Crash of a Cessna F406 Caravan II off Barrow: 2 killed

Date & Time: Aug 17, 2003 at 1256 LT
Type of aircraft:
Operator:
Registration:
N6591L
Flight Phase:
Survivors:
No
Schedule:
Barrow - Wainwright
MSN:
406-0053
YOM:
1990
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7000
Captain / Total hours on type:
1000.00
Aircraft flight hours:
7675
Circumstances:
The certificated airline transport pilot, with one non-revenue passenger, departed in the twin engine turboprop airplane from a rural airport on a CFR Part 135, VFR cargo flight over ocean waters. The flight did not reach its destination, and was reported overdue. Search personnel searched along the airplane's anticipated route of flight, over ocean waters. Shortly after initiation of the search, airborne search personnel reported sighting floating debris, consisting of what appeared to be aircraft seats, cardboard boxes, and small portions of aircraft wreckage, about 30.5 miles southwest of the flight's departure airport, and about 10 miles from shore. The airplane is presumed to have sunk in ocean waters estimated to be between 50 and 70 feet deep. Underwater search and recovery efforts were unsuccessful, and the airplane, pilot, and passenger remain missing. A review of archived radar data disclosed that as the accident airplane approached an area about 30.5 miles southwest of the departure airport, it descended to 500 feet msl, and then entered a right turn. As the turn progressed, the airplane continued to descend to 400 feet msl, with a radar-derived ground speed of 180 knots. The last radar return was recorded with the same radar-derived groundspeed, on an approximate heading of 200 degrees. A pilot who is familiar with geographical locations in the area reported that migrating whales are commonly sighted in the area where the radar depicted a descending right turn.
Probable cause:
An in-flight collision with ocean waters while maneuvering for an undetermined reason.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Sully Lake: 1 killed

Date & Time: Aug 2, 2003 at 1700 LT
Type of aircraft:
Registration:
C-GUXW
Flight Type:
Survivors:
Yes
Schedule:
Pelican Narrows - Sully Lake
MSN:
611
YOM:
1954
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The single engine aircraft departed Pelican Narrows with two passengers and one pilot on board. While approaching Sully Lake, the engine lost power. The aircraft lost height and crashed in Sully Lake. Both passengers exited the cabin and were seriously injured while the pilot was killed. They spent a night on the shore and were rescued and evacuated to hospital a day later.
Probable cause:
A cracked cylinder resulted in a loss of engine power and the pilot attempted a force landing on a small lake. The altitude at which the event began may have given the pilot very little time to successfully complete a forced landing.

Crash of a Cessna 525 CitationJet CJ1 off Coupeville

Date & Time: Jul 22, 2003 at 1015 LT
Type of aircraft:
Registration:
N996JR
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Victoria - Boise
MSN:
525-0147
YOM:
1996
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8500
Captain / Total hours on type:
2689.00
Aircraft flight hours:
590
Circumstances:
The corporate jet airplane experienced a loss of elevator trim control (runaway trim) that resulted in an uncommanded nose-low pitch attitude. The pilot reported that following the loss of elevator trim authority the airplane was extremely difficult to control and the elevator control forces were extremely high. The pilot continued to maneuver the airplane, but eventually ditched it into a nearby marine cove. The runaway trim condition was not immediately recognized by the pilot and he stated that, by that point in the event sequence, the control forces were so great that he had little time to troubleshoot the system and elected to continue on his established heading and ditch the airplane. Pulling the circuit breaker, which is called for by the checklist in the event of a trim runaway, would have arrested the trim movement. Post accident examination and functional testing of the airplane's electric pitch trim printed circuit board (PCB) showed a repeatable fault in the operation of the PCB's K6 relay, resulting in the relay contacts remaining closed. This condition would be representative of the autopilot pitch trim remaining engaged, providing an electrical current to drive continuous nose-down trim to the elevator trim motor. Examination of the airplane's maintenance records showed that the PCB was removed and replaced in conjunction with the
phase inspection prior to the accident. Further examination of the airplane's maintenance records revealed that the replacement PCB was originally installed in an airplane that experienced an "electric trim runaway on the ground." Following the trim runaway, the PCB was removed and shipped to the manufacturer. After receiving the PCB the manufacturer tested the board and no discrepancies were noted. The unit was subsequently approved for return to service and later installed on the accident airplane. The investigation revealed a single-point failure of trim runaway (failed K6 relay) and a latent system design anomaly in the autopilot/trim disconnect switch on the airplane's pitch trim PCB. This design prohibited the disengagement of the electric trim motor during autopilot operation. As a result of the investigation, the FAA issued three airworthiness directives (AD 2003-21-07, AD 2003-23-20, and AD 2004-14-20), and the pitch trim printed circuit board was redesigned and evaluated for compliance with safety requirements via system safety assessment.
Probable cause:
The loss of airplane pitch control (trim runway and mistrim condition) resulting from a failure in the airplane's electric pitch trim system. Factors that contributed to the accident were the manufacturer's inadequate design of the pitch trim circuitry that allowed for a single-point failure mode, and the absence of an adequate failure warning system to clearly alert the pilot to the pitch trim runaway condition in sufficient time to respond in accordance with the manufacturer's checklist instructions.
Final Report:

Crash of a Cessna 401A off Gustavus: 4 killed

Date & Time: Jul 13, 2003 at 2135 LT
Type of aircraft:
Operator:
Registration:
N6296Q
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Port Angeles – Gustavus
MSN:
401A-0096
YOM:
1969
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2100
Circumstances:
The private pilot departed on a cross-country personal flight with five passengers, en route to an Alaskan coastal community. The airplane had about 140 gallons of usable fuel aboard. The flight's intended destination was located about 757 nautical miles away. The pilot planned to make one stop in order to purchase fuel before continuing on to the destination airport. As the accident flight progressed towards the intended fuel stop airport, the pilot requested to continue on to another airport located about 100 miles away, and closer to the final destination airport. As the flight neared the second fuel stop airport, the pilot again made a request to the Air Traffic Control (ATC) specialist on duty, and said, in part: "I'm going to change my destination ah...one more time, this will be the final time..." The flight was then cleared to the pilot's intended destination airport. When the flight was about 22 miles southeast of the destination airport, the pilot informed the ATC specialist that he was concerned about his remaining fuel. He stated, in part: " ... I'm really low on fuel, and still 30 miles out." When asked by the ATC specialist how much fuel he had remaining, the pilot responded by saying: " Well... lets see, its very low... Below 5 gallons in both tanks." The ATC specialist then informed the pilot of an alternate airport that was located closer to the flight's present position, but the pilot was not familiar with the airport, and he elected to proceed on. Shortly thereafter, the pilot reported to the ATC specialist he was "...out of gas, both engines." The pilot selected a forced landing site located about 12 miles short of his intended destination airport, in open ocean waters. According to the two surviving passengers, after the collision with the water, all of the airplane's occupants lost consciousness momentarily. When the two survivors regained consciousness, there was about 2 feet of water in the airplane, and the airplane was sinking. The survivors said four of the six occupants successfully evacuated the airplane into the water. They added that the pilot was one of the four occupants who exited the sinking airplane. The two remaining occupants remained inside the airplane as it sank. The four survivors then began to swim to the closest shoreline, located about 1 mile from the accident site. During the swim to shore, the two surviving occupants became separated from the other two other occupants. To date, neither the two occupants who remained in the airplane, nor the pilot and the one occupant who were able to exit the airplane before it sank, have been located.
Probable cause:
The pilot's inadequate in-flight decision making process, and failure to refuel the airplane prior to fuel exhaustion, which resulted in a total loss of engine power. A factor associated with the accident was the lack of a suitable forced landing site.
Final Report:

Crash of a Cessna 402C off Treasure Cay: 2 killed

Date & Time: Jul 13, 2003 at 1530 LT
Type of aircraft:
Operator:
Registration:
N314AB
Survivors:
Yes
Schedule:
Fort Lauderdale – Treasure Cay
MSN:
402C-0413
YOM:
1980
Flight number:
RSI502
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7904
Captain / Total hours on type:
4964.00
Aircraft flight hours:
17589
Circumstances:
On July 13, 2003, about 1530 eastern daylight time, Air Sunshine, Inc. (doing business as Tropical Aviation Services, Inc.), flight 527, a Cessna 402C, N314AB, was ditched in the Atlantic Ocean about 7.35 nautical miles west-northwest of Treasure Cay Airport (MYAT), Treasure Cay, Great Abaco Island, Bahamas, following the in-flight failure of the right engine. Four of the nine passengers sustained no injuries, three passengers and the pilot sustained minor injuries, and one adult and one child passenger died after they evacuated the airplane. The airplane sustained substantial damage. The airplane was being operated under the provisions of 14 Code of Federal Regulations Part 135 as a scheduled international passenger commuter flight from Fort Lauderdale/Hollywood International Airport, Fort Lauderdale, Florida, to MYAT. Visual meteorological conditions prevailed for the flight, which operated on a visual flight rules flight plan.
Probable cause:
The in-flight failure of the right engine and the pilotís failure to adequately manage the airplaneís performance after the engine failed. The right engine failure resulted from inadequate maintenance that was performed by Air Sunshine's maintenance personnel during undocumented maintenance. Contributing to the passenger fatalities was the pilotís failure to provide an emergency briefing after the right engine failed.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Lake Wicksteed

Date & Time: Jun 5, 2003 at 1800 LT
Operator:
Registration:
C-GOGC
Flight Type:
Survivors:
Yes
MSN:
750
YOM:
1981
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
22000
Captain / Total hours on type:
8500.00
Circumstances:
The aircraft with a single pilot on board was performing firefighting operations in the vicinity of Lake Wicksteed, approximately 10 nautical miles north of Hornepayne, Ontario. The aircraft was scooping water from Lake Wicksteed for the nearby fire. The lake is approximately 7300 feet in length with gentle rising terrain along its shoreline. This was the third scooping from the lake, and the approach was flown in an easterly direction in light wind conditions. The pilot performed the inbound checks, lowered the water probes to begin filling the float water tanks, and touched down on the lake. Within a short time, he observed water spraying from the overflow vents located on top of the floats, indicating that the tanks were filled to capacity. He pressed a button on the yoke to retract the probes, and the aircraft immediately nosed over into the lake in a wings-level attitude and began to sink. The accident occurred at approximately 1800 eastern daylight time. The pilot extricated himself from the aircraft and held on to the side of the partially submerged aircraft. A witness to the occurrence immediately boarded a powered, aluminum boat and went to assist the pilot, while a second witness travelled to Hornepayne to notify the authorities and emergency services. Once the pilot reached the shore, he was taken to a nearby cottage where he remained until emergency services arrived. The aircraft came to rest on the bottom of the shallow lake in an inverted attitude with the floats above the surface of the water.
Probable cause:
Findings as to Causes and Contributing Factors:
1. Ministry of Natural Resources DHC-6 SOPs were not followed, and the Vital Action checklist was not fully completed during the approach. As a result, the bomb door armed switch on the centre panel was not selected Off after the previous water bombing run and prior to the scooping operation.
2. After completing the water scooping operation, the pilot unintentionally selected the bomb door push button switch instead of the adjacent probe switch. Because the bomb door armed switch on the centre panel was left On, the bomb doors extended into the water. Drag from the doors and the water rushing into the door openings resulted in the aircraft nosing over in the water.
3. The hinged cover plate for the bomb door push button switch was not re-installed following maintenance to replace the push button switch. The push button was exposed, making an inadvertent selection more likely.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Sitka

Date & Time: May 30, 2003 at 1430 LT
Type of aircraft:
Operator:
Registration:
N60TF
Flight Type:
Survivors:
Yes
Schedule:
Sitka - Salmon Lake
MSN:
1205
YOM:
1958
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3720
Captain / Total hours on type:
500.00
Aircraft flight hours:
6060
Circumstances:
The airline transport certificated pilot departed from a paved runway for a short flight to a remote lake in an amphibious float-equipped airplane to deliver supplies to a client. The pilot reported that he was transporting several loads of equipment to the lake, and failed to visually check the gear position while looking for a new unloading area. He also indicated that he was distracted when he had to reset the flaps, and by a minor malfunction with the airplane's GPS receiver. He said he forgot to raise the landing gear wheels, and landed on the lake with the wheels extended. During the landing touchdown on the lake, the airplane nosed over and received damage to the left wing and fuselage. The airplane is equipped with floats that have landing gear position lights installed on the instrument panel. The airplane also has a mirror enabling the pilot to visually observe the landing gear position.
Probable cause:
The pilot's failure to retract the landing gear wheels of an amphibious float equipped airplane after departure from a paved runway, which resulted in a nose over when the airplane was landed on a nearby lake with the wheels extended. A contributing factor in the accident was the pilot's diverted attention during the short flight from the airport to the lake.
Final Report:

Crash of a Cessna 414 Chancellor off Port Jefferson

Date & Time: May 26, 2003 at 1428 LT
Type of aircraft:
Operator:
Registration:
N1234
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Orlando – White Plains
MSN:
414-0525
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1250
Aircraft flight hours:
4259
Circumstances:
The commercial pilot/owner was on a cross-country flight from Orlando, Florida, to Salisbury, Maryland, on an instrument flight rules (IFR) flight plan. The pilot stated that all five fuel tanks were topped off and verified as full before departure. The fueler, in a written statement, reported that he added 100 gallons of fuel and that the fuel tank levels were topped off. In addition to the main tanks, the airplane was equipped with two large-capacity auxiliary tanks (31.5 gallons of useable fuel each) and a locker tank, and the airplane's total useable fuel capacity was 183 gallons. As the airplane approached Maryland, the pilot requested weather for White Plains, New York (HPN) and then changed his destination to HPN. As he approached the New York area at 21,000 feet, air traffic control (ATC) instructed the pilot to fly a published arrival procedure and to maintain an altitude of 16,000 feet. The pilot stated that, due to poor weather and air traffic congestion, he became concerned about possible delays and informed ATC that he had "minimal fuel." He did not declare an emergency. ATC then issued the pilot a descent clearance, and he reduced both throttles to idle. In preparation to level off at the new altitude, the pilot increased power on both throttles, and the right engine stopped producing power. The pilot was unable to maintain the assigned altitude and told the controller that he had "lost an engine, and needed vectors to the nearest runway." The left engine stopped producing power about 2 minutes later. The pilot ditched the airplane and exited the airplane before it sank. The airplane was not recovered. The pilot reported that there were no mechanical problems with the airplane before the flight.
Probable cause:
Loss of power to both engines for undetermined reasons.
Final Report:

Crash of a Piper PA-31-310 Navajo off Barbados: 2 killed

Date & Time: May 18, 2003 at 2046 LT
Type of aircraft:
Registration:
G-ILEA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Canouan – Bridgetown
MSN:
31-7812117
YOM:
1978
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
390
Captain / Total hours on type:
70.00
Circumstances:
The aircraft was on a flight from Canouan, a small island in the St Vincent group, to Barbados. Shortly after entering Barbados airspace, radar recordings show the aircraft deviated to the south of a direct easterly track to Barbados and descended from cruise flight level (FL) 55 to an altitude of 2,300 feet. The aircraft levelled at 2,300 feet and resumed an easterly track for about six minutes before once again deviating to the south and commencing a further descent. About 16 minutes after the aircraft's initial descent from FL55, the pilots of a commercial aircraft flying from Grenada to Barbados relayed a MAYDAY call from G-ILEA to Barbados Arrivals reporting that the pilot "had lost one engine; it appeared he was losing fuel and he doubted that he would be able to make it to Barbados". Some three and a half minutes after the initial MAYDAY call, the pilot of the commercial aircraft relayed a further message stating that the pilot intended to ditch. The final radar return for the aircraft showed it at an altitude of 600 feet about 55 miles on the 259° radial from Barbados Airport. Despite an extensive search and rescue operation, no trace of the aircraft or its two occupants was found. A reconciliation of fuel receipts and flight times shows that, at best, the aircraft would have been short of fuel for the flight, and at worst could have run out of fuel.
Probable cause:
No trace of the aircraft or its occupants has been discovered and the lack of any wreckage makes it difficult to come to firm conclusions on the cause of this accident. The reported pilot's statement from he relayed MAYDAY transmission that "it appeared he was losing fuel" points to some problem with the fuel system, but there was no indication on how the pilot came to this judgement. A rupture in a fuel tank or a leak from one or more of the aircraft's fuel drains would have been difficult or impossible to detect visually from the cockpit. Loss of a fuel filler cap may have resulted in loss of fuel. However, the relatively low fuel level in the tanks would probably have limited or precluded such a loss and since the caps on both sides are visible from the cockpit it might be expected that the pilot would have stated the problem in his emergency call. Alternatively, the pilot's assessment that he was losing fuel may have been based simply on a perceived rate of change of fuel contents on the fuel gauges. Indeed the reported use by the pilot of the phrase "appears to be losing fuel" may point to some uncertainty on the matter or that there was no physical evidence of fuel loss.
Final Report:

Crash of a Cessna 421C Golden Eagle III off Rhodes

Date & Time: May 3, 2003 at 1235 LT
Operator:
Registration:
D-IWWW
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
421C-0042
YOM:
1976
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft suffered a double engine failure and the pilot attempted to ditch the aircraft off Rhodes. All occupants were rescued while the aircraft sank and was lost.
Probable cause:
Double engine failure for unknown reasons.