Crash of a GAF Nomad N.22C off Cagayancillo: 14 killed

Date & Time: Jul 2, 2000 at 1050 LT
Type of aircraft:
Operator:
Registration:
86
Flight Type:
Survivors:
Yes
Schedule:
Cagayancillo – Puerto Princesa
MSN:
86
YOM:
1979
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
14
Circumstances:
Few minutes after takeoff from Cagayancillo Airport, the pilot reported engine problems and was cleared to return for an emergency landing. On final approach, the aircraft was not properly aligned so the captain increased engine power and initiated a go-around. The aircraft lost height and crashed in the sea about 2 km offshore. A passenger was rescued while 14 other occupants were killed, among them General Santiago Madrid, Chief of the southwestern military command.
Probable cause:
Engine failure for unknown reasons.

Crash of a Kawasaki C-1A off Shimano: 8 killed

Date & Time: Jun 27, 2000
Type of aircraft:
Operator:
Registration:
88-1027
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Yonago AFB - Yonago AFB
MSN:
8027
Location:
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
The crew (four pilots and four technicians) departed Yonago-Miho AFB on a post maintenance local flight. After several circuits, while in cruising altitude, the aircraft entered an uncontrolled descent and crashed in the sea off Shimano. All eight occupants were killed.

Crash of a De Havilland DHC-2 Beaver in Hotnarko Lake: 3 killed

Date & Time: Jun 19, 2000 at 1630 LT
Type of aircraft:
Registration:
C-GAXE
Flight Phase:
Survivors:
Yes
Schedule:
Hotnarko Lake - Nimpo Lake
MSN:
841
YOM:
1955
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total hours on type:
150.00
Circumstances:
The de Havilland DHC-2 (Beaver) floatplane, serial number 841, departed Hotnarko Lake, British Columbia, at about 1630 Pacific daylight time. The pilot and six passengers were on board, with fishing gear and fish. Soon after take-off, the pilot entered a left turn. Before the turn was completed, the aircraft rolled, without command, further left to about 40 degrees of bank and the nose dropped. The aircraft did not respond to initial pilot inputs and continued in a left, diving turn toward the trees at the edge of the lake. The pilot tried to get the aircraft back onto the lake. The aircraft started to recover from the bank and the nose started to come up; however, the aircraft struck the lake surface before a level attitude could be regained. It broke apart on contact with the water and sank soon after. The pilot and four of the passengers managed to free themselves from the wreckage, but only three passengers and the pilot managed to swim to shore. One passenger slipped below the water surface before reaching the shore and drowned. Two passengers remained in the aircraft below the water surface, one secured by his seat belt, and drowned.
Probable cause:
Findings as to Causes and Contributing Factors:
1. When the pilot entered a turn, the combined effects of the increased g-forces, power reduction, the aircraft=s heavy weight, the aft CofG, retraction of the flaps, and the wind conditions resulted in
the aircraft stalling. The aircraft struck the lake surface before the pilot was able to re-establish a level-flight attitude.
2. The aircraft was operating in excess of 385 pounds above the maximum gross takeoff weight, and the CofG was about 2.7 inches aft of the aft limit. This loading configuration aggravated the stall characteristics of the aircraft.
3. The pilot reduced power and raised the flaps before the climb was complete, contrary to the Pilot Operating Handbook, thereby increasing the aircraft's stall speed.
Other Findings:
1. The shoulder harnesses worn by the pilot and the front passenger likely prevented serious head injuries.
2. The centre seat broke from its footings. This may have incapacitated the two passengers inside the aircraft or impeded their escape.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off Liverpool: 5 killed

Date & Time: Jun 14, 2000 at 0950 LT
Operator:
Registration:
G-BMBC
Flight Type:
Survivors:
No
Schedule:
Douglas - Liverpool
MSN:
31-7952172
YOM:
1979
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
18000
Circumstances:
The aircraft, operated by an Air Operator's Certificate holder, was engaged on an air ambulance operation from Ronaldsway in the Isle of Man to Liverpool. Having flown under VFR on a direct track to the Seaforth dock area of Liverpool the pilot flew by visual reference along the northern coast of the Mersey Estuary to carry out a visual approach to Runway 09 at Liverpool. During the turn on to the final approach, when approximately 0.8 nm from the threshold and 0.38 nm south of the extended centreline, the aircraft flew into the sea and disappeared. All five occupants were killed.
Probable cause:
The investigation concluded that the pilot lost control of the aircraft at a late stage of the approach due either to disorientation, distraction, incapacitation, or a combination of these conditions.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off Whyalla: 8 killed

Date & Time: May 31, 2000 at 1905 LT
Operator:
Registration:
VH-MZK
Survivors:
No
Schedule:
Adelaide - Whyalla
MSN:
31-8152180
YOM:
1981
Flight number:
WW904
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
2211
Captain / Total hours on type:
113.00
Aircraft flight hours:
11837
Circumstances:
On the evening of 31 May 2000, Piper Chieftain, VH-MZK, was being operated by Whyalla Airlines as Flight WW904 on a regular public transport service from Adelaide to Whyalla, South Australia. One pilot and seven passengers were on board. The aircraft departed at 1823 central Standard Time (CST) and, after being radar vectored a short distance to the west of Adelaide for traffic separation purposes, the pilot was cleared to track direct to Whyalla at 6,000 ft. A significant proportion of the track from Adelaide to Whyalla passed over the waters of Gulf St Vincent and Spencer Gulf. The entire flight was conducted in darkness. The aircraft reached 6,000 ft and proceeded apparently normally at that altitude on the direct track to Whyalla. At 1856 CST, the pilot reported to Adelaide Flight Information Service (FIS) that the aircraft was 35 NM south-south-east of Whyalla, commencing descent from 6,000 ft. Five minutes later the pilot transmitted a MAYDAY report to FIS. He indicated that both engines of the aircraft had failed, that there were eight persons on board and that he was going to have to ditch the aircraft, but was trying to reach Whyalla. He requested that assistance be arranged and that his company be advised of the situation. About three minutes later, the pilot reported his position as about 15 NM off the coast from Whyalla. FIS advised the pilot to communicate through another aircraft that was in the area if he lost contact with FIS. The pilot’s acknowledgment was the last transmission heard from the aircraft. A few minutes later, the crew of another aircraft heard an emergency locater transmitter (ELT) signal for 10–20 seconds. Early the following morning, a search and rescue operation located two deceased persons and a small amount of wreckage in Spencer Gulf, near the last reported position of the aircraft. The aircraft, together with five deceased occupants, was located several days later on the sea–bed. One passenger remained missing.
Probable cause:
Engine operating practices:
• High power piston engine operating practices of leaning at climb power, and leaning to near ‘best economy’ during cruise, may result in the formation of deposits on cylinder and piston surfaces that could cause preignition.
• The engine operating practices of Whyalla Airlines included leaning at climb power and leaning to near ‘best economy’ during cruise.
Left engine:
The factors that resulted in the failure of the left engine were:
• The accumulation of lead oxybromide compounds on the crowns of pistons and cylinder head surfaces.
• Deposit induced preignition resulted in the increase of combustion chamber pressures and increased loading on connecting rod bearings.
• The connecting rod big end bearing insert retention forces were reduced by the inclusion, during engine assembly, of a copper–based anti-galling compound.
• The combination of increased bearing loads and decreased bearing insert retention forces resulted in the movement, deformation and subsequent destruction of the bearing inserts.
• Contact between the edge of the damaged Number 6 connecting rod bearing insert and the Number 6 crankshaft journal fillet resulted in localised heating and consequent cracking of the nitrided surface zone.
• Fatigue cracking in the Number 6 journal initiated at the site of a thermal crack and propagated over a period of approximately 50 flights.
• Disconnection of the two sections of the journal following the completion of fatigue cracking in the journal and the fracture of the Number 6 connecting rod big end housing most likely resulted in the sudden stoppage of the left engine.
Right engine:
The factors that were involved in the damage/malfunction of the right engine following the left engine malfunction/failure were:
• Detonation of combustion end-gas.
• Disruption of the gas boundary layers on the piston crowns and cylinder head surface increasing the rate of heat transfer to these components.
• Increased heat transfer to the Number 6 piston and cylinder head resulted in localised melting.
• The melting of the Number 6 piston allowed combustion gases to bypass the piston rings.
The flight:
The factors that contributed to the flight outcome were:
• The pilot responded to the failed left engine by increasing power to the right engine.
• The resultant change in operating conditions of the right engine led to loss of power from, and erratic operation of, that engine.
• The pilot was forced to ditch the aircraft into a 0.5m to 1m swell in the waters of Spencer Gulf, in dark, moonless conditions.
• The absence of upper body restraints, and life jackets or flotation devices, reduced the chances of survival of the occupants.
• The Emergency Locator Transmitter functioned briefly on impact but ceased operating when the aircraft sank.
Final Report:

Crash of a Piper PA-31-350 Panther II in Zurich: 1 killed

Date & Time: May 26, 2000 at 2023 LT
Operator:
Registration:
HB-LTC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Zurich - Geneva
MSN:
31-7952003
YOM:
1979
Flight number:
HBLTC
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1119
Captain / Total hours on type:
9.00
Aircraft flight hours:
8387
Circumstances:
On 25 and 26 May 2000 aircraft HB-LTC was used for a commercial flight from Zurich to Béziers (F) and back. To this end, the pilot made a positioning flight from Geneva to Zurich on 24 May 2000. The reconstruction of the following events is based on recorded radio conversations and witness statements. On 25 May 2000 at approx. 07:20 hrs, the pilot placed a telephone order with the refuelling service of Jet Aviation Zurich AG. According to statements from aircraft refuelling attendant A concerned, the pilot asked for the aircraft to be fully refuelled with aviation gasoline (AVGAS) for a flight to France. When aircraft refuelling attendant A arrived at the aircraft, the pilot was present. The refuelling attendant saw the winglets on the HB-LTC and asked the pilot whether the machine had been modified and therefore needed jet kerosene. Before the pilot could even answer, the refuelling attendant realised, from the square engine housings, that the machine was equipped with reciprocating engines. The pilot confirmed that HB-LTC had been modified but pointed out that this modification involved only the airframe and that the aircraft had not been converted to turboprop operation. Refuelling attendant A then filled the HB-LTC’s four fuel tanks with 372 l of AVGAS 100LL (low lead). The aircraft was therefore fully refuelled and at that time had 726 l of fuel. Refuelling attendant A later reported that he had not noticed markings which described the types of fuel permitted for this aircraft, either on the wing or on the tank seals. During the refuelling operation, which ended at approx. 07:30 hrs, the pilot was in the cockpit. Nobody observed him draining the tanks after refuelling. The seven passengers for the flight to Béziers (F) arrived on 25 May 2000 at about eight o’clock in the morning at the General Aviation Centre (GAC) at Zurich airport. At 08:18:42 hrs the pilot received start-up clearance from Zurich Apron (ZRH APR) and at 08:26:25 hrs indicated that he was ready to taxi. Taxi clearance was granted without delay and the aircraft taxied to the holding point of runway 28. Several passengers later stated that the pilot carried out a run up of the engines while the following time of waiting. At 08:32:01 hrs HB-LTC indicated to aerodrome control (Zurich Tower – ZRH TWR) that it was ready to take off. The aircraft was queued in the traffic and was cleared for take-off at 08:45:27 hrs. The aircraft landed in Béziers (F) some two hours later. On 26 May 2000 between 15:35 and 15:45 hrs HB-LTC was refuelled in Béziers with 107 l of AVGAS 100LL. The aircraft then flew with the same passengers from Béziers (F) back to Zurich, where it landed at 19:10 hrs. Before the flight back to Geneva, the pilot obviously decided to refuel. According to the statements of aircraft refuelling attendant B at approx. 19:45 hrs the pilot ordered “Kraftstoff JET-A1” by telephone. Unlike the telephone conversations of air traffic control at Zurich airport, incoming and outgoing telephone calls made to and from the refuelling service of Jet Aviation Zurich AG were not recorded. The precise wording of the pilot’s fuel order cannot therefore be established with certainty. Aircraft refuelling attendant B then forwarded the order by radio to his colleague, aircraft refuelling attendant C. A third aircraft refuelling attendant D heard on his radio how aircraft refuelling attendant B gave the instruction to aircraft refuelling attendant C to refuel aircraft HB-LTC with JET A-1 fuel. Then aircraft refuelling attendant C drove tanker FL 7 to HB-LTC, which was parked in GAC Sector 1. According to his statements, he positioned the tanker with its right-hand side in front of the aircraft so that he could reach the filler caps on both wings using the hose affixed to that side of the tanker. Then aircraft refuelling attendant C, still next to the tanker, began to complete the delivery note, while the pilot came up to him and indicated the desired quantity of fuel in English. The pilot gave him a credit card and aircraft refuelling attendant C then explained to him that after refuelling he would have to complete the transaction in the office. The pilot remarked that he had a slot. Aircraft refuelling attendant C later stated that this gave him to understand that the pilot did not have much time. The aircraft refuelling attendant replied to the pilot that he would only need an additional two or three minutes. Because it had started to rain shortly before refuelling, the pilot evidently withdrew into the aircraft after his conversation with aircraft refuelling attendant C. According to his partner, the pilot conducted a brief conversation with her from his mobile telephone during this phase. As the investigation showed, this telephone call took place between 19:50:06 and 19:51:28 hrs. In the meantime, aircraft refuelling attendant C had connected HB-LTC to the tanker and then pumped 50 l of JET A-1 fuel into each of the two inboard main cells. The aircraft refuelling attendant later stated that he had not noticed markings or labels which described the permitted types of fuel for this aircraft, either on the tank seals or in the vicinity of the tank openings. He then drove the tanker to the office, debited the credit card and returned it with the receipt and the delivery note to the aircraft. He presented the debit slip and the delivery note to the pilot for signature. In the process the aircraft refuelling attendant asked the pilot what aircraft type HB-LTC was. The pilot answered that his aircraft was a modified PA31. The aircraft refuelling attendant then entered “PA31” on the delivery note and then gave the pilot the carbon copy. At 20:08:44 hrs the pilot made radio contact with Zurich Clearance Delivery (ZRH CLD) air traffic control and received departure clearance with the instruction to change to the ZRH APR frequency for start-up clearance. The apron gave HB-LTC start-up clearance at 20:10:00 hrs. Three minutes and 50 seconds later the pilot requested taxi clearance and was then instructed to taxi to the holding point of runway 28. After the transfer to ZRH TWR at 20:15:02 hrs the pilot stated he was ready for take off at 20:17:30 hrs. A short time after this he was able to line up runway 28 and at 20:20:58 hrs ZRH TWR gave him take-off clearance. According to witness statements, HB-LTC took off normally and went into a climb. In the region of runway intersection 28/16 and at an altitude of approx. 50 m AGL the aircraft stopped climbing, maintained level flight briefly and began to descend slightly. At the same time, HB-LTC began to make a gentle right turn and overflew the woods to the north of runway 28. Because of this unusual flight pattern, the duty aerodrome controller (ADC) at 20:22:08 hrs asked the pilot whether everything was normal: “Tango Charlie, normal operations?” The pilot replied in the negative: “(Ne)gative, Hotel Tango Charlie!” In this phase, the aircraft began to make a left turn with a high bank angle and witnesses observed that the landing gear was lowered. At 20:22:21 hrs the pilot radioed that he was in an emergency situation: “Mayday, Mayday, Mayday, Hotel Tango Charlie”. During the first 90° of the turn, HB-LTC descended only slightly. After crossing the extended centerline of runway 28 the aircraft increasingly lost height in the tight left turn. When the aircraft had almost completed the full turn, its bank attitude began to reduce. At a height of approx. 10 m AGL HB-LTC collided with the trees in a copse. The aircraft passed through the copse and came to rest upside down in the “Glatt” river. The pilot was fatally injured on impact. Coordinates of the final position of the wreck: 682 700/256 700, elevation 420 m AMSL corresponding to 1378 ft AMSL.
Probable cause:
The investigation established the following causal factors for the accident:
• A misunderstanding occurred when the fuel was ordered.
• The refuelling attendant concerned did not notice the fuel grade rating placards attached to the aircraft.
• The refuelling attendant concerned did not realise that the aircraft was equipped with reciprocating engines.
• The pilot did not notice the fuel grade rating placards on the tanker vehicle.
• The pilot did not realise the incorrect refuelling on the receipt for the fuel provision.
The following factors allowed or favoured the occurrence of the accident:
• The delivery nozzle on the filler gun was of an outside diameter which allowed the aircraft involved in the accident to be refuelled.
• The level of training and knowledge of the refuelling personnel concerned was inadequate.
• The Federal Office for Civil Aviation never inspected the refuelling operation before the accident.
• Until the time of the accident, the Federal Office for Civil Aviation had issued no regulations on the training of refuelling personnel, the size of delivery nozzles and tank openings on aircraft or on the identification of filler guns and tank openings.
The following points may have exacerbated the outcome of the accident:
• The pilot decided on an about turn which brought him onto a collision course with obstacles.
• The retention mechanism of the safety belt was not working.
Final Report:

Crash of a Beechcraft 200 Super King Air in the Pacific Ocean

Date & Time: May 23, 2000 at 1945 LT
Registration:
N24CV
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Parker – Carlsbad
MSN:
BB-1524
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1659
Captain / Total hours on type:
1058.00
Aircraft flight hours:
1350
Circumstances:
En route from Arizona to California, the pilot became nauseous and began to vomit. The pilot advised air traffic that he was sick and radio contact was lost. The airplane had descended from 16,500 feet msl and was on an established course to his destination and level at 10,500 feet msl being flown by the autopilot. The last thing that he recalled was approaching his destination. When the pilot regained consciousness he looked outside the airplane to determine where he was. The surface was obscured in cloud cover. On his left side was a Navy F18 fighter plane, and they briefly communicated by hand signals. The F18 pilot indicated he should turn around towards land. The accident pilot determined that he was 186 nautical miles southwest of his destination and over the ocean. He reversed his course. The pilot attempted to contact air traffic without success; another aircraft relayed the pilot's message to air traffic. The pilot declared a medical emergency and advised that because of low fuel he would not be able to return to land. Within 10 minutes the fuel onboard was exhausted and the pilot configured the airplane for the best angle of glide and ditching at sea. Subsequently, the pilot descended through low stratus and ditched the airplane in the ocean at dusk. The pilot exited the airplane with a hand held VHF radio, two flashlights, a cell phone, and a trash bag for flotation; he climbed onto the top of the fuselage to await rescue. At this time it was dark. After about 30 minutes a Navy S3B circled the downed plane until a rescue helicopter arrived and rescued him. While at the pilot's Arizona residence he sprayed for bugs and insects using the pesticide 'Dursban.' During the process he opened the spray container to replenish the pesticide and the built-up pressure sprayed the vapor into his face. He cleaned himself up and then departed for the airport and the return flight to Palomar. He had bought food to eat during the flight, and shortly thereafter, he became sick in flight. The EPA as of June 8, 2000, has banned Dursban from the commercial market.
Probable cause:
Physical incapacitation of the pilot from improper handling of a pesticide.
Final Report:

Crash of a Cessna 401A in the Pacific Ocean: 2 killed

Date & Time: May 9, 2000
Type of aircraft:
Registration:
CC-CBX
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Santiago - Robinson Crusoe Island
MSN:
401A-0121
YOM:
1969
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
En route from Santiago-Los Cerrillos Airport to Robinson Crusoe Island, the twin engine airplane crashed in unknown circumstances in the Pacific Ocean. Both pilots were killed.
Crew:
Luis Bochetti Melo,
Luis Bochetti del Canto.

Crash of a Douglas DC-10-30F in Entebbe

Date & Time: Apr 30, 2000 at 0548 LT
Type of aircraft:
Operator:
Registration:
N800WR
Flight Type:
Survivors:
Yes
Schedule:
London - Entebbe
MSN:
46955/228
YOM:
1976
Flight number:
DAZ405
Location:
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
69000
Aircraft flight cycles:
20900
Circumstances:
The aircraft departed London-Gatwick Airport on a cargo flight to Entebbe, carrying seven crew members and a load of 50 tons of various goods. After landing by night on runway 17, the aircraft was unable to stop within the remaining distance (runway 17/35 is 12,000 feet long), overran and plunged in the Lake Victoria. The aircraft broke in two and all seven crew members were rescued 10 minutes later.
Probable cause:
On final approach, the aircraft was well above the glide and landed too far down a wet runway, about 4,000 - 5,000 feet past the runway threshold. It was reported that the nose gear landed 13 seconds after both main landing gears. The crew failed to initiate a go-around procedure.

Crash of a Douglas C-47A-5-DK in Ennadai Lake: 2 killed

Date & Time: Mar 17, 2000 at 1230 LT
Operator:
Registration:
C-FNTF
Flight Type:
Survivors:
No
Schedule:
Points North Landing - Ennadai Lake
MSN:
12344
YOM:
1944
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8200
Captain / Total hours on type:
840.00
Copilot / Total flying hours:
4300
Copilot / Total hours on type:
85
Circumstances:
The Douglas DC-3 departed Points North Landing, Saskatchewan, about 1125 central standard time on a visual flight rules flight to Ennadai Lake, Nunavut, with two pilots and 6600 pounds of cargo on board. The flight was one of a series of flights to position building materials for the construction of a lodge. The pilots had completed a similar flight earlier in the day. The runway at Ennadai, oriented northeast/southwest, was an ice strip about 2700 feet long by 150 feet wide marked with small evergreens. The ice strip was constructed on the lake, and the approaches were flat, without obstacles. The snow was cleared so there were no snow ridges on the runway ends. The arrival at Ennadai Lake, toward the southwest, appeared to be similar to previous arrivals. The aircraft was observed to touch down nearly halfway along the ice strip, the tail of the aircraft remained in the air, and the aircraft took off almost immediately. The main landing gear was seen to retract. The aircraft reached the end of the runway then abruptly entered a steep, nose-up attitude, banked sharply to the left, turned left, and descended into the ice. The left wing made first contact with the ice. The aircraft rotated around the left wing and struck the ice in a steep, nose-down attitude about 400 feet from the end of the ice strip. There was no fire. The crew were killed instantly. Canadian Forces rescue specialists were air-dropped to the site on the day of the accident.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot lost control of the aircraft while conducting a go-around from a balked landing on an ice strip.
2. The aircraft's centre of gravity (C of G) on the accident flight was beyond the aft C of G limit.
3. The actual C of G of the aircraft at basic operating weight was 16.7 inches aft of the C of G provided in the weight and balance report.
4. The load sheet index number used by the crew was inaccurate.
5. The stack of 2x4 lumber was inadequately secured and may have shifted rearward during the go-around.
6. The crew did not recalculate the aircraft's weight and balance for the second flight.
7. Leaks in the heater shroud allowed carbon monoxide gas to contaminate cockpit and cabin air.
8. The captain's carboxyhaemoglobin level was 17.9%, which may have adversely affected his performance, especially his decision making and his visual acuity.
Other Findings:
1. The carbon monoxide detector had no active warning system. The user directions for the detector, which are printed on the back of the detector, are obscured when the detector is installed.
2. The company maintenance facility overhauled the heater as required by the Transport Canada-approved inspection program.
3. Although the manufacturer's maintenance instruction manual for the S200 heater, part number 27C56, lists inspection and overhaul procedures, it does not specify their intervals.
4. No maintenance instructions are available for the heater, part number 27C56. The company maintenance facility did not conduct inspections, overhauls, or pressure decay tests as specified for later manufactured heaters.
Final Report: