Crash of a Canadair CL-215-6B11 off Port de Pollença: 2 killed

Date & Time: Mar 25, 2003
Type of aircraft:
Operator:
Registration:
UD.13-29
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
1124
YOM:
1990
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was completing a training flight consisting of dropping survival equipment when the aircraft crashed in unknown circumstances in the sea off Port de Pollença. Two crew members were rescued while two others were killed.

Crash of a De Havilland DHC-2 Beaver off Whitsunday Island

Date & Time: Mar 6, 2003 at 1615 LT
Type of aircraft:
Operator:
Registration:
VH-AQV
Flight Type:
Survivors:
Yes
Schedule:
Hamilton Island - Whitsunday Island
MSN:
1257
YOM:
1958
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1757
Captain / Total hours on type:
50.00
Circumstances:
The pilot was conducting a charter positioning flight from Hamilton Island Marina to Whitehaven Beach, Whitsunday Island. At approximately 1615LT, pilot was landing the aircraft towards the south, about 600 metres off the beach, to avoid mechanical turbulence associated with terrain at the southern end of Whitehaven Beach. He reported that the approach and flare were normal, however, as the aircraft touched down on the right float, the aircraft swung sharply right and then sharply left. The left wing contacted the water, and the aircraft overturned. The pilot exited the upturned aircraft through the left rear passenger door and activated a 121.5 MHz distress beacon.
Probable cause:
The wind strength and sea state at the time of the occurrence were not ideal for floatplane operations, particularly given the pilot's relative lack of experience in open water operations. In comparison, it was unlikely the non-standard floats contributed significantly to the development of the accident. The loss of directional control suggests a lower than ideal pitch attitude at touchdown, a configuration which reduces a floatplane's directional stability. The pilot's use of a distress beacon for search and rescue purposes was appropriate, however the timeliness of his rescue from the upturned aircraft can be attributed to the effectiveness of the company's flight monitoring system and subsequent search and rescue actions.
Final Report:

Crash of a Cessna 402B off Karachi: 8 killed

Date & Time: Feb 24, 2003
Type of aircraft:
Operator:
Registration:
AP-BFG
Flight Phase:
Survivors:
No
Schedule:
Karachi - Kabul
MSN:
402B-1304
YOM:
1977
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Aircraft flight hours:
6793
Circumstances:
The aircraft was chartered by the Afghan Government to carry a delegation from Karachi to Kabul. After takeoff from Karachi-Quaid-e-Azam Airport, the twin engine aircraft continued to climb to an altitude of 9,000 feet when it entered an uncontrolled descent. At an altitude of 2,500 feet, the aircraft disappeared from radar screens then crashed in the Arabian Sea few km offshore. The stabilizers and the tail were found few hundred metres from the main wreckage. All eight occupants were killed, among them Juma Mohammad Mohammadi, Afghan Minister of Industry and four members of his cabinet as well as one Chinese businessman.
Probable cause:
The Pakistan board of investigations determined that the probable cause of this accident was a structural failure due to overload. The aircraft weight was 7,183 lbs at the time of the accident as the maximum load as mentioned in the operational manual is 6,300 lbs, which means 883 pounds above max gross weight. It is believed that during climbout, the tail and stabilizers detached due to overload conditions.

Crash of a Cessna 402B off Marathon

Date & Time: Feb 20, 2003 at 1220 LT
Type of aircraft:
Registration:
N554AE
Flight Type:
Survivors:
Yes
Schedule:
Havana – Marathon – Miami
MSN:
402B-1308
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4000
Captain / Total hours on type:
817.00
Aircraft flight hours:
11303
Circumstances:
The fuel tanks were filled the day before the accident date, and on the day of the accident, the airplane was flown from that airport to the Miami International Airport, where the pilot picked up 2 passengers and flew uneventfully to Cuba. He performed a preflight inspection of the airplane in Cuba and noted both auxiliary fuel tanks were more than half full and both main tanks were half full. The flight departed, climbed to 8,000 feet; and was normal while in Cuban airspace. When the flight arrived at TADPO intersection, he smelled strong/fumes of fuel in the cabin. The engine instruments were OK at that time. The flight continued and when it was 10-12 miles from Marathon, he smelled something burning in the cabin like plastic material/paper; engine indications at that time were normal. He declared "PAN" three times with the controller, and shortly thereafter the right engine began missing and surging. He then observed fire on top of the right engine cowling near the louvers. He secured the right engine however the odor of fuel and fumes got worse to the point of irritating his eyes. He declared an emergency with the controller, began descending at blue line airspeed, and the fumes/odor got worse. Approximately 5 minutes after the right engine began missing and surging, the left engine began acting the same way. He secured the left engine but the propeller did not completely feather. At 400 feet he lowered full flaps and (contrary to the Pilot's Operating Handbook and FAA Approved Airplane Flight Manual) the landing gear in preparation for ditching. He intentionally stalled the airplane when it was 5-7 feet above the water, evacuated the airplane with a life vest, donned then inflated it. The airplane sank within seconds and he was rescued approximately 20 minutes later. The pilot first reported 4 months and 19 days after the accident that his passport which was in the airplane at the time of the accident had burned pages. He was repeatedly asked for a signed, dated statement that explained where it was specifically located in the airplane, and that it was not burned before the accident flight; he did not provide a statement. Examination of the airplane by FAA and NTSB revealed no evidence of an in-flight fire to any portion of the airplane, including the right engine or engine compartment area, or upper right engine cowling. Examination of the left engine revealed no evidence of preimpact failure or malfunction. The left magneto operated satisfactorily on a test bench, while the right magneto had a broken distributor block; and the electrode tang which fits in a hole of the distributor gear; no determination was made as to when the distributor block fractured or the electrode tang became bent. The left propeller blades were in the feathered position. Examination of the right engine revealed no evidence or preimpact failure or malfunction. The right hand stack assembly was fractured due to overload; no fatigue or through wall thickness erosion was noted. Both magnetos operated satisfactorily on a test bench. The right propeller was in the feathered position. An aluminum fuel line that was located in the cockpit that had been replaced the day before the accident was examined with no evidence or failure or malfunction; no fuel leakage was noted.
Probable cause:
The loss of engine power to both engines for undetermined reasons.
Final Report:

Crash of a Beechcraft B60 Duke off Santo Domingo: 1 killed

Date & Time: Jan 3, 2003 at 2030 LT
Type of aircraft:
Operator:
Registration:
HI-774CT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Santo Domingo - Santo Domingo
MSN:
P-445
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The twin engine airplane departed Santo Domingo-Las Américas International Airport on a short flight to the Santo Domingo-Herrera Airport located downtown. Following a night takeoff, the pilot encountered a loss of power on the right engine and was unable to feather its propeller. As the propeller was windmilling, he was unable to maintain a safe altitude and elected to ditch the aircraft that crashed in the sea about 800 metres offshore. The pilot was seriously injured and the passenger was killed.

Crash of a Cessna 208B Super Cargomaster in Manteo: 1 killed

Date & Time: Dec 25, 2002 at 0100 LT
Type of aircraft:
Operator:
Registration:
N1122Y
Flight Type:
Survivors:
No
Schedule:
Elizabeth City - Manteo
MSN:
208B-0392
YOM:
1994
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
19091
Captain / Total hours on type:
500.00
Aircraft flight hours:
5229
Circumstances:
At 0029, the pilot contacted Norfolk Approach and stated he was ready for takeoff on runway 01 at Elizabeth City. The controller instructed the pilot to fly runway heading and climb to 3,000 feet. At 0032, the controller advised the pilot that the flight was radar contact and for the pilot to fly heading 160 degrees. At 0034, the Norfolk Approach controller instructed the pilot to contact the FAA Washington Air Route Traffic Control Center. At 0034, the pilot of N1122Y contacted the controller at Washington Center, stating he was coming up on 3,000 feet. The controller acknowledged, and the pilot requested the non-directional beacon (NDB) approach to runway 5 at Dare County Airport, Manteo. At 0036, the controller instructed the pilot to fly heading 145 degrees for Manteo and fly direct to the NDB when he receives the signal. The pilot acknowledged and the controller also asked the pilot if he had the current weather for Manteo. The pilot responded that he did have the current weather. At 0043, the controller cleared the pilot for the NDB runway 5 approach at Manteo and to maintain 2,000 feet until the flight crossed the beacon outbound. The pilot acknowledged. At 0046, the controller informed the pilot that radar contact with the flight was lost and for the pilot to report a cancellation or a downtime on his radio frequency. The pilot acknowledged. At 0057:21, the controller called the pilot and the pilot responded by reporting the flight was procedure turn inbound. No further transmissions were received from the pilot. When the pilot did not report that he was on the ground, and further radio contact could not be established, controllers initiated search and rescue efforts. The wreckage of the airplane was located in the waters of Croatan Sound, about 1.5 miles west of the Dare County Regional Airport about 1000. The pilot was not located in the airplane. The body of the pilot was located in the waters of Croatan Sound on February 11, 2003. Post crash examination of the airplane, flight controls, and engine showed no evidence of precrash failure or malfunction. The propeller separated from the airplane and was not located after the accident. Damage to the mounting bolts for the propeller was consistent with the propeller separating due to impact with the water. Postmortem examination of the pilot showed no findings which could be considered causal to the accident.
Probable cause:
The pilot's continued descent below the minimum descent altitude, for undetermined reasons, while performing a NDB approach, resulting in the airplane crashing into water 1.5 miles from the airport. A factor in the accident was a cloud ceiling below the minimum descent altitude and low visibility.
Final Report:

Crash of an ATR72-202 off Magong: 2 killed

Date & Time: Dec 21, 2002 at 0152 LT
Type of aircraft:
Operator:
Registration:
B-22708
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Taipei - Macau
MSN:
322
YOM:
1992
Flight number:
GE791
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
14247
Captain / Total hours on type:
10608.00
Copilot / Total flying hours:
4578
Copilot / Total hours on type:
4271
Aircraft flight hours:
19254
Aircraft flight cycles:
25529
Circumstances:
The aircraft departed Taipei-Chiang Kai Shek Airport at 0105LT on a cargo flight to Macau with two pilots on board and a load consisting of leather parts and electronic materials. While cruising at an altitude of 18,000 feet off the Penghu Islands, the crew contacted ATC and was cleared to descend to 16,000 feet due to icing conditions. At 01h52, at an altitude of 17,853 feet, the stall warning sounded and the stick shaker activated. The crew disconnected the autopilot system and elected to maintain control of the airplane. Sixteen seconds later, the aircraft entered an uncontrolled descent and reached the speed of 320 knots with a rate of descent of 603 feet per second (more than 36,000 feet per minute) before crashing in the sea 17 km southwest of the city of Magong. Few debris were found floating on water and both pilots were killed.
Probable cause:
The following findings were identified:
1. The accident flight encountered severe icing conditions. The liquid water content and maximum droplet size were beyond the icing certification envelope of FAR/JAR 25 appendix C.
2. TNA's training and rating of aircraft severe icing for this pilots has not been effective and the pilots have not developed a familiarity with the Note, CAUTION and WARNING set forth in Flight Crew Operating Manual and Airplane Flight Manual to adequately perform their duties.
3. After the flight crew detected icing condition and the airframe de-icing system was activated twice, the flight crew did not read the relative Handbook, thereby the procedure was not able to inform the flight crew and to remind them of "be alert to severe icing detection".
4. The "unexpected decrease in speed" indicated by the airspeed indicator is an indication of severe icing.
5. The flight crew did not respond to the severe Icing conditions with pertinent alertness and situation awareness that the aircraft might have encountered conditions which was "outside that for which the aircraft was certificated and might seriously degrade the performance and controllability of the aircraft".
6. The flight crew was too late in detecting the severe icing conditions. After detection, they did not change altitude immediately, nor take other steps required in the Severe Icing Emergency Procedures.
7. The aircraft was in an "unusual or uncontrolled rolling and pitching" state, and a stall occurred thereafter.
8. After the aircraft had developed a stall and an abnormal attitude, the recovery maneuvering did not comply with the operating procedures and techniques for Recovery of Unusual Attitudes. The performance and controllability of the aircraft may have been seriously degraded by then. It cannot be confirmed whether the unusual attitudes of the aircraft could have been recovered if the crew's operation had complied with the relevant procedures and techniques.
9. During the first 25 minutes, the extra drag increased about 100 counts, inducing a speed diminishing about 10 knots.
10. During the airframe de-icing system was intermittently switched off, it is highly probable that residual ice covered on the wings of the aircraft.
11. Four minutes prior to autopilot disengaged, the extra drag increased about 500 counts, and airspeed decayed to 158 knots, and lift-drag ratio loss about 64% rapidly.
12. During the 10s before the roll upset, the longitudinal and lateral stability has been modified by the severe ice accumulated on the wings producing the flow separation. Before autopilot disengaged, the aerodynamic of the aircraft (lift/drag) was degraded of about 40%.
Final Report:

Crash of a GAF Nomad N.22A off Zamboanga

Date & Time: Dec 17, 2002
Type of aircraft:
Operator:
Registration:
53
Flight Type:
Survivors:
Yes
Schedule:
Sanga-Sanga - Zamboanga
MSN:
053
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Sanga-Sanga Airport (Tawi-Tawi Island), the pilot started the descent to Zamboanga Airport. On final approach, the twin engine aircraft lost height and crashed in the sea 300 metres offshore. All 14 occupants were rescued while the aircraft sank.

Crash of a Fokker F27 Friendship 600 off Manila: 19 killed

Date & Time: Nov 11, 2002 at 0607 LT
Type of aircraft:
Registration:
RP-C6888
Flight Phase:
Survivors:
Yes
Schedule:
Manila - Laoag - Basco
MSN:
10571
YOM:
1978
Flight number:
LPN585
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
29
Pax fatalities:
Other fatalities:
Total fatalities:
19
Circumstances:
Shortly after takeoff from Manila-Ninoy Aquino Airport runway 31, while in initial climb, the captain reported technical problems and elected to return for an emergency landing. Finally, he attempted to ditch the aircraft off Manila. While contacting water, the aircraft lost its tail and sank by a depth of about 15 metres. Fifteen people were rescued while 19 others were killed, among them a crew member.
Probable cause:
Failure of the left engine during initial climb for unknown reasons. It was reported that thick black smoke was coming out from the left engine shortly after liftoff.

Crash of a Cessna 208B Super Cargomaster off Mobile: 1 killed

Date & Time: Oct 23, 2002 at 1945 LT
Type of aircraft:
Registration:
N76U
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mobile - Montgomery
MSN:
208B-0775
YOM:
1999
Flight number:
BDC282
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4584
Captain / Total hours on type:
838.00
Aircraft flight hours:
4001
Circumstances:
The airplane was destroyed by impact forces. There was no evidence of fire. Wreckage examinations and all recovered wreckage from the impact area revealed no evidence of an inflight collisionor breakup, or of external contact by a foreign object. An examination of the engine and the propeller indicated that the engine was producing power at impact. The recovered components showed no evidence of preexisting powerplant, system, or structural failures. Wreckage examinations showed crushing and bending consistent with a moderate angle of descent and a moderate right-wing-down attitude at impact. The amount of wreckage recovered indicates that all parts of the airplane were at the crash site. The wreckage was scattered over an area of about 600 feet. An examination of radar and airplane performance data indicated that the accident airplane initiated a descent from 3,000 feet immediately after the accident pilot was given a second traffic advisory by air traffic control. The pilot reported that the traffic was above him. At the time the pilot stated that he needed to deviate, data indicate that the accident airplane was in or entering an uncontrolled descent. Radar data indicated that, after departure from the airport, the closest identified airplane to the accident airplane was a DC-10, which was at an altitude of about 4,000 feet. The horizontal distance between the two airplanes was about 1.1 nautical miles, and the vertical distance between the airplanes was about 1,600 feet. The accident airplane was never in a location at which wake turbulence from the DC-10 would have intersected the Cessna's flightpath (behind and below the DC-10's flightpath). Given the relative positions of the accident airplane and the DC-10, wake turbulence was determined to not be a factor in this accident. Although the DC-10 was left of the position given to the pilot by Mobile Terminal Radar Approach Control, air traffic controllers do not have strict angular limits when providing traffic guidance. The Safety Board's airplane performance simulation showed that, beginning about 15 seconds before the time of the pilot's last transmission ("I needed to deviate, I needed to deviate"), his view of the DC-10 moved diagonally across the windscreen from his left to straight in front of the Cessna while tripling in size. The airplane performance simulation also indicated that the airplane experienced high bank and pitch angles shortly after the pilot stated, "I needed to deviate" (about 13 seconds after the transmission, the simulation showed the airplane rolling through 90° and continuing to roll to a peak of about 150° 3 seconds later) and that the airplane appeared to have nearly recovered from these extreme attitudes at impact. Performance data indicated that the airplane would had to have been structurally/aerodynamically intact to reach the point of ground impact from the point of inflight upset. There was no evidence of any other aircraft near the accident airplane or the DC-10 at the time of the accident. Soon after the accident, U.S. Coast Guard aircraft arrived at the accident scene. The meaning of the pilot's statement that he needed to deviate could not be determined. A review of air traffic control radar and transcripts revealed no evidence of pilot impairment or incapacitation before the onset of the descent and loss of control. A sound spectrum study conducted by the Safety Board found no evidence of loud noises during the pilot's last three radio transmissions but found that background noise increased, indicating that the cockpit area was still intact and that the airspeed was increasing. The study further determined that the overspeed warning had activated, which was consistent with the performance study and extreme fragmentation of the wreckage. Radar transponder data from the accident airplane were lost below 2,400 feet. The signal loss was likely caused by unusual attitudes, which can mask transponder antenna transmissions. A garbled transponder return recorded near the DC-10 was likely caused by the accident airplane's transponder returns masking the DC-10's returns (since the accident airplane was projected to be in line between the DC-10 and the ground radar) or by other environmental phenomena. Red transfer or scuff marks were observed on many pieces of the airplane wreckage, and these marks were concentrated on the lower airframe skin forward of the main landing gear and the nose landing gear area. The Safety Board and four laboratories compared the red-marked airplane pieces to samples of red-colored items found in the wreckage. These examinations determined that most of the red marks were caused by parts of the airplane, cargo, and items encountered during the wreckage recovery. The marks exhibited random directions of motion, and none of the marks exhibited evidence of an in-flight collision with another aircraft. A small piece of black, anodized aluminum found embedded in the left wing was subsequently identified as a fragment from a cockpit lighting dimmer. The accident occurred at night, with the moon obscured by low clouds. Instrument meteorological conditions prevailed, although visual conditions were reported between cloud layers. The terminal aerodrome forecast reported a possible cloud layer at 3,000 feet. Weather data and observations by the DC-10 pilot indicated that, after flying about 100 to 500 feet above the cloud layer and soon after sighting the DC-10, the accident airplane would have entered clouds. A number of conditions were present on the night of the accident that would have been conducive to spatial disorientation. For example, no visible horizon references existed between the cloud layers in which the pilot was flying because of the night conditions. In addition, to initiate a visual search and visually acquire the DC-10, varying degrees of eye and head movements would have accompanied the pilot's shifting of attention outside the cockpit. Once the DC-10 was visually acquired by the pilot, it would have existed as a light source moving against an otherwise featureless background, and its relative motion across and rising in the Cessna's windscreen could have been disorienting, especially if the pilot had fixated on it for any length of time. Maneuvering the airplane during this search would likely have compounded the pilot's resultant disorientation.
Probable cause:
The pilot's spatial disorientation, which resulted in loss of airplane control. Contributing to the accident was the night instrument meteorological conditions with variable cloud layers.
Final Report: