Crash of a Swearingen SA226T Merlin IIIB off Bergen: 3 killed

Date & Time: Jun 20, 2008 at 1026 LT
Type of aircraft:
Operator:
Registration:
LN-SFT
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bergen - Bergen
MSN:
T-342
YOM:
1980
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
15750
Captain / Total hours on type:
12000.00
Copilot / Total flying hours:
6310
Aircraft flight hours:
13551
Aircraft flight cycles:
5732
Circumstances:
The flight was a skill-test for a candidate that was hired as a first officer on SA226-T(B) Merlins for the operator Helitrans. He was one of two candidates that were employed by the company in early 2008. They underwent ground school and flight training in cooperation with the Swedish Type Rating Training Organisation (TRTO) Trafikkhögskolan. Later it became clear that the Swedish Civil Aviation Authority (CAA) did not accept skill-tests limited to first officer duties on a single pilot certified airplane, as the Norwegian CAA did. The candidates did not possess the skills to act as commanders on the Merlin, and there was a period of uncertainty while the operator and the Norwegian CAA discussed how to conduct the skill-tests, in particular whether to use a simulator or an actual airplane. After several months the issues were resolved and an examiner was appointed. There was a limited slot on a Thursday and a Friday where the examiner, the instructor/commander and the aircraft was available at Bergen Airport Flesland. The first candidate performed the skill-test on Thursday. The weather was not suited for flying skill tests. It was low ceiling, rain showers and winds up to 40 kt and turbulence. Turbulence caused the stick pusher to activate during the demonstration of slow flight. The commander decided to pull the circuit breaker for the Stall Avoidance and Stability Augmentation System (SAS) presumably to avoid nuisance activations of the stick pusher. After the slow flight demonstration, the examiner asked the candidate to demonstrate a stall. The candidate found this exercise frightening as she experienced great difficulties, having to use all her available physical strength to regain normal flight with the engines on full power and in IMC conditions. The weather was similar on Friday with even stronger winds. The SAS circuit breaker was not reset. This was confirmed during the start-up check. The examiner requested a similar program during this skill-test as he did the day before. However, when it came to demonstrating stalls, the examiner asked for a slow flight up to first indication of stall, and not an actual stall. He asked for call outs and a minimum loss of altitude recovery. The commander undertook the tasks of adding power and retracting gear and flaps on the candidate’s request. It was IMC. During this exercise the crew lost control of attitude and airspeed. The stall warning came on, but the airspeed decreased, even with full power applied. Radar data show that the altitude increased 200 – 400 ft during the period where control was lost. Airspeed decreased to about 30 kt and a sink rate of about 10 000 ft/min eventually developed. The airplane hit the sea in a near horizontal attitude about 37 sec. after control was lost. All three on board were fatally injured. The accident aircraft was used for coastguards duties and was modified with external sensors and antennas. The AIBN made a Computational Fluid Dynamics analysis in order to determine whether these installations influenced on stability and flight characteristics in the slow flight and pre-stall regime. It was found that the modifications reduced the overall performance, but did not result in any significant degradation of stability and control in this regime. There was no investigation as to any influence on the characteristics of a fully developed stall. The AIBN is of the opinion that this accident highlights the need for a change in the current training on initial stall recovery techniques, especially the focus on minimum loss of altitude at the expense of breaking the stall by lowering the nose and thus reducing the angle of attack. The AIBN has issued two safety recommendations to the Norwegian CAA; one regarding the conduct of skill-tests for pilots in a multi crew concept on single pilot airplanes, and one suggesting increased focus on flight examiners tasks.
Probable cause:
The following findings were identified:
- Even if the weather on the day of the accident was within the permitted limits, it was not suitable to perform 'airwork' or training exercises,
- The captain thought the weather was not suitable for conducting the skill test for the second candidate. That he nevertheless agreed to take the test may be due to the fact that he felt
a pressure to complete the mission,
- The flight was conducted in challenging conditions and there is reason to believe that atmospheric turbulences may have contributed to the loss of control during the skill flight,
- The flight was completed in clouds, and it can be assumed that the lack of visual references in the clouds contributed to the loss of control.
Final Report:

Crash of a Rockwell Shrike Commander 500S off Alice Town

Date & Time: Jun 9, 2008 at 1401 LT
Operator:
Registration:
N501AP
Flight Type:
Survivors:
Yes
Schedule:
Nassau – Fort Lauderdale
MSN:
500-3224
YOM:
1974
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On June 9, 2008, about 1401 eastern daylight time, an Aero Commander 500S, N501AP, registered to and operated by Gramar 500, Inc., experienced a loss of engine power in both engines and was ditched in the Atlantic Ocean about 1/2 mile south of North Bimini, Bahamas. Visual meteorological conditions prevailed in the area and a visual flight rules flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight from Nassau International Airport (MYNN), Nassau, Bahamas, to Ft. Lauderdale Executive Airport (FXE), Ft. Lauderdale, Florida. The airplane was destroyed due to salt water immersion, and the airline transport rated pilot, the sole occupant, was not injured. The pilot stated that when the flight was past Bimini, the right engine started running rough and losing power. He turned southeast to enter a left base for runway 09 at South Bimini Airport, and the left engine also began to run rough and lost power. The pilot ditched the aircraft, evacuated into a life raft, and was rescued by a pleasure boater. The pilot also stated that 25 gallons of fuel were added while at MYNN, for a total fuel supply of 90 gallons. Both engines were test run 8 days after the accident using a test propeller. Both engines ran to near maximum RPM. One magneto from each engine was replaced prior to the test run.

Crash of a De Havilland DHC-2 Beaver in Stehekin: 2 killed

Date & Time: May 17, 2008 at 1645 LT
Type of aircraft:
Operator:
Registration:
N9558Q
Survivors:
Yes
Schedule:
Chelan - Stehekin
MSN:
1151
YOM:
1958
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5747
Captain / Total hours on type:
637.00
Aircraft flight hours:
12070
Circumstances:
The amphibious-float-equipped airplane departed from a paved runway for the 40-nautical mile flight to its destination, where a water landing on a lake was to be made. The pilot did not raise the landing gear after takeoff. During the flight, the air was bumpy and turbulent, and this resulted in the gear advisory system activating numerous times. The purpose of the system is to alert the pilot of the landing gear position--up for a water landing or down for a runway landing--when the airspeed decreased below a set threshold value. The pilot disabled the system by pulling its circuit breaker because the alerts were becoming a nuisance; he intended to reset the breaker during descent, but did not do so. Upon reaching the destination, the pilot set up a 150- to 200-feet-per-minute rate of descent for a glassy water landing on the lake. With the landing gear in the down position, the airplane contacted the water and abruptly nosed over. The airplane came to rest floating inverted, suspended by the floats. The pilot reported that the day of the accident was his nineteenth consecutive duty day, including office duty and flight duty. He stated that he feels the lack of days off during the previous 19 days was a contributing factor to this accident. When asked what would have prevented the accident, the pilot suggested consistency in using the checklist. On two flights earlier in the day he had used a written checklist; on the accident flight he did not.
Probable cause:
The pilot's failure to retract the landing gear wheels prior to performing a water landing. Contributing to the accident were the pilot's disabling of the landing gear warning/advisory system and possible fatigue due to his work schedule.
Final Report:

Crash of an Antonov AN-32 off Annobón Island: 11 killed

Date & Time: Apr 16, 2008 at 1423 LT
Type of aircraft:
Operator:
Registration:
3C-5GE
Flight Type:
Survivors:
No
Schedule:
Bata - Annobón Island
MSN:
16 09
YOM:
1988
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The aircraft departed Bata on a special flight to Annobón Island carrying six politicians completing an election tour and a crew of five. While approaching Annobón Island, the crew encountered poor weather conditions with strong winds and heavy rain falls. Control was lost and the aircraft crashed in the sea. Four dead bodies were found.

Crash of a Swearingen SA227AC Metro III off Sydney: 1 killed

Date & Time: Apr 9, 2008 at 2327 LT
Type of aircraft:
Operator:
Registration:
VH-OZA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sydney – Brisbane
MSN:
AC-600
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4873
Captain / Total hours on type:
175.00
Aircraft flight hours:
32339
Aircraft flight cycles:
46710
Circumstances:
On 9 April 2008, at 2325 Eastern Standard Time, a Fairchild Industries Inc. SA227-AC (Metro III) aircraft, registered VH-OZA, departed Sydney Airport, New South Wales on a freight charter flight to Brisbane, Queensland with one pilot on board. The aircraft was subsequently observed on radar to be turning right, contrary to air traffic control instructions to turn left to an easterly heading. The pilot reported that he had a ‘slight technical fault’ and no other transmissions were heard from the pilot. Recorded radar data showed the aircraft turning right and then left, followed by a descent and climb, a second right turn and a second descent before radar returns were lost when the aircraft was at an altitude of 3,740 ft above mean sea level and descending at over 10,000 ft/min. Air traffic control initiated search actions and search vessels later recovered a small amount of aircraft wreckage floating in the ocean, south of the last recorded radar position. The pilot was presumed to be fatally injured and the aircraft was destroyed. Both of the aircraft’s on-board flight recorders were subsequently recovered from the ocean floor. They contained data from a number of previous flights, but not for the accident flight. There was no evidence of a midair breakup of the aircraft.
Probable cause:
Contributing Safety Factors:
- It was very likely that the aircraft’s alternating current electrical power system was not energised at any time during the flight.
- It was very likely that the aircraft became airborne without a functioning primary attitude reference or autopilot that, combined with the added workload of managing the ‘slight technical fault’, led to pilot spatial disorientation and subsequent loss of control.
Other Safety Factors:
- The pilot’s Metro III endorsement training was not conducted in accordance with the operator’s approved training and checking manual, with the result that the pilot’s competence and ultimately, safety of the operation could not be assured. [Significant safety issue].
- The chief pilot was performing the duties and responsibilities of several key positions in the operator’s organisational structure, increasing the risk of omissions in the operator’s training and checking requirements.
- The conduct of the flight single-pilot increased the risk of errors of omission, such as not turning on or noticing the failure of aircraft items and systems, or complying with directions.
Final Report:

Crash of a Grumman G-21A Goose off Marathon

Date & Time: Jan 29, 2008 at 1723 LT
Type of aircraft:
Registration:
N21A
Flight Type:
Survivors:
Yes
Schedule:
Marathon - Marathon
MSN:
B129
YOM:
1946
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16000
Captain / Total hours on type:
100.00
Aircraft flight hours:
24456
Circumstances:
On January 29, 2008, about 1723 eastern standard time, a Grumman G-21A, amphibian airplane N21A, impacted the ocean during landing near Marathon, Florida. The certificated airline transport pilot and passenger received serious injuries and the airplane sustained substantial damage. The flight was operated as a personal flight under the provisions of 14 Code of Federal Regulations (CFR) Part 91, and no flight plan was filed. Visual meteorological conditions prevailed at the time of the accident. The flight departed from the Florida Keys Marathon Airport (MTH) in Marathon, Florida, on January 29, 2008, about 1615. According to the pilot he departed MTH and after take off and the checklist accomplished he proceeded in a westerly direction to inspect a water-work area. The pilot stated that other then that, he had no further recollection of the flight. According to the Federal Aviation Administration (FAA) the passenger stated that the pilot was practicing takeoffs and landings. During a water landing, the left wing contacted the water and the airplane water looped. A Good Samaritan rescued them from the water in his boat and brought them ashore where rescue personal were waiting. Examination of the airplane by the FAA revealed no mechanical malfunctions or failures of the airplane or engine, and none were reported by the pilot or passenger.
Probable cause:
The pilot’s failure to maintain control of the airplane during a water landing.
Final Report:

Crash of a Let L-410UVP-E3 off Los Roques: 14 killed

Date & Time: Jan 4, 2008 at 0910 LT
Type of aircraft:
Operator:
Registration:
YV2081
Flight Phase:
Survivors:
No
Schedule:
Caracas – Los Roques
MSN:
87 20 15
YOM:
1987
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
14
Circumstances:
At 0858LT, while cruising at an altitude of 7,500 feet some 83 km from the destination, the crew reported his position to ATC. About 10 minutes later, while cruising at an altitude of 3,000 feet, the captain declared an emergency following a double engine failure. The aircraft lost height and crashed in the sea some 29 km off Los Roques Airport. Few debris were found floating on water and all 14 occupants were killed, among them 8 Italians, one Swiss and five Venezuelans. At the time of the accident, weather conditions were poor. On 19 June 2013, an Italian-Venezuelan search team found the wreckage at a depth of 974 metres.
Probable cause:
Double engine failure for unknown reasons.

Crash of a GAF Nomad N.22B off Sabang: 5 killed

Date & Time: Dec 30, 2007 at 1130 LT
Type of aircraft:
Operator:
Registration:
P-833
Survivors:
Yes
Schedule:
Sabang - Medan
MSN:
168
YOM:
1983
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The twin engine aircraft departed Sabang-Maimum Saleh airport at 1110LT on a maritime survey flight to Medan. About 15 minutes into the flight, the crew informed ATC about engine problems and elected to return to Sabang. On final approach in poor weather conditions, the aircraft crashed in the sea and sank about 200 metres offshore. Two people were rescued while five others were killed.

Crash of a Beechcraft B90 King Air off Saona Island: 1 killed

Date & Time: Dec 21, 2007 at 1217 LT
Type of aircraft:
Registration:
YV2327
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Caracas – La Romana
MSN:
LJ-499
YOM:
1970
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
While descending to La Romana Airport following a flight from Caracas, the crew informed ATC about technical problems and ditched the aircraft about 64 km off Saona Island, southeast of La Romana. One passenger was killed while six other occupants were rescued by Porto Rico Coast Guards.

Crash of a Cessna 208B Grand Caravan off Chub Cay

Date & Time: Dec 20, 2007 at 1700 LT
Type of aircraft:
Operator:
Registration:
N954PA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
La Isabela - West Palm Beach
MSN:
208B-0556
YOM:
1996
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
7390
Circumstances:
On December 20, 2007 at approximately 1630EST, N954PA a Cessna 208B Caravan aircraft, owned and operated by Agape Flight Inc [United States FAR Part 91 Operator] enroute from Santo Domingo, Dominican Republic to West Palm Beach, Florida incurred sudden engine stoppage. At the time N954PA was flying at 12,000 ft. The aircraft was diverted to the nearest airport but was unable to glide the required distance and landed 30 nautical miles (NM) West North West (WNW) of Chub Cay. There were 2 crew members on board the aircraft. No injuries were reported by the crew. The aircraft is submerged in approximately eighteen to twenty feet of water, with the aircraft tail being visible at low tide. Both crews were qualified in accordance with the United States Code of Federal Regulations.
Probable cause:
The engine power loss was caused by a loss of fuel pressure resulting from a loss of drive to the fuel pump. The drive loss was caused by worn and cracked splines on the drive shaft. The damage to the splines of the fuel pump drive shaft was likely caused by cracking below the chrome plating covering the splines, which deteriorated into spalling and wear leading to decouple between the
accessories gearbox and fuel pump. The remaining engine damage was caused by exposure to salt water.
Contributing factors:
Maintenance changed the fuel control unit and coupling shaft on July 17, 2007 due to original FCU failing emergency power checks. However there is no record to show whether or not the splines of fuel pump drive shaft inspection as per P&WC’s applicable Maintenance Manual has been accomplished.
Final Report: