Crash of a Canadair CL-415-6B11 off La Ciotat: 1 killed

Date & Time: Nov 17, 1997 at 1030 LT
Type of aircraft:
Operator:
Registration:
F-ZBFQ
Flight Type:
Survivors:
Yes
Schedule:
Marseille - Marseille
MSN:
2025
YOM:
1996
Flight number:
Pélican 43
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The crew departed Marseille-Marignane Airport with three other similar aircraft to conduct a training mission in the bay of La Ciotat. Following several scooping manoeuvres, the crew simulated an engine failure and then performed a complete landing when the aircraft suffered severe vibrations. The crew increased engine power in an attempt to take off when the seaplane overturned and came to rest upside down. The copilot was seriously injured while the captain was killed.
Probable cause:
It was reported that the hatches were open when the aircraft landed on the sea, causing severe vibrations and the subsequent loss of control.

Crash of a Britten-Norman BN-2A-III-2 Trislander off Little Farmer's Cay

Date & Time: Nov 9, 1997
Type of aircraft:
Operator:
Registration:
F-OGOR
Flight Phase:
Survivors:
Yes
MSN:
1049
YOM:
1977
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances in the sea off Little Farmer's Cay. There were no casualties.

Crash of a Cessna 208B Grand Caravan off Barrow: 8 killed

Date & Time: Nov 8, 1997 at 0808 LT
Type of aircraft:
Operator:
Registration:
N750GC
Flight Phase:
Survivors:
No
Schedule:
Barrow - Wainwright
MSN:
208B-0504
YOM:
1996
Flight number:
HAG500
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
3500
Captain / Total hours on type:
200.00
Aircraft flight hours:
1466
Circumstances:
The pilot, who was also the station manager, arrived at the airport earlier than other company employees to prepare for a scheduled commuter flight, transporting seven passengers and cargo to another village during hours of arctic, predawn darkness. Heavy frost was described on vehicles and airplanes the morning of the accident, and the lineman who serviced the airplane described a thin glaze of ice on the upper surface of the left wing. The pilot was not observed deicing the airplane prior to flight, and was described by the other employees as in a hurry to depart on time. The pilot directed the lineman to place fuel in the left wing only, which resulted in a fuel imbalance between 450 and 991 pounds (left wing heavy). The first turn after takeoff was into the heavy left wing. The airplane was observed climbing past the end of the runway, and descending vertically into the water. No preimpact mechanical anomalies were found with the airplane or powerplant. The aileron trim indicator was found in the full right wing down position. Postaccident flight tests with left wing heavy lateral fuel imbalances, disclosed that approximately one-half of right wing down aileron control deflection was used to maintain level flight, thus leaving only one-half right wing down aileron control efficacy. Research has shown that frost on airfoils can result in reduced stall angles of attack (often below that required to activate stall warning devices), increases in stall speeds between 20% and 40%, asymmetric stalls resulting in large rolling moments, and differing stall angles of attack for wings with upward and downward deflected ailerons (as when recovering from turns).
Probable cause:
The pilot's disregard for lateral fuel loading limits, his improper removal of frost prior to takeoff, and the resulting inadvertent stall/spin. Factors involved in this accident were the improper asymmetrical fuel loading which reduced lateral aircraft control, the self-induced pressure to takeoff on time by the pilot, and inadequate surveillance of the company operations by company management.
Final Report:

Crash of a De Havilland DHC-2 Beaver off Ketchikan: 1 killed

Date & Time: Sep 29, 1997 at 1747 LT
Type of aircraft:
Operator:
Registration:
N4787C
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ketchikan - Ketchikan
MSN:
1330
YOM:
1959
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2071
Captain / Total hours on type:
1200.00
Aircraft flight hours:
24267
Circumstances:
The float equipped airplane was observed taking off in light winds and calm water, and obtaining a steep climb and nose high attitude. Witnesses described hearing no reduction of engine noise from takeoff power to climb power. The airplane entered a steep left bank about 200 feet above the water, then rolled rapidly to the right and impacted at a steep angle into the water. The airplane had been modified with a Short Take Off and Landing (STOL) kit. Certification flight tests had determined that this modification eliminated aerodynamic warning of impending stalls, and therefore required an audible stall warning. Test results also required the addition of both a ventral fin, and horizontal stabilizer finlets, to meet directional stability certification. These tests determined that the least stable condition was in the takeoff flap configuration, during climb. The Supplemental Type Certificate (STC) for the modification required the ventral fin, and an audible stall warning system be installed. The manufacturer provided a marketing video, produced prior to the STC approval, which stated the stall warning system was not required in the U.S. The company indicated this tape was used for training, and was a basis for pilots routinely disabling the stall warning horn by pulling the circuit breaker. At the time of the accident, the airplane did not have the ventral fin installed, a takeoff flaps setting was selected, and the audible stall warning circuit breaker was in the pulled (disabled) position. The local FAA Flight Standards Office had inspected the accident airplane 14 times in the previous 29 months, and made no mention of the ventral fin not being installed.
Probable cause:
The pilot's excessive climb and turning maneuver at low altitude, the pilot's inadvertent stall, and the intentional operation of the airplane with the required stall warning system disabled. Factors associated with this accident were the pilot's overconfidence in the modified airplane's ability, the uninstalled ventral fin, inadequate compliance with the STC by the company, unclear information by the manufacturer, and inadequate surveillance by the FAA.
Final Report:

Crash of a Lockheed C-141B Starlifter in Atlantic Ocean: 9 killed

Date & Time: Sep 13, 1997 at 1710 LT
Type of aircraft:
Operator:
Registration:
65-9405
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Windhoek - Georgetown - McGuire AFB
MSN:
6142
YOM:
1965
Flight number:
REACH4201
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
9
Aircraft flight hours:
36430
Circumstances:
Some 65 nautical miles west off the Namibian coast, a US Air Force Lockheed C-141B Starlifter collided with a German Air Force Tupolev 154M in mid-air. Both aircraft crashed, killing all 33 occupants. The Tupolev 154M (11+02), call sign GAF074, operated on a flight from Cologne/Bonn Airport in Germany to Kaapstad, South Africa. En route refueling stops were planned at Niamey, Niger and Windhoek, Namibia. On board were ten crew members and 14 passengers. The C-141B, (65-9405), call sign REACH 4201, had delivered UN humanitarian supplies to Windhoek and was returning to the U.S. via Georgetown on Ascension Island in the South Atlantic Ocean. On board were nine crew members. GAF074 departed Niamey, Niger at 10:35 UTC. REACH 4201 took off from Windhoek at 14:11 UTC and climbed to its filed for and assigned cruise level of 35,000 feet (FL350). At the same time, GAF074 was not at its filed for cruise level of FL390 but was still at its initially assigned cruise level FL350. Windhoek ATC was in sole and continuous radio contact with REACH 4201, with no knowledge of GAF 074's movement. Luanda ATC was in radio contact with GAF074, but they were not in radio contact with REACH 4201. Luanda ATC did receive flight plans for both aircraft but a departure message for only REACH 4201. At 15:10 UTC both aircraft collided at FL350 and crashed into the sea.
Probable cause:
The primary cause of this accident, in my opinion, was GAF 074 flying a cruise level (FL350) which was not the level they had filed for (FL390). Neither FL350 nor FL390 were the correct cruise levels for that aircraft's magnetic heading according to International Civil Aviation Organization regulations. The appropriate cruise level would have been FL290, FL330, FL370, FL410, etc. A substantially contributing factor was ATC agency Luanda's poor management of air traffic through its airspace. While ATC communications could be improved, ATC agency û Luanda did have all the pertinent information it needed to provide critical advisories to both aircraft. If ATC agency Luanda was unable to contact GAF 074, it should have used other communication means (HF radio, telefax or telephone) to contact REACH 4201 through ATC agency Windhoek, as outlined in governing documents. Another substantially contributing factor was the complicated and sporadic operation of the Aeronautical Fixed Telecommunications Network (AFTN). Routing of messages to affected air traffic control agencies is not direct and is convoluted, creating unnecessary delays and unfortunate misroutings. Specifically, ATC agency Windhoek did not receive a flight plan or a departure message on GAF 074, which could have been used by the controllers to identify the conflict so they could have advised REACH 4201. In my opinion, the absence of TCAS was not a cause or substantially contributing factor, but the presence of a fully operational TCAS could have prevented the accident." (William H.C. Schell, jr., Colonel, USAF President, Accident Investigation Board).

Crash of a Tupolev TU-154M in the Atlantic Ocean: 24 killed

Date & Time: Sep 13, 1997 at 1710 LT
Type of aircraft:
Operator:
Registration:
11+02
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bonn – Niamey – Windhoek – Cape Town
MSN:
89A813
YOM:
1989
Flight number:
GAF074
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
24
Circumstances:
Some 65 nautical miles west off the Namibian coast, a US Air Force Lockheed C-141B Starlifter collided with a German Air Force Tupolev 154M in mid-air. Both aircraft crashed, killing all 33 occupants. The Tupolev 154M (11+02), call sign GAF074, operated on a flight from Cologne/Bonn Airport in Germany to Kaapstad, South Africa. En route refueling stops were planned at Niamey, Niger and Windhoek, Namibia. On board were ten crew members and 14 passengers. The C-141B, (65-9405), call sign REACH 4201, had delivered UN humanitarian supplies to Windhoek and was returning to the U.S. via Georgetown on Ascension Island in the South Atlantic Ocean. On board were nine crew members. GAF074 departed Niamey, Niger at 10:35 UTC. REACH 4201 took off from Windhoek at 14:11 UTC and climbed to its filed for and assigned cruise level of 35,000 feet (FL350). At the same time, GAF074 was not at its filed for cruise level of FL390 but was still at its initially assigned cruise level FL350. Windhoek ATC was in sole and continuous radio contact with REACH 4201, with no knowledge of GAF 074's movement. Luanda ATC was in radio contact with GAF074, but they were not in radio contact with REACH 4201. Luanda ATC did receive flight plans for both aircraft but a departure message for only REACH 4201. At 15:10 UTC both aircraft collided at FL350 and crashed into the sea.
Probable cause:
The primary cause of this accident, in my opinion, was GAF 074 flying a cruise level (FL350) which was not the level they had filed for (FL390). Neither FL350 nor FL390 were the correct cruise levels for that aircraft's magnetic heading according to International Civil Aviation Organization regulations. The appropriate cruise level would have been FL290, FL330, FL370, FL410, etc. A substantially contributing factor was ATC agency Luanda's poor management of air traffic through its airspace. While ATC communications could be improved, ATC agency Luanda did have all the pertinent information it needed to provide critical advisories to both aircraft. If ATC agency Luanda was unable to contact GAF 074, it should have used other communication means (HF radio, telefax or telephone) to contact REACH 4201 through ATC agency Windhoek, as outlined in governing documents. Another substantially contributing factor was the complicated and sporadic operation of the Aeronautical Fixed Telecommunications Network (AFTN). Routing of messages to affected air traffic control agencies is not direct and is convoluted, creating unnecessary delays and unfortunate misroutings. Specifically, ATC agency Windhoek did not receive a flight plan or a departure message on GAF 074, which could have been used by the controllers to identify the conflict so they could have advised REACH 4201. In my opinion, the absence of TCAS was not a cause or substantially contributing factor, but the presence of a fully operational TCAS could have prevented the accident." (William H.C. Schell, jr., Colonel, USAF President, Accident Investigation Board).

Crash of a SIAI-Marchetti SF.600TP Canguro off Fortune Island: 5 killed

Date & Time: Sep 2, 1997 at 0800 LT
Operator:
Registration:
RP-C1298
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
008
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The crew consisting of pilots and technicians were completing a training flight after PADC just acquired this aircraft. Shortly after takeoff from Fortune Island, the twin engine aircraft crashed in unknown circumstances in the sea. SAR operations were initiated and few debris were found floating on water three days later. All five occupants perished.

Crash of a Canadian Vickers PBV-1A Canso A in the San Vicente Reservoir

Date & Time: Aug 1, 1997 at 1500 LT
Registration:
N322FA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Santa Ana - Santa Ana
MSN:
CV-560
YOM:
1944
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10200
Captain / Total hours on type:
160.00
Aircraft flight hours:
17427
Circumstances:
After touching down to scoop another load of water, the pilot added power and the aircraft pitched forward. The pilot heard a pop and felt a sudden decelerative force. When the nose began to bowsuck, he applied more back pressure but the aircraft did not respond. The floor split open and water began rushing into the cockpit. The left nose gear door locking pin was found separated from its hydraulic actuator. It displayed a bend that corresponded to its retracted position in the pin guide. The deformation prevented investigators from reinserting the damaged pin back through the guide. The left mycarta block remained attached to the door and did not exhibit any damage.
Probable cause:
The implosion of the unlocked left nose gear door which resulted in the hydraulic disintegration of the forward fuselage. The cause of the locking pin actuator malfunction was not determined.
Final Report:

Crash of a Beechcraft 65 Queen Air in the Atlantic Ocean

Date & Time: Jul 24, 1997 at 1620 LT
Type of aircraft:
Registration:
N816Q
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Kendall-Tamiami – Kingston
MSN:
LC-38
YOM:
1960
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1785
Captain / Total hours on type:
21.00
Aircraft flight hours:
4300
Circumstances:
About 1 hour after departure and 15 minutes after reaching the cruising altitude of 9,000 feet, the left engine quit. The flight crew feathered the left propeller and turned toward the closest
airport which was 80 miles away. The aircraft would not maintain altitude and entered a 500 foot per minute descent. About 20 minutes after engine failure the aircraft was ditched in the ocean about 50 miles from the closest airport. The flight crew and passengers were rescued the following morning and the aircraft was not recovered. The second pilot and owner of the aircraft stated the aircraft was about 90 pounds over the maximum allowable weight at the time of departure. The previous owner of the aircraft stated that both engines had exceeded the recommended overhaul time by about 450 flight hours.
Probable cause:
Failure of the aircraft to maintain altitude for undetermined reasons following loss of power in one engine.
Final Report:

Crash of an Antonov AN-24RV off Santiago de Cuba: 44 killed

Date & Time: Jul 11, 1997 at 2156 LT
Type of aircraft:
Operator:
Registration:
CU-T1262
Flight Phase:
Survivors:
No
Schedule:
Santiago de Cuba - Havana
MSN:
27307610
YOM:
1972
Flight number:
CU787
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
39
Pax fatalities:
Other fatalities:
Total fatalities:
44
Circumstances:
Shortly after takeoff from Santiago de Cuba-Antonio Maceo Airport, while climbing by night at an altitude of 500 feet, the aircraft entered an uncontrolled descent and crashed in the sea few hundred metres offshore. The aircraft disintegrated on impact and all 44 occupants were killed, among them six Spanish and two Brazilian citizens.
Probable cause:
Loss of control following the failure of the left engine for unknown reasons.