground. Five other people on the ground were injured.
Probable cause:
Loss of control following an engine failure for unknown reasons.

Crash of a Douglas DC-9-31 in Charlotte: 37 killed

Date & Time: Jul 2, 1994 at 1843 LT
Type of aircraft:
Operator:
Registration:
N954VJ
Survivors:
Yes
Site:
Schedule:
Columbia - Charlotte
MSN:
47590
YOM:
1973
Flight number:
US1016
Crew on board:
5
Crew fatalities:
Pax on board:
52
Pax fatalities:
Other fatalities:
Total fatalities:
37
Captain / Total flying hours:
8065
Captain / Total hours on type:
1970.00
Copilot / Total flying hours:
12980
Copilot / Total hours on type:
3180
Aircraft flight hours:
53917
Aircraft flight cycles:
63147
Circumstances:
USAir Flight 1016 was a domestic flight from Columbia (CAE) to Charlotte (CLT). The DC-9 departed the gate on schedule at 18:10. The first officer was performing the duties of the flying pilot. The weather information provided to the flightcrew from USAir dispatch indicated that the conditions at Charlotte were similar to those encountered when the crew had departed there approximately one hour earlier. The only noted exception was the report of scattered thunderstorms in the area. Flight 1016 was airborne at 18:23 for the planned 35 minute flight. At 18:27, the captain of flight 1016 made initial contact with the Charlotte Terminal Radar Approach Control (TRACON) controller and advised that the flight was at 12,000 feet mean sea level (msl). The controller replied "USAir ten sixteen ... expect runway one eight right." Shortly afterward the controller issued a clearance to the flightcrew to descend to 10,000 feet. At 18:29, the first officer commented "there's more rain than I thought there was ... it's startin ...pretty good a minute ago ... now it's held up." On their airborne weather radar the crew observed two cells, one located south and the second located east of the airport. The captain said "looks like that's [rain] setting just off the edge of the airport." One minute later, the captain contacted the controller and said "We're showing uh little buildup here it uh looks like it's sitting on the radial, we'd like to go about five degrees to the left to the ..." The controller replied "How far ahead are you looking ten sixteen?" The captain responded "About fifteen miles." The controller then replied "I'm going to turn you before you get there I'm going to turn you at about five miles northbound." The captain acknowledged the transmission, and, at 18:33, the controller directed the crew to turn the aircraft to a heading of three six zero. One minute later the flightcrew was issued a clearance to descend to 6,000 feet, and shortly thereafter contacted the Final Radar West controller. At 18:35 the Final Radar West controller transmitted "USAir ten sixteen ... maintain four thousand runway one eight right.'' The captain acknowledged the radio transmission and then stated to the first officer "approach brief." The first officer responded "visual back up ILS." Following the first officer's response, the controller issued a clearance to flight 1016 to "...turn ten degrees right descend and maintain two thousand three hundred vectors visual approach runway one eight right.'' At 18:36, the Final Radar West controller radioed flight 1016 and said "I'll tell you what USAir ten sixteen they got some rain just south of the field might be a little bit coming off north just expect the ILS now amend your altitude maintain three thousand." At 18:37, the controller instructed flight 1016 to ''turn right heading zero niner zero." At 18:38, the controller said "USAir ten sixteen turn right heading one seven zero four from SOPHE [the outer marker for runway 18R ILS] ... cross SOPHE at or above three thousand cleared ILS one eight right approach." As they were maneuvering the airplane from the base leg of the visual approach to final, both crew members had visual contact with the airport. The captain then contacted Charlotte Tower. The controller said "USAir ten sixteen ... runway one eight right cleared to land following an F-K one hundred short final, previous arrival reported a smooth ride all the way down the final." The pilot of the Fokker 100 in front also reported a "smooth ride". About 18:36, a special weather observation was recorded, which included: ... measured [cloud] ceiling 4,500 feet broken, visibility 6 miles, thunderstorm, light rain shower, haze, the temperature was 88 degrees Fahrenheit, the dewpoint was 67 degrees Fahrenheit, the wind was from 110 degrees at 16 knots .... This information was not broadcast until 1843; thus, the crew of flight 1016 did not receive the new ATIS. At 18:40, the Tower controller said "USAir ten sixteen the wind is showing one zero zero at one nine." This was followed a short time later by the controller saying "USAir ten sixteen wind now one one zero at two one." Then the Tower controller radioed a wind shear warning "windshear alert northeast boundary wind one nine zero at one three.'' On finals the DC-9 entered an area of rainfall and at 18:41:58, the first officer commented "there's, ooh, ten knots right there." This was followed by the captain saying "OK, you're plus twenty [knots] ... take it around, go to the right." A go around was initiated. The Tower controller noticed Flight 1016 going around "USAir ten sixteen understand you're on the go sir, fly runway heading, climb and maintain three thousand." The first officer initially rotated the airplane to the proper 15 degrees nose-up attitude during the missed approach. However, the thrust was set below the standard go-around EPR limit of 1.93, and the pitch attitude was reduced to 5 degrees nose down before the flightcrew recognized the dangerous situation. When the flaps were in transition from 40 to 15 degrees (about a 12-second cycle), the airplane encountered windshear. Although the DC-9 was equipped with an on-board windshear warning system, it did not activate for unknown reasons. The airplane stalled and impacted the ground at 18:42:35. Investigation revealed that the headwind encountered by flight 1016 during the approach between 18:40:40 and 18:42:00 was between 10 and 20 knots. The initial wind component, a headwind, increased from approximately 30 knots at 18:42:00 to 35 knots at 18:42:15. The maximum calculated headwind occurred at 18:42:17, and was calculated at about 39 knots. The airplane struck the ground after transitioning from a headwind of approximately 35 knots, at 18:42:21, to a tailwind of 26 knots (a change of 61 knots), over a 14 second period.
Probable cause:
The board determines that the probable cause of the accident was:
- The flight crew's decision to continue an approach into severe convective activity that was conducive to a microburst,
- The flight crew's failure to recognize a windshear situation in a timely manner,
- The flight crew's failure to establish and maintain the proper airplane attitude and thrust setting necessary to escape the windshear,
- The lack of real-time adverse weather and windshear hazard information dissemination from air traffic control, all of which led to an encounter with and failure to escape from a microburst-induced windshear that was produced by a rapidly developing thunderstorm located at the approach end of runway 18R.
The following contributing factors were reported:
- The lack of air traffic control procedures that would have required the controller to display and issue ASR-9 radar weather information to the pilots of flight 1016,
- The Charlotte tower supervisor's failure to properly advise and ensure that all controllers were aware of and reporting the reduction in visibility and the RVR value information, and the low level windshear alerts that had occurred in multiple quadrants,
- The inadequate remedial actions by USAir to ensure adherence to standard operating procedures,
- The inadequate software logic in the airplane's windshear warning system that did not provide an alert upon entry into the windshear.
Final Report:

Crash of a Bae 4101 Jetstream 41 in Columbus: 5 killed

Date & Time: Jan 7, 1994 at 2321 LT
Type of aircraft:
Operator:
Registration:
N304UE
Survivors:
Yes
Site:
Schedule:
Washington DC - Columbus
MSN:
41016
YOM:
1993
Flight number:
UA6291
Crew on board:
3
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
3660
Captain / Total hours on type:
192.00
Copilot / Total flying hours:
2430
Copilot / Total hours on type:
31
Aircraft flight hours:
1069
Aircraft flight cycles:
1000
Circumstances:
The airplane stalled and crashed 1.2 nautical miles east of runway 28L during an ILS approach. The captain initiated the approach at high speed & crossed the FAF at a high speed without first having the airplane properly configured for a stabilized approach. The airspeed was not monitored nor maintained by the flightcrew. The airline had no specified callouts for airspeed deviations during instrument approaches. The captain failed to apply full power & configure the airplane in a timely manner. Both pilots had low flight time and experience in in the airplane and in any EFIS-equipped airplane. Additionally, the captain had low time and experience as a captain. Inadequate consideration was given to the possible consequences of pairing a newly upgraded captain, on a new airplane, with a first officer who had no airline experience in air carrier operations, nor do current FAA regulations address this issue.
Probable cause:
The accident was the consequence of the following factors:
(1) An aerodynamic stall that occurred when the flightcrew allowed the airspeed to decay to stall speed following a very poorly planned and executed approach characterized by an absence
of procedural discipline;
(2) Improper pilot response to the stall warning, including failure to advance the power levers to maximum, and inappropriately raising the flaps;
(3) Flightcrew inexperience in 'glass cockpit' automatic aircraft, aircraft type, and in seat position, a situation exacerbated by a side letter of agreement between the company and its pilots;
(4) The company's failure to provide adequate crew resource management training, and the FAA's failure to require such training;
(5) The company's failure to provide adequate stabilized approach criteria, and the FAA's failure to require such criteria; and
(6) The unavailability of suitable training simulators that precluded fully effective flightcrew training.
Note: Items 1, 2, and 3 were approved by a Board vote of 4-0. Item 5 was adopted 3-1, with the dissenting Member believing the item was a contributory cause. The Board was divided 2-2 on items 4 and 6, two Members believing them causal and two Members, contributory.
Final Report:

Crash of a De Havilland DH.104 Dove 5 in Melbourne

Date & Time: Dec 3, 1993 at 2037 LT
Type of aircraft:
Operator:
Registration:
VH-DHD
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Melbourne - Melbourne
MSN:
04104
YOM:
1948
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18154
Captain / Total hours on type:
1500.00
Aircraft flight hours:
21259
Circumstances:
The pilot had planned to conduct a night charter flight over Melbourne and Port Phillip Bay, starting from and returning to Essendon Airport. Dinner was to be served in flight. The pilot gave a safety briefing to the passengers before starting the engines. He completed engine runups and pre-takeoff checks, including selecting 20° of flap. At 2036 ESuT, in daylight, the pilot initiated takeoff on runway 17 using standard take-off power setting of 7.5 lb/in2 of boost and 3,000 RPM. Wind conditions were light and variable, visibility was about 10 km and the temperature was 19°C. The aircraft became airborne and, just as it achieved the take-off safety speed of 84 kts, at a height not above 50 ft, the right engine lost power. The aircraft yawed right. The pilot reported to the investigation team that he briefly noticed a reading of 3 lb of boost on the MAP gauge and assessed the problem as a possible partial right engine failure. He then selected the landing gear up but it did not retract. He cycled the landing gear selector once and the gear then retracted. By this time several seconds had elapsed and the airspeed had decayed to 76 kts. The pilot then assessed the airspeed as too low to retract the flaps and left them at 20°. The airspeed continued to decay until VMCA, 72 kts, was reached. When indicated airspeed had further decayed to 68 kts, the pilot reduced power on the left engine to avoid an uncontrollable roll to the right. He was able to maintain wings level and attempted to track the aircraft toward a street but was unable to maintain height. The aircraft collided with powerlines and then struck the roofs of several houses before coming to rest, on its left side, against the front wall of a house. About one minute had elapsed from initiation of takeoff until the accident. The pilot and all but one of the passengers remained conscious throughout the accident sequence. All occupants were evacuated, some without assistance and others with the assistance of the pilot, other passengers, emergency services personnel or bystanders.
Probable cause:
The following factors were reported:
- The right engine fuel control unit fuel pump failed causing the engine to fail at a critical phase of flight.
- Maintenance inspections did not detect the abnormal wear on the thrust face of the right engine fuel control unit fuel pump.
- The landing gear did not retract on the first attempt and aircraft performance decayed while the pilot resolved this problem.
- The pilot was probably forced to abandon the emergency procedures to concentrate on maintaining control of the aircraft.
- The aircraft was unable to maintain altitude and airspeed with the right propeller windmilling and 20° of flap.
- The investigation identified organisational factors concerning deficiencies in the manuals and procedures available to, and used by, the operator for the operation and maintenance of the accident aircraft.
Final Report:

Crash of a Cessna 404 Titan II in Bogotá: 13 killed

Date & Time: Jul 24, 1993 at 1340 LT
Type of aircraft:
Operator:
Registration:
HK-3001G
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Bogotá - Cali
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
13
Circumstances:
Shortly after takeoff from Bogotá-El Dorado Airport, while climbing, the crew informed ATC about the failure of the left engine and was cleared to return for an emergency landing. While turning to the left, the aircraft stalled and crashed on a building housing a car dealership. All seven occupants on board the Cessna as well as six people on the ground were killed, among them the Director and the Deputy Director of the Civil Aviation Authority of Colombia. Seven other people on the ground were injured.
Probable cause:
Failure of the left engine during initial climb for unknown reasons. The aircraft then stall due to insufficient speed.

Crash of a Beechcraft 200 Super King Air in Ankara: 6 killed

Date & Time: Feb 17, 1993 at 1222 LT
Operator:
Registration:
10011
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Güvercinlik - Diyarbakir
MSN:
BB-1411
YOM:
1991
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
Shortly after takeoff from Güvercinlik AFB, while climbing in poor weather conditions, the crew reported engines problems and severe vibrations. He was cleared to divert to Ankara-Esenboğa Airport when the aircraft lost height and crashed on the parking of a post office located in the district of Yenimahalle in Ankara. The aircraft disintegrated on impact and all five occupants were killed as well as one people on the ground, among them General Eşref Turgut Bitlis, Chief of the Turkish Police. At the time of the accident, visibility was limited to 1,500 metres due to snow falls with an OAT of -4° C.
Crew:
Yaşar Erian, pilot,
Yüzbaşı Tuğrul Sezginler, pilot.
Passengers:
Gen Eşref Turgut Bitlis,
Col Fahir Işık,
Sgt-Maj Emin Öner.

Crash of a Piper PA-31T Cheyenne II in Cologne: 1 killed

Date & Time: Feb 5, 1993 at 1044 LT
Type of aircraft:
Registration:
D-IDDI
Flight Phase:
Survivors:
No
Site:
Schedule:
Cologne - Berlin
MSN:
31-7920014
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Shortly after takeoff from Cologne-Bonn Airport, while in initial climb, the pilot declared an emergency and was cleared to return. While completing a turn, he lost control of the airplane that entered a dive and crashed onto a house located in Lind, less than 2 km south of the airport. The pilot, sole on board, was killed. There were no casualties on the ground.