Crash of a Rockwell Shrike Commander 500S off Vestmannaeyjar: 2 killed

Date & Time: Mar 6, 2001 at 0856 LT
Registration:
N272BB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Keflavik – Stornoway
MSN:
500-3173
YOM:
1973
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2456
Captain / Total hours on type:
120.00
Copilot / Total flying hours:
704
Copilot / Total hours on type:
13
Circumstances:
Two private pilots, citizens of the United States, who intended to participate in the “London - Sydney Air Race” set to take place 11 March to 7 April 2001, were operating the private aircraft, N272BB. The flight originated at Cape Cod in the United States and the aircraft was to be flown via Greenland, Iceland and Scotland to London, England, where the air-race was to commence. The aircraft arrived at Narsarsuaq, Greenland, on 4 March 2001 at 01:35 hrs. The next morning the pilots requested fuel and according to a statement by the Narsarsuaq airport personnel, 338 litres of LL100 avgas were put on the main fuel tanks that were filled. No fuel was put on the aircraft internal ferry-tank. The pilots received weather briefing and en-route information before departure and there was no anomalies noted by the airport personnel. The flight was planned at Fl-130 from Narsarsuaq, over the Greenland ice cap, to 62°N 040°W and then at FL110 to the border between the Greenland Soendrestrom Flight Information Region and the Reykjavik Flight Information Region. The takeoff from Narsarsuaq airport was at 14:29 hrs. The flight from Narsarsuaq Airport to Iceland was uneventful and the aircraft landed at Keflavik Airport Iceland at 18:59 hrs. Initially the pilots planned to continue the flight from Iceland that night but after studying the weather forecast they decided to stay overnight. At 19:50 hrs 447 litres of LL100 was put in the aircraft main tanks and the aircraft was then placed in a hangar. In the morning of 6 March 2001 the pilots arrived at Flight Operations Office at Keflavik Airport. The pilots were provided with current weather information and weather maps for the planned route and flight planning preparations for the flight to Stornoway, Scotland and onwards to London, England was completed. The plan was from Keflavik Airport (KEF) VOR, direct to ALDAN reporting point (62° 58' 49'' N 018° 45' 50'' W), direct to 61° N 012° 34' W, direct to 60° N 010° W, and direct to Stornoway. The flight level was 150 and the True Air Speed (TAS) was 145 kts. Prestwick in Scotland was filed as the alternate airport. The instrument flight plan was filed with the Air Traffic Control Centre in Reykjavik. The estimated flying time from KEF-VOR to ALDAN was 0:30 hrs, to 61° N 012° 34' W total 2:00 hrs and 02:30 hrs to 60° N 010° W. The planned time from Keflavik Airport to Stornoway was 4:00 hrs or the estimated time of arrival was at 12:19 hrs. The fuel endurance was given 10 hrs. The aircraft was cleared by ATC in accordance with the submitted instrument flight plan and assigned transponder code was 3575. The aircraft taxied out from the ramp at 08:08 hrs towards runway 11 and the take-off was at 08:19 hrs. After take-off the communication with Keflavik Approach Control was normal. The flight was then changed over to Reykjavik Area Control Centre (OACC) at 08:46 hrs and normal communication was established. The track to Aldan will take the aircraft overhead VM-NDB, 53 NM from KEF VOR, and then to Aldan, 120 NM from KEF VOR. Error was on the ATC slip indicating 30 minutes to Aldan. The controller changed that to 1:01, or estimate for Aldan at 09:20. The last communication with the crew took place at 08:49:50 when the aircraft was climbing slowly through about 14400 feet towards the planned cruising level, FL150. At 09:24:55 hrs Reykjavik OACC called N272BB in order to confirm the position, but there was no answer and repeated calls were in vain. The Shanwick Air Traffic Control Centre was notified at 09:29:15 hrs of the N272BB estimates and again at 09:38:01 hrs that ATC had lost contact with the aircraft. A subsequent replay of the ATC radar data showed that at 08:56 hrs the aircrafts target was lost from radar. The last plotted position was at 63° 32' 04'' N 020° 39' 36'' W, or about 8 NM from the south coast of Iceland. At 12:12 hrs a decision was taken to initiate a search in the area by available ships and fishing vessels in the area. An Icelandic Coast Guard helicopter was launched from Reykjavik into the search area at 12:32 hrs. At 13:49 hrs a debris from the missing aircraft and human remains were subsequently found floating on the ocean in a line spread north-westwards over a distance of about 5 NM from the point the target disappeared from radar. Both female pilots were killed.
Probable cause:
The following findings were identified:
- The aircraft was operated in overweight conditions,
- The flight departed Iceland into unfavourable weather conditions,
- The aircraft was climbing in icing conditions prior to it went out of control,
- The reason for the departure from a normal flight could not be positively determined,
- The aircraft went into an uncontrolled descent, followed by an overstress and possible in-flight break-up during an attempted recovery.
Final Report:

Crash of a Short 360-300 off Edinburgh: 2 killed

Date & Time: Feb 27, 2001 at 1731 LT
Type of aircraft:
Operator:
Registration:
G-BNMT
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Edinburgh – Belfast
MSN:
3723
YOM:
1987
Flight number:
LOG670A
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
13569
Captain / Total hours on type:
972.00
Copilot / Total flying hours:
438
Copilot / Total hours on type:
72
Circumstances:
The aircraft landed at Edinburgh Airport, Scotland, at 00:03 and was parked there on Stand 31 in conditions including light and moderate snowfall. After preparation for a Royal Mail charter flight 670A to Belfast, start clearance was given at 15:03. At 15:12 hrs the crew advised ATC they were shutting down due to a technical problem. The crew then advised their company that a generator would not come on line. An avionics technician carried out diagnosis during which both engines were ground-run twice. No fault was found and the flight crew requested taxi clearance at 17:10. A normal take off from runway 06 was carried out followed by a reduction to climb power at 1,200 feet amsl. At 2,200 feet amsl the aircraft anti-icing systems were selected on. Three seconds later the torque on each engine reduced rapidly to zero. A MAYDAY call was made by the crew advising that they had experienced a double engine failure. The aircraft was ditched in the Firth of Forth estuary some 100 meters from the shoreline near Granton Harbour. Both pilots were killed. Weather reported just before the accident with a temperature of +2°C, dewpoint of -3°C, visibility of more then 10 km, broken clouds at 4500 feet and cover at 8000 feet.
Probable cause:
The following causal factors were identified:
1) The operator did not have an established practical procedure for flight crews to fit engine intake blanks (‘bungs’) in adverse weather conditions. This meant that the advice contained in the aircraft manufacturer’s Maintenance Manual ‘Freezing weather-precautions’ was not complied with. Furthermore intake blanks were not provided on the aircraft nor were any readily available at Edinburgh Airport.
2) A significant amount of snow almost certainly entered into the engine air intakes as a result of the aircraft being parked heading directly into strong surface winds during conditions of light to moderate snowfall overnight.
3) The flow characteristics of the engine intake system most probably allowed large volumes of snow, ice or slush to accumulate in areas where it would not have been readily visible to the crew during a normal pre-flight inspection.
4) At some stage, probably after engine ground running began, the deposits of snow, ice or slush almost certainly migrated from the plenum chambers down to the region of the intake anti-ice vanes. Conditions in the intakes prior to takeoff are considered to have caused re-freezing of the contaminant, allowing a significant proportion to remain in a state which precluded its ingestion into the engines during taxi, takeoff and initial climb.
5) Movement of the intake anti-icing vanes, acting in conjunction with the presence of snow, ice or slush in the intake systems, altered the engine intake air flow conditions and resulted in the near simultaneous flameout of both engines.
6) The standard operating procedure of selecting both intake anti-ice vane switches simultaneously, rather than sequentially with a time interval, eliminated a valuable means of protection against a simultaneous double engine flameout.
Final Report:

Crash of a Beechcraft 65-A90 King Air in Tooele Valley: 9 killed

Date & Time: Jan 14, 2001 at 1729 LT
Type of aircraft:
Registration:
N616F
Flight Type:
Survivors:
No
Schedule:
Mesquite – Tooele Valley
MSN:
LJ-165
YOM:
1966
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
5149
Captain / Total hours on type:
321.00
Aircraft flight hours:
9725
Circumstances:
The pilot and eight parachutists were returning from a skydive meet. The pilot had obtained a weather briefing, which advised of instrument meteorological conditions at the destination, and filed a VFR flight plan, but it was never activated. Witnesses heard, but could not see, a twin engine turboprop pass over the airport, heading north out over the Great Salt Lake. They described the weather conditions as being a low ceiling with 1/4-mile visibility, light snow, haze, and fog. They said it was almost dark. The airplane impacted the water approximately 1/2-mile off shore. It had been stripped of all avionics except for one transceiver and a handheld GPS receiver. One member of the skydive club, who had flown with the pilot, said he had previously encountered poor weather conditions and descended over the Great Salt Lake until he could see the ground, then proceeded to the airport. Another member related a similar experience, but said they descended over the Great Salt Lake in the vicinity of the accident site. The pilot was able to navigate in deteriorating weather conditions to Tooele Airport, using various landmarks. Examination of the airframe, engines, and propellers did not reveal evidence of any anomalies that would have precluded normal operation.
Probable cause:
The pilot's exercise of poor judgment and his failure to maintain a safe altitude/clearance above the water. Contributing factors were the weather conditions that included low ceiling and visibility obscured by snow and mist, an inadequately equipped airplane for flying in instrument meteorological conditions, and the pilot's overconfidence in his personal ability in that he had reportedly done this on two previous occasions.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 100 off Vancouver

Date & Time: Nov 1, 2000 at 1510 LT
Operator:
Registration:
C-GGAW
Flight Phase:
Survivors:
Yes
Schedule:
Vancouver - Victoria
MSN:
086
YOM:
1967
Flight number:
8O151
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4000
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
2000
Copilot / Total hours on type:
1650
Circumstances:
A de Havilland DHC-6-100 float-equipped Twin Otter (serial number 086), operated by West Coast Air Ltd., was on a regularly scheduled flight as Coast 608 from Vancouver Harbour water aerodrome, British Columbia, to Victoria Harbour water aerodrome. The flight departed at about 1510 Pacific standard time with two crew members and 15 passengers on board. Shortly after lift-off, there was a loud bang and a noise similar to gravel hitting the aircraft. Simultaneously, a flame emanated from the forward section of the No. 2 (right-hand) engine, and this engine completely lost propulsion. The aircraft altitude was estimated to be between 50 and 100 feet at the time. The aircraft struck the water about 25 seconds later in a nose-down, right wing-low attitude. The right-hand float and wing both detached from the fuselage at impact. The aircraft remained upright and partially submerged while the occupants evacuated the cabin through the main entrance door and the two pilot doors. They then congregated on top of the left wing and fuselage. Within minutes, several vessels, including a public transit SeaBus, arrived at the scene. The SeaBus deployed an inflatable raft for the occupants, and they were taken ashore by several vessels and transported to hospital for observation. There were no serious injuries. The aircraft subsequently sank. All of the wreckage was recovered within five days.
Probable cause:
Findings as to Causes and Contributing Factors:
1. A planetary gear disintegrated in the propeller reduction gearbox of the No. 2 engine and caused the engine drive shaft to disconnect from the propeller, resulting in a loss of propulsion from this engine.
2. The planetary gear oil strainer screen wires fractured by fatigue as a consequence of the installation at the last overhaul. This created an unsafe condition and it is most probable that the release of wire fragments and debris from this strainer screen subsequently initiated or contributed to distress of the planetary gear bearing sleeve and resulted in the disintegration of the planetary gear.
3. Although airspeed was above Vmc at the time of the power loss, the aircraft became progressively uncontrollable due to power on the remaining engine not being reduced to relieve the asymmetric thrust condition until impact was imminent.
Findings as to Risk:
1. The propeller reduction gearboxes were inspected in accordance with the West Coast Air maintenance control manual. These inspections exceeded requirements of the de Havilland Equalized Maintenance Maximum Availability program. Since the last inspection, 46 hours of flight time before the accident, did not reveal any anomaly, a risk remains of adverse developments with
resulting consequences occurring during the unmonitored period between inspections.
2. Regulations require the installation of engine oil chip detectors, but not the associated annunciator system on the DHC-6. Without an annunciator system, monitoring of engine oil contamination is limited to the frequency and thoroughness of maintenance inspections. An annunciator system would have provided a method of continuous monitoring and may have warned the crew of the impending problem.
3. Although regulations do not require the aircraft to be equipped with an auto-feather system, its presence may have assisted the flight crew in handling the sudden loss of power by reducing the drag created by a windmilling propeller.
4. Since most air taxi and commuter operators use their own aircraft rather than a simulator for pilot proficiency training, higher-risk emergency scenarios can only be practiced at altitude and discussed in the classroom. As a result, pilots do not gain the benefit of a realistic experience during training.
Other Findings:
1. The fact that the aircraft remained upright and floating in daylight conditions contributed to the successful evacuation of the cabin without injury and enabled about half of the passengers to locate and don their life vests.
2. The aircraft was at low altitude and low airspeed at the time of power loss. The selection of full flaps may have contributed to a single-engine, high-drag situation, making a successful landing difficult.
Final Report:

Crash of a Cessna 340 off Nadi

Date & Time: Sep 29, 2000 at 1600 LT
Type of aircraft:
Registration:
N130DR
Flight Type:
Survivors:
Yes
Schedule:
Nouméa - Nadi
MSN:
340-0041
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On September 29, 2000, at 1600 hours local time, a Cessna 340, N130DR, was destroyed when it impacted the water in Nadi Bay, about 1,500 feet short of the runway 09 threshold at Nadi International Airport in the Republic of the Fiji Islands. The commercial pilot, a citizen of the United States and the sole occupant, received minor injuries. Visual meteorological conditions prevailed for the ferry flight, operated by Benchmark Aviation under 14 CFR Part 91, that departed from Magenta Airport, New Caledonia, NWWM at 1200.

Crash of an Antonov AN-2 in the Gulf of Mexico: 1 killed

Date & Time: Sep 19, 2000
Type of aircraft:
Operator:
Flight Phase:
Flight Type:
Survivors:
Yes
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The pilot Angel Lenin Iglesias Hernández stole the aircraft at Pinar del Río Airport, took off with nine of his family members and elected to reach Florida. En route, the aircraft ran out of fuel and crashed in the Gulf of Mexico about 145 km southwest of Key West. A passenger was killed while nine other occupants were rescued by the crew of the bulk carrier christened 'Chios Dream'.
Probable cause:
Engine failure due to fuel exhaustion.

Crash of a Piper PA-31-350 Navajo Chieftain off Hilo: 1 killed

Date & Time: Aug 25, 2000 at 1735 LT
Operator:
Registration:
N923BA
Survivors:
Yes
Schedule:
Kona – Kona
MSN:
31-8252024
YOM:
1982
Flight number:
BIA057
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2067
Captain / Total hours on type:
465.00
Aircraft flight hours:
3492
Circumstances:
The pilot ditched the twin engine airplane in the Pacific ocean after experiencing a loss of engine power and an in-flight engine fire while in cruise flight. The flight was operating at 1,000 feet msl, when the pilot noticed a loss of engine power in the right engine. At the same time the pilot was noticing the power loss, passengers noted a fire coming from the right engine cowling. The pilot secured the right engine and feathered the propeller. He attempted to land the airplane at a nearby airport; however, when he realized that the airplane was unable to maintain altitude he elected to ditch the airplane in the ocean. Prior to executing the forced landing, the pilot instructed the passengers to don their life jackets and assume the crash position. After touchdown, all but one passenger exited the airplane through the main cabin and pilot doors. It was reported that the remaining passenger was frightened, and could not swim. One survivor saw the remaining passenger sitting in the seat with the seat belt still secured and the life vest inflated. The pilot and passengers were then rescued from the ocean via rescue helicopter and boat. Postaccident examination of the airplane revealed that the right engine's oil converter plate gasket had deteriorated and extruded from behind the converter plate, allowing oil to spray in the accessory section and resulting in the subsequent engine fire. The engine manufacturer had previously issued a mandatory service bulletin (MSB) requiring inspection of the gasket every 50 hours for evidence of gasket extrusion around the cover plate or oil leakage. Maintenance records revealed that the inspection had been conducted 18.3 hours prior to the accident. At the time of the accident, the right engine had accumulated 386.8 hours since its last overhaul, and gasket replacement. The MSB was issued one month prior to the accident, after the manufacturer received reports of certain oil filter converter plate gaskets extruding around the oil filter converter plate. The protruding or swelling of the gasket allowed oil to leak and spray from between the plate and the accessory housing. A series of tests were conducted on exemplar gaskets by submerging them in engine oil heated to 245 degrees F; after about 290 hours, the gasket material displayed signs of deterioration similar to that of the accident gasket. A subsequent investigation revealed that the engine manufacturer had recently changed gasket suppliers, which resulted in a shipment of gaskets getting into the supply chain that did not meet specifications. As a result of this accident, the engine manufacturer revised the MSB to require the replacement of the gasket every 50 hours. The FAA followed suit and issued an airworthiness directive to mandate the replacement of the gasket every 50 hours.
Probable cause:
Deterioration and failure of the oil filter converter plate gasket, which resulted in a loss of engine power and a subsequent in-flight fire.
Final Report:

Crash of an Airbus A320-212 off Bahrain: 143 killed

Date & Time: Aug 23, 2000 at 1930 LT
Type of aircraft:
Operator:
Registration:
A4O-EK
Survivors:
No
Schedule:
Cairo - Bahrain - Muscat
MSN:
481
YOM:
1994
Flight number:
GF072
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
135
Pax fatalities:
Other fatalities:
Total fatalities:
143
Captain / Total flying hours:
4416
Captain / Total hours on type:
1083.00
Copilot / Total flying hours:
608
Copilot / Total hours on type:
408
Aircraft flight hours:
17370
Aircraft flight cycles:
13990
Circumstances:
On 23 August 2000, at about 1930 local time, Gulf Air flight GF072, an Airbus A320-212, a Sultanate of Oman registered aircraft A4O-EK, crashed at sea at about 3 miles north-east of Bahrain International Airport. GF072 departed from Cairo International Airport, Egypt, with two pilots, six cabin crew and 135 passengers on board for Bahrain International Airport, Muharraq, Kingdom of Bahrain. GF072 was operating a regularly scheduled international passenger service flight under the Convention on International Civil Aviation and the provisions of the Sultanate of Oman Civil Aviation Regulations Part 121 and was on an instrument flight rules (IFR) flight plan. GF072 was cleared for a VOR/DME approach for Runway 12 at Bahrain. At about one nautical mile from the touch down and at an altitude of about 600 feet, the flight crew requested for a left hand orbit, which was approved by the air traffic control (ATC). Having flown the orbit beyond the extended centreline on a south-westerly heading, the captain decided to go-around. Observing the manoeuvre, the ATC offered the radar vectors, which the flight crew accepted. GF072 initiated a go-around, applied take-off/go-around thrust, and crossed the runway on a north-easterly heading with a shallow climb to about 1000 feet. As the aircraft rapidly accelerated, the master warning sounded for flap over-speed. A perceptual study, carried out as part of the investigation, indicated that during the go-around the flight crew probably experienced a form of spatial disorientation, which could have caused the captain to falsely perceive that the aircraft was ‘pitching up’. He responded by making a ‘nose-down’ input, and, as a result, the aircraft commenced to descend. The ground proximity warning system (GPWS) voice alarm sounded: “whoop, whoop pull-up …”. The GPWS warning was repeated every second for nine seconds, until the aircraft impacted the shallow sea. The aircraft was destroyed by impact forces, and all 143 persons on board were killed.
Probable cause:
The factors contributing to the above accident were identified as a combination of the individual and systemic issues. Any one of these factors, by itself, was insufficient to cause a breakdown of the safety system. Such factors may often remain undetected within a system for a considerable period of time. When these latent conditions combine with local events and environmental circumstances, such as individual factors contributed by “frontline” operators (e.g.: pilots or air traffic controllers) or environmental factors (e.g.: extreme weather conditions), a system failure, such as an accident, may occur.
The investigation showed that no single factor was responsible for the accident to GF072. The accident was the result of a fatal combination of many contributory factors, both at the individual and systemic levels. All of these factors must be addressed to prevent such an accident happening again.
(1) The individual factors particularly during the approach and final phases of the flight were:
(a) The captain did not adhere to a number of SOPs; such as: significantly higher than standard aircraft speeds during the descent and the first approach; not stabilising the approach on the correct approach path; performing an orbit, a non-standard manoeuvre, close to the runway at low altitude; not performing the correct go-around procedure; etc.
(b) In spite of a number of deviations from the standard flight parameters and profile, the first officer (PNF) did not call them out, or draw the attention of the captain to them, as required by SOP’s.
(c) A perceptual study indicated that during the go-around after the orbit, it appears that the flight crew experienced spatial disorientation, which could have caused the captain to perceive (falsely) that the aircraft was ‘pitching up’. He responded by making a ‘nose-down’ input, and as a result, the aircraft descended and flew into the shallow sea.
(d) Neither the captain nor the first officer perceived, or effectively responded to, the threat of increasing proximity to the ground, in spite of repeated hard GPWS warnings.
(2) The systemic factors, identified at the time of the above accident, which could have led to the above individual factors, were:
(a) Organisational factors (Gulf Air):
(i) A lack of training in CRM contributing to the flight crew not performing as an effective team in operating the aircraft.
(ii) Inadequacy in the airline's A320 training programmes, such as: adherence to SOPs, CFIT, and GPWS responses.
(iii) The airline’s flight data analysis system was not functioning satisfactorily, and the flight safety department had a number of deficiencies.
(iv) Cases of non-compliance, and inadequate or slow responses in taking corrective actions to rectify them, on the part of the airline in some critical regulatory areas, were identified during three years preceding the accident.
(b) Safety oversight factors:
A review of about three years preceding the accident indicated that despite intensive efforts, the DGCAM as a regulatory authority could not make the operator comply with some critical regulatory
requirements.
Final Report:

Crash of a Cessna 208 Caravan I in Lake Teslin: 2 killed

Date & Time: Aug 14, 2000 at 2357 LT
Type of aircraft:
Operator:
Registration:
C-GMPB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Prince Rupert – Teslin Lake – Dease Lake
MSN:
208-0082
YOM:
1986
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3768
Captain / Total hours on type:
282.00
Circumstances:
A Cessna 208 Caravan I on amphibious floats, C-GMPB, serial number 20800082, was ferrying members of the Royal Canadian Mounted Police (RCMP) Emergency Response Team from Teslin, Yukon, to a site on the south end of Teslin Lake, British Columbia. At about 1645 Pacific daylight time, three team members, two dogs, and gear were unloaded on a gravel bar across from the mouth of the Jennings River. The aircraft departed for the Teslin airport at about 2355 with the pilot and one RCMP engineer on board. Shortly after take-off, the aircraft was seen to pitch up into a steep climb, stall, then descend at a steep angle into the water. The aircraft was destroyed, and the pilot and the passenger were fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot's decision to depart from the unlit location was likely the result of the many psychological and physiological stressors encountered during the day.
2. The pilot most likely experienced spatial disorientation-precipitated by local geographic and environmental conditions-and lost control of the aircraft.
Findings as to Risk:
1. Without a safety management program that routinely disseminates safety information, RCMP pilots may be inadequately sensitized to the limitations of decision making and judgement.
2. The RCMP had no current, concise standard operating procedures (SOPs) for its non-604 operations. Without useable SOPs, the pilots in some instances operate without clearly established limits and outside of acceptable tolerances.
Final Report:

Crash of a Cessna 402C II off Vieques: 1 killed

Date & Time: Jul 8, 2000 at 0455 LT
Type of aircraft:
Registration:
N405MN
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
San Juan - Christiansted
MSN:
402C-0221
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2400
Captain / Total hours on type:
235.00
Aircraft flight hours:
13702
Circumstances:
After departure from San Juan, the pilot of N405MN contacted the FAA San Juan Approach Control, was identified on radar by the controller, and told to climb to 7,000 feet. About 1 minute later, the pilot is told to proceed direct to St. Croix. About 4 minutes later, the pilot requested radar vectors to St. Croix, and was told to fly heading 140 degrees. Radar data showed the flight leveled at the cruise altitude of 7,000 feet at about 0444. At about 0453:36, the pilot requested a lower altitude, and was cleared to 2,000 feet. The pilot acknowledged the clearance, and no further transmissions were received from the pilot. The flight began descent from 7,000 feet at about 0454. At 0454:29, the aircraft's transponder reports the flight is at 6,500 feet. At 0454:41, the transponder reports the flight is at 5,600 feet, and at 0454:49, at 4,000 feet. At 0454:53, the transponder reports the flight is at 1,100 feet. The flight is not observed on radar after this. No other aircraft or radar returns are observed near the flight as it began it's descent. One main landing gear tire, wheel, and brake assembly; the left wing lower skin from the area above the wing flap; the left wing baggage compartment door; the right nose baggage compartment door; the cabin floor cover; and some items from the U.S. mail cargo, were recovered floating in the ocean, at points north of the last observed radar contact with the airplane, on the day of the accident and in the days after the accident. The recovered components had damage from being separated from the airplane. None of the recovered components had any fire, heat, or soot damage. The remainder of the airplane was not located and recovered. The depth of the sea in the area of the accident site was reported by the Coast Guard to be about 6,000 feet. U.S. Post Office personnel reported the flight carried 1,517 pounds of U.S. mail. No hazardous materials were in the mail. A 75-pound pouch of mail was recovered from the ocean and identified as having been placed on N405MN. The weather at the time of the accident was reported to scattered clouds with visibility 10 miles.
Probable cause:
The airplanes entry into an uncontrolled descent for undetermined reasons from which it crashed into the ocean.
Final Report: