Crash of a Cessna 402B in Biddeford: 1 killed

Date & Time: Apr 10, 2011 at 1805 LT
Type of aircraft:
Operator:
Registration:
N402RC
Flight Type:
Survivors:
No
Site:
Schedule:
White Plains - Portland
MSN:
402B-1218
YOM:
1977
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4735
Captain / Total hours on type:
120.00
Aircraft flight hours:
6624
Circumstances:
The multi-engine airplane was being repositioned to its base airport, and the pilot had requested to change the destination, but gave no reason for the destination change. Radar data indicated that the airplane entered the left downwind leg of the traffic pattern, flew at pattern attitude, and then performed a right approximate 250-degree turn to enter the final leg of the approach. During the final leg of the approach, the airplane crashed short of the runway into a house located in a residential neighborhood near the airport. According to the airplane's pilot operating handbook, the minimum multi-engine approach speed was 95 knots indicated airspeed (KIAS), and the minimum controllable airspeed was 82 KIAS. According to radar data, the airplane's ground speed was about 69 knots with the probability of a direct crosswind. Post accident examination of the propellers indicated that both propellers were turning at a low power setting at impact. During a controlled test run of the right engine, a partial power loss was noted. After examination of the throttle and control assembly, two o-rings within the assembly were found to be damaged. The o-rings were replaced with comparable o-rings and the assembly was reinstalled. During the subsequent test run, the engine operated smoothly with no noted anomalies. Examination of the o-rings revealed that the damage was consistent with the o-rings being pinched between the corner of the top o-ring groove and the fuel inlet surface during installation. It is probable that the right engine had a partial loss of engine power while on final approach to the runway due to the damaged o-ring and that the pilot retarded the engine power to prevent the airplane from rolling to the right. The investigation found no mechanical malfunction of the left engine that would have prevented the airplane from maintaining the published airspeed.
Probable cause:
The pilot did not maintain minimum controllable airspeed while on final approach with a partial loss of power in the right engine, which resulted in a loss of control. Contributing to the accident was the partial loss of engine power in the right engine due to the improperly installed o-rings in the engine’s throttle and control assembly.
Final Report:

Crash of a Casa 212 Aviocar in Saskatoon: 1 killed

Date & Time: Apr 1, 2011 at 1830 LT
Type of aircraft:
Operator:
Registration:
C-FDKM
Survivors:
Yes
Site:
Schedule:
Saskatoon - Saskatoon
MSN:
196
YOM:
1981
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7400
Captain / Total hours on type:
75.00
Copilot / Total flying hours:
7800
Copilot / Total hours on type:
1800
Aircraft flight hours:
21292
Circumstances:
At 1503 Central Standard Time, the Construcciones Aeronauticas SA (CASA) C-212-CC40 (registration C-FDKM, serial number 196) operated by Fugro Aviation Canada Ltd., departed from Saskatoon/Diefenbaker International Airport, Saskatchewan, under visual flight rules for a geophysical survey flight to the east of Saskatoon. On board were 2 pilots and a survey equipment operator. At about 1814, the right engine lost power. The crew shut it down, carried out checklist procedures, and commenced an approach for Runway 27. When the flight was 3.5 nautical miles from the runway on final approach, the left engine lost power. The crew carried out a forced landing adjacent to Wanuskewin Road in Saskatoon. The aircraft impacted a concrete roadway noise abatement wall and was destroyed. The survey equipment operator sustained fatal injuries, the first officer sustained serious injuries, and the captain sustained minor injuries. No ELT signal was received.
Probable cause:
Conclusions
Findings as to Causes and Contributing Factors:
1. The right engine lost power when the intermediate spur gear on the torque sensor shaft failed. This resulted in loss of drive to the high-pressure engine-driven pump, fuel starvation, and immediate engine stoppage.
2. The ability of the left-hand No. 2 ejector pump to deliver fuel to the collector tank was compromised by foreign object debris (FOD) in the ejector pump nozzle.
3. When the fuel level in the left collector tank decreased, the left fuel level warning light likely illuminated but was not noticed by the crew.
4. The pilots did not execute the fuel level warning checklist because they did not perceive the illumination of the fuel level left tank warning light. Consequently, the fuel crossfeed valve remained closed and fuel from only the left wing was being supplied to the left engine.
5. The left engine flamed out as a result of depletion of the collector tank and fuel starvation, and the crew had to make a forced landing resulting in an impact with a concrete noise abatement wall.
Findings as to Risk:
1. Depending on the combination of fuel level and bank angle in single-engine uncoordinated flight, the ejector pump system may not have the delivery capacity, when the No. 1 ejector inlet is exposed, to prevent eventual depletion of the collector tank when the engine is operated at full power. Depletion of the collector tank will result in engine power loss.
2. The master caution annunciator does not flash; this leads to a risk that the the crew may not notice the illumination of an annunciator panel segment, in turn increasing the risk of them not taking action to correct the condition which activated the master caution.
3. When cockpit voice and flight data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.
4. Because the inlets of the ejector pumps are unscreened, there is a risk that FOD in the fuel tank may become lodged in an ejector nozzle and result in a decrease in the fuel delivery rate to the collector tank.
Other Findings:
1. The crew’s decision not to recover or jettison the birds immediately resulted in operation for an extended period with minimal climb performance.
2. The composition and origin of the FOD, as well as how or when it had been introduced into the fuel tank, could not be determined.
3. The SkyTrac system provided timely position information that would have assisted search and rescue personnel if position data had been required.
4. Saskatoon police, firefighters, and paramedics responded rapidly to the accident and provided effective assistance to the survivors.
Final Report:

Crash of an Antonov AN-12BP in Pointe-Noire: 23 killed

Date & Time: Mar 21, 2011 at 1530 LT
Type of aircraft:
Operator:
Registration:
TN-AGK
Flight Type:
Survivors:
No
Site:
Schedule:
Brazzaville - Pointe-Noire
MSN:
40 20 06
YOM:
1963
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
23
Circumstances:
The four engine airplane departed Brazzaville-Maya Maya Airport on a cargo service to Pointe-Noire, carrying five passengers, four crew members and a load of 750 kilos of meat. On final approach to Pointe-Noire Airport runway 17, the aircraft rolled to the right, got inverted and crashed in the residential area of Mvoumvou located 4 kilometers short of runway. The aircraft was totally destroyed as well as several houses. All nine occupants and 14 people on the ground were killed.
Probable cause:
It is believed that the loss of control on final approach was the consequence of the failure of both right engines n°3 and 4.

Crash of an Ilyushin II-76TD in Karachi: 11 killed

Date & Time: Nov 28, 2010 at 0145 LT
Type of aircraft:
Operator:
Registration:
4L-GNI
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Karachi - Khartoum - Douala
MSN:
43452546
YOM:
1982
Flight number:
MGC4412
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
11
Captain / Total flying hours:
7272
Captain / Total hours on type:
5502.00
Copilot / Total flying hours:
2220
Aircraft flight hours:
8357
Aircraft flight cycles:
3373
Circumstances:
On 27th November, 2010 the operating crew of mishap aircraft flew from Fujairah (UAE) to JIAP, Karachi (Pakistan) at 1000 UTC. The load onboard was weighing 9 tons (Packaged Boeing
747 engine). The aircraft had flown to Fujairah airport from Kandahar. According to the provided information on the 27-11-2010 the crew comprising Aircraft Commander, Second Pilot, Navigator, Flight Engineer, Flight Radio Operator, and Flight Operator flew from Fujairah (UAE) to JIAP Karachi. After landing the crew members were shifted to “Regent Plaza” hotel in Karachi. The stay of crew in the hotel was not less than 8 hours. The aircraft was refuelled at JIAP, Karachi and total fuel onboard was 74 tons. A cargo load of 30.5 tons was also loaded after refuelling the aircraft. The aircraft mass was 197 tons with its CG at 30% Mean Aerodynamic Chord (MAC) before undertaking the mishap flight. The aircraft was scheduled for departure from JIAP, Karachi at 2025 UTC 28th November, 2010) on route “Karachi – Khartoum – Douala, Cameroon to deliver humanitarian aid (tents). The crew arrived at airport around 1900 UTC. The weather conditions were satisfactory. The weather details are mentioned in this report at Para 1.7. After starting engines the crew taxied the plane to Runway 25L and reported to the air traffic controller that the plane would take off in 3 minutes and the aircraft took off at 2048 UTC. According to the radar data the aircraft ascended to 600 feet, started descending and then disappeared from the radar screen. The air traffic controller did not receive any information from the crew members about emergency conditions onboard. The aircraft crashed at about 2050 UTC on a bearing of 070 degree and approximately 02 NM from JIAP, Karachi at geographical location N24°53.651’, E 067°06.406’.
Probable cause:
The cause of the occurrence was uncontained failure of the 2nd stage disk of LP compressor of Engine # 4 due to fatigue fracture which resulted in in-flight fire and damage to adjacent areas of right wing / flaps to an extent that flight could not be sustained.
The use of mishap engine beyond its manufacturer’s assigned life without assessment and life enhancement by the manufacturer was the cause of its uncontained fatigue failure.
Final Report:

Crash of a Piper PA-31 Cheyenne in Bankstown: 2 killed

Date & Time: Jun 15, 2010 at 0805 LT
Type of aircraft:
Operator:
Registration:
VH-PGW
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Bankstown - Brisbane - Albury
MSN:
31-8414036
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2435
Captain / Total hours on type:
779.00
Aircraft flight hours:
6266
Circumstances:
The twin engine aircraft, with a pilot and a flight nurse on board, was being operated by Skymaster Air Services under the instrument flight rules (IFR) on a flight from Bankstown Airport, New South Wales (NSW) to Archerfield Airport, Queensland. The aircraft was being positioned to Archerfield for a medical patient transfer flight from Archerfield to Albury, NSW. The aircraft departed Bankstown at 0740 Eastern Standard Time. At 0752, the pilot reported to air traffic control (ATC) that he was turning the aircraft around as he was having ‘a few problems. At about 0806, the aircraft collided with a powerline support pole located on the eastern side of the intersection of Sackville Street and Canley Vale Road, Canley Vale, NSW. The pilot and flight nurse sustained fatal injuries and the aircraft was destroyed by impact damage and a post-impact fire.
Probable cause:
Contributing safety factors:
• While the aircraft was climbing to 9,000 feet the right engine sustained a power problem and the pilot subsequently shut down that engine.
• Following the shutdown of the right engine, the aircraft's descent profile was not optimized for one engine inoperative flight.
• The pilot conducted a descent towards Bankstown Airport that was consistent with a normal arrival profile without first verifying that the aircraft was capable of achieving adequate performance with one engine inoperative.
• Following the engine problem, the aircraft's flightpath and the pilot’s communication with air traffic control indicated that the pilot's situation awareness was less than optimal.
• The aircraft collided with a powerline support pole on the eastern side of the intersection of Sackville Street and Canley Vale Road, Canley Vale, about 6 km north-west of Bankstown Airport.
Other safety factors:
• The pilot did not broadcast a PAN following the engine shutdown and did not provide air traffic control with further information about the nature of the problem in order for the controller to positively establish the severity of the situation.
• Section 4 of Civil Aviation Advisory Publication (CAAP) 5.23-2(0), Multi-engine Aeroplane Operations and Training of July 2007 did not contain sufficient guidance material to support the flight standard in Appendix A subsection 1.2 of the CAAP relating to Engine Failure in the Cruise. [Minor safety issue]
Other key finding:
• Given the pilot’s extensive experience and testing in the PA-31 aircraft type, and subsequent endorsement training on a high performance turboprop multi-engine aircraft since the issue by CASA in 2008 of a safety alert in respect of the pilot’s PA-31 endorsement, it was unlikely that any deficiencies in that endorsement training contributed to the accident.
Final Report:

Crash of a Piper PA-31-325 Navajo C/R (Panther) in Guatemala City: 4 killed

Date & Time: May 26, 2010 at 0855 LT
Type of aircraft:
Registration:
TG-LAP
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Guatemala City - San Salvador
MSN:
31-8012043
YOM:
1980
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The twin engine aircraft departed Guatemala City-La Aurora Airport at 0840LT on a flight to San Salvador-Ilopango Airport, carrying two passengers and one pilot. About 4-5 minutes after takeoff, while climbing in IMC conditions, the pilot reported technical problems with the instruments and was cleared for an immediate return. Shortly later, the aircraft entered an uncontrolled descent and crashed in a meat packing plant located in the approach path. The aircraft was destroyed by impact forces as well as the building. All three occupants as well as one people in the factory were killed.
Probable cause:
Loss of control following the failure of the attitude indicator while climbing in IMC conditions.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Clearwater

Date & Time: May 16, 2010 at 1013 LT
Operator:
Registration:
XB-LTH
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Clearwater – Port-au-Prince
MSN:
46-36428
YOM:
2007
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2662
Captain / Total hours on type:
23.00
Aircraft flight hours:
207
Circumstances:
The airplane was loaded more than 500 pounds (about 12 percent) over the certificated maximum gross weight. The airplane lifted off from the 3,500-foot-long runway about one-half to two-thirds down the length of the runway. The pilot retracted the airplane's landing gear and flaps before reaching the airplane manufacturer's recommended retraction speeds. The airplane was unable to gain sufficient altitude and subsequently impacted trees and a house located beyond the departure end of the runway. A postaccident examination of the wreckage and recorded non-volatile memory revealed no evidence of any preimpact mechanical abnormalities.
Probable cause:
The overweight condition of the airplane due to the pilot's inadequate preflight planning, resulting in the airplane's degraded climb performance. Contributing to the accident was the pilot's retraction of the flaps prior to reaching the manufacturer's recommended flap retraction speed.
Final Report:

Crash of a Cessna T303 Crusader in Louisa: 1 killed

Date & Time: Mar 4, 2010 at 1245 LT
Type of aircraft:
Registration:
N9305T
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Manassas - Louisa - Danville
MSN:
303-00001
YOM:
1981
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2255
Aircraft flight hours:
1374
Circumstances:
During takeoff, one witness noted that at least one engine seemed to be running rough and not making power. Several other witnesses, located about 1/2 mile northwest of the airport, observed the accident airplane pass overhead in a right turn. They reported that the engine noise did not sound normal. Two of the witnesses noted grayish black smoke emanating from the airplane. The airplane then rolled left and descended nose down into the front yard of a residence. Review of maintenance records revealed the airplane underwent an annual inspection and extensive maintenance about 3 months prior to the accident. One of the maintenance issues was to troubleshoot the right engine that was reportedly running rough at cruise. During the maintenance, the right engine fuel pump, metering valve, and fuel manifold were removed and replaced with overhauled units. Additionally, the right engine fuel flow was reset contrary to procedures contained in an engine manufacturer service information directive; however, the fuel pump could not be tested due to thermal damage and the investigation could not determine if the fuel flow setting procedure contributed to the loss of power on the right engine. On-scene examination of the wreckage and teardown examination of both engines did not reveal any preimpact mechanical malfunctions. Teardown examination of the right propeller revealed that the blades were not at or near the feather position, which was contrary to the emergency procedure published by the manufacturer, to secure the engine and feather the propeller in the event of an engine power loss. The right propeller exhibited signatures consistent with low or no power at impact, while the left propeller exhibited signatures consistent of being operated with power at impact.
Probable cause:
The pilot's failure to maintain aircraft control and secure the right engine during a loss of engine power after takeoff. Contributing to the accident was the loss of engine power on the right engine for undetermined reasons.
Final Report:

Crash of a GAF Nomad N.22B in Cotabato City: 9 killed

Date & Time: Jan 28, 2010 at 1138 LT
Type of aircraft:
Operator:
Registration:
18
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Cotabato City - Zamboanga
MSN:
18
YOM:
1975
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
Shortly after takeoff from Cotabato City Airport, while in initial climb, the twin engine aircraft lost height and crashed in a residential area near the airport. The aircraft was destroyed and all 8 occupants were killed as well as one person on ground. It it believed that one of the engine failed shortly after rotation.

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Aurora: 2 killed

Date & Time: Jan 23, 2010 at 1852 LT
Registration:
N222AQ
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Aurora – Broomfield
MSN:
61-0164-004
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
555
Circumstances:
The visibility at the time of the accident was 1/2 mile with fog and the vertical visibility was 100 feet. A witness stated that the pilot checked the weather, but that he appeared to be in a hurry and took off without performing a preflight inspection of the aircraft. After takeoff, air traffic control instructed the pilot to turn left to a heading of 270 degrees. The pilot reported to the controller that he was at 1,300 feet climbing to 3,000 feet and the controller cleared the pilot to climb to 4,000 feet; the pilot acknowledged the clearance. Witnesses on the ground noted that the airplane was loud; one witness located about 1.5 miles from the departure airport reported that the airplane flew overhead at treetop height. The airplane impacted trees and a residence about 2.3 miles north-northeast of the departure airport. The airplane's turning ground track and the challenging visibility conditions were conducive to the onset of pilot spatial disorientation. Post accident inspection failed to reveal any mechanical failure that would have resulted in the accident. The pilot purchased the airplane about three months prior to the accident; at that time he reported having 72.6 hours of instrument flight experience and 25 hours of multi-engine experience, with none in the accident airplane make and model. After purchasing the airplane, the pilot received 52 hours of flight instruction in the accident airplane in 7 days. Logbook records were not located to establish subsequent flight experience.
Probable cause:
The pilot's spatial disorientation and subsequent failure to maintain airplane control.
Final Report: