Crash of a De Havilland DHC-2 Beaver off Quadra Island: 5 killed

Date & Time: Feb 28, 2005 at 1916 LT
Type of aircraft:
Operator:
Registration:
C-GAQW
Flight Phase:
Survivors:
No
Schedule:
Campbell River – Frances Bay – Knight’s Inlet – Frances Bay – Campbell River
MSN:
1353
YOM:
1959
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The single engine aircraft departed Campbell River on a night flight to Knight's Inlet with four passengers and one pilot on board. As it failed to arrive at destination, SAR operations were initiated by RCAF & RCMP but no trace of the airplane and its occupants was found. On 15 of July 2005, the wreckage was found at a depth of 260 metres of Quadra Island by the families of the victims. TSB did not proceed to any investigations for this occurrence.

Crash of a Casa 212 Aviocar 100 off Sarmi: 15 killed

Date & Time: Feb 22, 2005 at 0715 LT
Type of aircraft:
Operator:
Registration:
P-2032
Survivors:
Yes
Schedule:
Jayapura - Sarmi
MSN:
220/60N
YOM:
1985
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
15
Circumstances:
On final approach to Sarmi Airport, the crew reported engine problems when the aircraft lost height and crashed in the sea about 400 metres from the runway threshold. The wreckage was found 100 metres offshore. Three passengers were rescued while 15 other occupants were killed.

Crash of a Partenavia P.68 off Puerto Villamil: 2 killed

Date & Time: Dec 21, 2004 at 1219 LT
Type of aircraft:
Operator:
Survivors:
No
Schedule:
Baltra Island - Puerto Villamil
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The twin engine aircraft departed Galapagos International Airport (Baltra Island) at 1200LT on a flight to Puerto Villamil Airport, Isabela Island, carrying one passenger and one pilot. At 1219LT, the pilot was cleared to descend to Puerto Villamil Airport when he lost control of the airplane that crashed in the sea. The wreckage was found few hundred metres offshore at 1655LT. Both occupants were killed. The accident occurred three minutes prior to landing.

Crash of a Convair CV-340-70 in Miami

Date & Time: Dec 4, 2004 at 0851 LT
Type of aircraft:
Operator:
Registration:
N41626
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Miami – Nassau
MSN:
274
YOM:
1955
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3100
Captain / Total hours on type:
2400.00
Copilot / Total flying hours:
9169
Copilot / Total hours on type:
964
Aircraft flight hours:
18465
Circumstances:
The pilot stated that when the airplane was 3 miles east of the shoreline, at 3,000 feet, he felt a short tremor in the left engine followed by loss of power from the left engine. The pilot elected to return to the departure airport while declaring an emergency to air traffic control. During the process of securing the left engine the pilot noticed the propeller did not feathered and the airplane was descending quickly. He maneuvered the airplane and ditched in a lake. On September 26, 2003 engine s/n: 34592 was removed from the accident airplane due to high oil consumption with 1,225 hours of time in service. It was reportedly preserved and stored at the operator's warehouse. The mechanic who reportedly preserved the engine stated he followed the steps in the manual that was provided by the operator. On October 27, 2004 the left engine, s/n: NK510332, which was producing metal for months, was removed and engine s/n: 34592 was taken out of preservation and installed in the left position on the accident airplane with a new overhauled propeller assembly. On November 06, 2004, the left engine's, s/n: 34592, propeller governor was replaced due to the left propeller slow to response to power setting. During the post accident engine examination, the engine's main oil screen was observed with deposits of metal flakes and fragments, the oil scavenge pump would not rotate and had deposits of metal fragments internally; the engine was seized and wound not rotate. Catastrophic damage was observed to the accessories drive gears, oil transfer tube, and protection covers in the front accessory area. It was observed during a visual inspection of the crankshaft and bearings, including the front journal and front crankpin had damaged and sections of their respective bearings missing. The master rod bearing had incurred a catastrophic failure. Several cylinders skirts were found with impact marks from piston rods. Before removing the propeller assembly from the engine, the propeller feather system was flush with fresh oil and pressured with a feathering pump; the propeller blades were observed moving toward the feather position. Examination of the propeller assembly revealed metal contamination throughout the system; the propeller's governor screen gasket was clogged with metal contamination. The maintenance manual provided by the operator used for the engine preservation details several tasks required to be accomplished to the engine for proper engine preservation (i.e. thrust bear, cylinder, and propeller shaft treatments), which the mechanic did not mention he performed. No documentation for inspection and condition status of the dehydrator plugs were available. Documentation for flushing of contamination from the metal producing engine, s/n NK510332, was not available nor knowledge by the operator if since a process was preformed to the left engine's oil tank and its system before installation of engine s/n: 34592. An FAA review of the cargo manifest discovered two different manifest weights. The cargo manifest obtained at the accident scene showed a total of 267 pieces of cargo annotated at a total weight of 10, 837 lbs. The sealed cargo manifest package showed a total of 267 pieces of cargo annotated at a total weight of 14,182 lbs. The maximum payload weight for the accident airplane is 13,586 lbs.
Probable cause:
The improper maintenance of the left engine by company maintenance personnel (failure to flush metal from the oil system and failure to properly preserve the engine for storage) resulting in a total failure of the master rod bearing and contamination of the engine oil system with metal, which prevented the left propeller from feathering. This resulted in the airplane being unable to maintain altitude following loss of engine power and subsequent ditching in a lake. A factor in this accident is the aircraft operator and flight crew exceeding the maximum allowable takeoff weight for the airplane.
Final Report:

Crash of a Beechcraft 1900C off Nassau

Date & Time: Oct 22, 2004 at 1345 LT
Type of aircraft:
Operator:
Registration:
N79YV
Survivors:
Yes
Schedule:
Arthur’s Town – Nassau
MSN:
UB-41
YOM:
1985
Flight number:
SAC204
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8000
Captain / Total hours on type:
112.00
Copilot / Total flying hours:
568
Copilot / Total hours on type:
178
Aircraft flight hours:
26397
Circumstances:
The occurrence of this accident was notified to the Flight Standards Inspectorate by the Nassau Control Tower. On October 22, 2004 about 1328 eastern daylight time (1828Z) a Beechcraft 1900C, N79YV registered to JODA LLC of Chesterfield Missouri, and operated by Southern Air Charter Limited of Nassau, Bahamas, was ditched. The accident occurred in approximately four (4) feet of water, approximately 82 yards off the southern shoreline of New Providence Island (6.98 nautical miles southeast of the Nassau International Airport). The State of Manufacture of the airframe and engines (United States) was advised of the accident on that day and invited to participate in the investigation. The NTSB as well as the FAA were also notified and subsequently made party to the investigation, as the aircraft was a United States registered aircraft operating on an approved United States 129.14 maintenance program. Visual Meteorological Conditions prevailed at the time and an outbound visual flight plan was on file. N79YV operated as a schedule air commuter on a domestic transport flight. The flight originated from Arthur’s Town, Cat Island Bahamas enroute to Nassau International Airport, Nassau, Bahamas. The airplane sustained substantial damage. The occupants of the aircraft consisted of eight (8) passengers and a crew of two (2). The Pilot in Command held an Airline Transport Pilot rating and the First Officer held a Commercial Pilot rating. Both crews were certificated by the Federal Aviation Administration, (FAA). No serious injuries or fatalities were reported.
Probable cause:
Failure of the right engine due to fuel exhaustion. No fuel was found in left or right collector tanks. On October 22, 2004 at 6:35 am, a total of 386 gallons of fuel was uplifted, which brought fuel total to 2800 pounds. A total of 3 flights were conducted lasting 29 minutes, 11 minutes and then 21 minutes (for a total of 61 minutes chock to chock time and a usage of 700 pounds of fuel) which brought fuel total down to 2100 pounds. On October 22, 2004 at 8:42am a further 146 gallons of fuel was uplifted. This additional 146 gallons brought fuel total back to 2800 pounds. No additional fuel slips were produced to show any further uplift of fuel. A total of 8 flights including the fateful flight were conducted with this 2800 pounds of fuel.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off Pompano Beach

Date & Time: Oct 21, 2004 at 1748 LT
Operator:
Registration:
N61518
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Moss Town – Fort Lauderdale
MSN:
31-7552022
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4500
Aircraft flight hours:
19269
Circumstances:
Before the start of the trip, the pilot was reportedly given $500.00 cash by the operator to purchase fuel. The pilot stated that the first leg of the flight from KFLL to MYEF departed with the main fuel tanks full and approximately 10 gallons in each of the auxiliary fuel tanks. There were no deviations en-route, and the uneventful flight lasted a reported 1 hour 40 minutes. After landing in Exuma International Airport, the main fuel tanks contained slightly more than 1/2 fuel capacity. Ten gallons of fuel were added to each of the two auxiliary fuel tanks at MYEF, no additional fuel was purchased. The flight departed for KFLL, and during the climb to 10,000 feet, he leaned the fuel/air mixture. During the cruise portion of the flight, the fuel in the auxiliary fuel tanks was consumed then he switched to the main fuel tanks to supply fuel to the engines. The flight crossed the DEKAL intersection at 4,000 feet, which is about 31 nautical miles southeast of KFLL, continued, and the right engine manifold pressure decreased, the cylinder head temperature reached red line indication, and the engine sputtered. He declared an emergency with air traffic control and the controller provided vectors to KFLL which he verbally acknowledged but did not comply with. While operating single engine, with the engine operating at full power, he reported no discrepancies with the left engine. He reported he could reach KFLL but was concerned about flying over a populated area at a low altitude, and was losing altitude. Contrary to the statement made by the pilot that he was not able to maintain altitude while flying single-engine, the airplane was capable of a rate of climb greater than 170 feet-per-minute if flown properly. He elected to ditch the airplane in the Atlantic Ocean; the airplane was not recovered. The operator was asked repeatedly by NTSB for historical fuel receipts and flight hours for N61518 but did not comply. NTSB review of fuel consumption calculations performed by the Federal Aviation Administration (FAA) Inspector-In-Charge revealed the aircraft would have experienced fuel exhaustion at the approximate location and time when the pilot declared an emergency with ATC following failure of the right engine. The NTSB did not receive the NTSB requested detailed, signed, dated statement from the pilot.
Probable cause:
The pilot's inadequate in-flight planning/decision, which resulted in fuel exhaustion and the loss of engine power in one engine. Contributing factors were the pilot's inadequate handling of the aircraft following failure of the right engine for his failure to extract maximum single engine performance, and his failure to properly refuel the aircraft.
Final Report:

Crash of a Britten-Norman BN-2A-27 near Vega Baja: 1 killed

Date & Time: Sep 29, 2004 at 1859 LT
Type of aircraft:
Operator:
Registration:
N902GD
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mayaguez – San Juan
MSN:
905
YOM:
1981
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
On September 29, 2004, about 1859, Atlantic standard time, the accident airplane, N902GD, operating as an "on demand" air taxi flight, transporting bank financial documents, departed
Mayaguez, Puerto Rico, and was later reported as not having arrived at its destination. Search and rescue assets later discovered airplane related debris, specific to the missing airplane, floating in the Atlantic Ocean, in the vicinity of geographic position 18 degrees 29 minutes north latitude, 066 degrees 27 minutes west longitude. The NTSB evaluated radar and weather data, and radar track data for the flight showed that after departure the accident airplane climbed to 1,700 feet, and then descended to 1,300 feet at 1840. From 1840 to 1850, the radar data indicated that the flight was proceeding east along the northern coast of Puerto Rico, at an altitude of 1,100 feet. About 1855, the data showed that the airplane climbed to 1,400 feet, and about 1856, it descended to about 1,000 feet. About 1858, the airplane descended to 800 feet, and then to 600 feet, before disappearing from radar at 18:59:18. Weather data showed that a weak upper air trough, a moist low level southeasterly flow and associated showers and thunderstorms had formed over Puerto Rico during the time of the accident flight. The weather data showed that at departure visual meteorological conditions existed, but doppler weather radar data showed that a 50 dBz (level 5) rain shower was positioned about 3 to 5 miles off the airplane's right wing from 1837 to 1838, and from 1855 to 1901 there was a level 4-5 (45-50 dBZ) rain shower along the accident airplane's track, and the radar track data along with the doppler weather radar data was consistent with the flight having penetrated the rain shower corresponding to the time radar contact with the flight was lost. The NTSB Weather Group Chairman's Report has been included as an attachment to the factual report.
Probable cause:
The pilot's improper inflight planning which resulted in an inflight encounter with weather (low ceilings and thunderstorms), his loss of aircraft control, and an inflight collision with the ocean during uncontrolled descent.
Final Report:

Crash of a Convair CV-440-38 Metropolitan off Tortola: 1 killed

Date & Time: Jul 12, 2004 at 0715 LT
Registration:
N4826C
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
San Juan - Sint Maarten
MSN:
391
YOM:
1956
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
27200
Captain / Total hours on type:
924.00
Copilot / Total flying hours:
256
Aircraft flight hours:
45771
Circumstances:
The copilot stated that the pre-flight and run-up before takeoff were performed with no discrepancies noted. After leveling off at 5,500 feet they noticed that the right engine cylinder head temperature and oil temperature was about 10 degrees above the normal parameter for that engine. Shortly after, both pilot's noticed a sharp decrease in the right engine mean effective pressure followed by vibration in the engine. The co-pilot looked at the right engine and informed the pilot that it was on fire around the front lower cylinders. Attempts by the pilot to extinguish the engine fire were unsuccessful. The pilot advised Air Traffic Control of their intention to ditch due to the right engine uncontrolled fire. The co-pilot, handed a life jacket to the pilot and then put his on. The pilot placed his life preserver to the side and did not put it on. While descending the co-pilot opened his side window, but the pilot did not. According to the co-pilot, shortly before ditching the pilot requested 10-degrees of flaps but the flaps did not move. Both pilots were at the controls of the airplane for the ditching. A review of maintenance records revealed that the right engine was installed on the airframe on May 14, 2003 at 45,660.5 hours total airframe time. A complete "C" Check was accomplished on June 15, 2004 at a total time of 45,741.8 hours with no discrepancies noted. The airplane ditched into the Caribbean Ocean 29 miles southeast of Beef Island, Virgin Islands, in an undetermined depth of water, neither the pilot or the airplane wreckage was recovered.
Probable cause:
The in-flight fire on the number two engine, for undetermined reasons.
Final Report:

Crash of a Canadair CL-215-1A10 off Chamadouro

Date & Time: Jul 9, 2004 at 1840 LT
Type of aircraft:
Operator:
Registration:
I-SRMB
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Seia - Seia
MSN:
1012
YOM:
1979
Flight number:
Tanker A2
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8972
Captain / Total hours on type:
750.00
Copilot / Total flying hours:
3495
Copilot / Total hours on type:
16
Circumstances:
Owned by SOREM, the aircraft was dispatched in Portugal and leased to OMNI - Aviação e Tecnologia for fire fighting missions. Following a scooping mission in the Aguíeira Reservoir off Chamadouro, the crew increased engine power and started a takeoff procedure when control was lost. The takeoff was abandoned but the aircraft collided with the shore and came to rest. Both pilots escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
Loss of directional control of the aircraft during takeoff and the track during deceleration (after the abortion decision) in order to avoid collision with the bank, was considered as the primary cause of the accident. The following contributing factors were identified:
- Poor Crew Resource Management,
- Lack of crew communication,
- The orographic conditions were substantially different from those where the crew received their training and developed their operational activities.
Final Report:

Crash of a Noorduyn Norseman VI in Birch Lake

Date & Time: Jul 3, 2004
Type of aircraft:
Operator:
Registration:
C-FOBE
Survivors:
Yes
MSN:
480
YOM:
1944
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing on Birch Lake, the second compartment of the right float ruptured. The aircraft nosed down and sank. All five occupants were able to evacuate the cabin and to swim to the shore. The aircraft was written off.
Probable cause:
Failure of the right float on landing that was leaking probably due to a crack located in the second compartment.