Crash of a Mitsubishi MU-2B-60 Marquise off Papeete: 5 killed

Date & Time: May 27, 1994 at 2354 LT
Type of aircraft:
Registration:
F-GDHV
Flight Type:
Survivors:
No
Schedule:
Rarotonga - Papeete
MSN:
779
YOM:
1980
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The aircraft was completing an ambulance flight from Rarotonga (Cook Islands) to Tahiti, carrying to Australian patients, two doctors and one pilot. On final approach to Papeete-Faaa Airport runway 04 by night, the twin engine aircraft descended too low and crashed in the sea about 6,4 km short of runway. The pilot did not send any distress call prior to impact and the aircraft struck the water surface in a flat attitude. All five occupants were killed. For unknown reasons, the pilot failed to realize his altitude was insufficient on short final. The lack of visibility and visual references were considered as contributing factors.

Crash of a Piper PA-46-310P Malibu in the Gulf of Mexico

Date & Time: May 7, 1994 at 1806 LT
Registration:
N3648E
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cozumel - Houston
MSN:
46-8408067
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1500
Circumstances:
The airplane was en route at 14,000 feet msl when the manifold pressure dropped from 30 to 18 inches. Eleven minutes later the oil light came 'on'. The airplane continued under partial power at an airspeed of 90 knots, while descending at 100 to 300 feet per minute (fpm). By 9,500 feet msl the engine oil pressure dropped to zero. The pilot shut down the engine and made a forced landing in the Gulf of Mexico near a ship. The airplane remained afloat for 5 to 7 minutes. During this time, the emergency exit was opened, all occupants donned a life vest, exited, and boarded the life raft, which the pilot had deployed. All were rescued by personnel from the ship. The airplane was not recovered; therefore, the cause of the power loss was not determined.
Probable cause:
A total loss of engine power with the cause undetermined. A factor was the lack of suitable terrain for the forced landing.
Final Report:

Crash of a Douglas C-47A-20-DK off Sydney

Date & Time: Apr 24, 1994 at 0910 LT
Registration:
VH-EDC
Flight Phase:
Survivors:
Yes
Schedule:
Sydney - Norfolk Island - Lord Howe Island
MSN:
12874
YOM:
1944
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9186
Captain / Total hours on type:
927.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
250
Aircraft flight hours:
40195
Circumstances:
This accident involved a DC-3 aircraft which was owned and operated by South Pacific Airmotive Pty Ltd, who were based at Camden, NSW. It was flown on commercial operations under an Air Operators Certificate held by Groupair, who were based at Moorabbin, Vic. The aircraft had been chartered to convey college students and their band equipment from Sydney to Norfolk Island to participate in Anzac Day celebrations on the island. A flight plan, submitted by the pilot in command, indicated that the aircraft was to proceed from Sydney (Kingsford-Smith) Airport to Norfolk Island, with an intermediate landing at Lord Howe Island to refuel. The flight was to be conducted in accordance with IFR procedures, with a departure time from Sydney of 0900. The aircraft, which was carrying 21 passengers, was crewed by two pilots, a supernumerary pilot and a flight attendant. Preparations for departure were completed shortly before 0900, and the aircraft was cleared to taxi for runway 16 via taxiway Bravo Three. The pilot in command occupied the left control position. The co-pilot was the handling pilot for the departure. The aircraft was cleared for takeoff at 0907:53. The crew subsequently reported to the investigation team that all engine indications were normal during the take-off roll and that the aircraft was flown off the runway at 81 kts. During the initial climb, at approximately 200 ft, with flaps up and the landing gear retracting, the crew heard a series of popping sounds above the engine noise. Almost immediately, the aircraft began to yaw left and at 0909:04 the pilot in command advised the TWR that the aircraft had a problem. The co-pilot determined that the left engine was malfunctioning. The crew subsequently recalled that the aircraft speed at this time had increased to at least 100 kts. The pilot in command, having verified that the left engine was malfunctioning, closed the left throttle and initiated propeller feathering action. During this period, full power (48 inches Hg and 2,700 RPM) was maintained on the right engine. However, the airspeed began to decay. The handling pilot reported that he had attempted to maintain 81 KIAS but was unable to do so. The aircraft diverged to the left of the runway centreline. The co-pilot and the supernumerary pilot subsequently reported that almost full right aileron had been used to control the aircraft. They could not recall the skid-ball indication. The copilot reported that he had full right rudder or near full right rudder applied. When he first became aware of the engine malfunction, the pilot in command assessed that, although a landing back on the runway may have been possible, the aircraft was capable of climbing safely on one engine. However, when he determined that the aircraft was not climbing, and that the airspeed had reduced below 81 kts, the pilot in command took control, and at 0909:38 advised the TWR that he was ditching the aircraft. He manoeuvred the aircraft as close as possible to the southern end of the partially constructed runway 16L. The aircraft was ditched approximately 46 seconds after the pilot in command first advised the TWR of the problem. The four crew and 21 passengers successfully evacuated the aircraft before it sank. They were taken on board pleasure craft and transferred to shore. After initial assessment, they were transported to various hospitals. All were discharged by 1430 that afternoon, with the exception of the flight attendant, who had suffered serious injuries.
Probable cause:
The following factors were considered significant in the accident sequence.
1. Compliance with the correct performance charts would have precluded the flight.
2. Clear and unambiguous presentation of CAA EROPs documentation should have precluded the flight.
3. The aircraft weight at takeoff exceeded the MTOW, the extent of which was unknown to the crew.
4. An engine malfunction and resultant loss of performance occurred soon after takeoff.
5. The operations manual take-off safety speed used by the crew was inappropriate for the overloaded condition of the aircraft.
6. The available single-engine aircraft performance was degraded when the co-pilot mishandled the aircraft controls.
7. The pilot in command delayed taking over control of the aircraft until the only remaining option was to conduct a controlled ditching.
8. There were organisational deficiencies in the management and operation of the DC-3 involving both Groupair and SPA.
9. There were organisational deficiencies in the safety regulation of both Groupair and SPA by the CAA district offices at Moorabbin and Bankstown.
10. There were organisational deficiencies relating to safety regulation of EROPS by the CAA.
Final Report:

Crash of a Grumman G-73 Turbo Mallard off Key West: 2 killed

Date & Time: Mar 18, 1994 at 1143 LT
Type of aircraft:
Operator:
Registration:
N150FB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Key West Harbour - Key West
MSN:
J-51
YOM:
1950
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7725
Captain / Total hours on type:
3100.00
Aircraft flight hours:
17119
Circumstances:
The flightcrew had completed a 14 cfr part 135 charter flight and had landed in the harbor at Key West, Florida. They had moored the seaplane and departed. About an hour later, they reboarded the seaplane to fly it to an airport for refueling, then to return to the harbor to board the passengers. During takeoff, the seaplane was observed to pitch nose up, roll left, and crash nose down in the harbor. Due to the damage done by tidal flow and recovery attempts, the exact condition of the aft bilge drain plugs was unknown. During a check of the CVR recording, the crew was not heard to call out the bilge pumps during the before-takeoff checklist. After lift-off, both pilots made comments about keeping the nose down due to water in the aft portion of the aircraft. Both pilots were killed.
Probable cause:
Failure of the pilot-in-command to assure the bilges were adequately pumped free of water (adequately preflighted), which resulted in the aft center of gravity limit to be exceeded, and failure of the aircrew to follow the checklist. A factor related to the accident was: the water leak.
Final Report:

Crash of a Lockheed AC-130H Hercules off Malindi: 8 killed

Date & Time: Mar 14, 1994
Type of aircraft:
Operator:
Registration:
69-6576
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Mombasa - Mogadishu
MSN:
4351
YOM:
1969
Location:
Country:
Region:
Crew on board:
14
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
En route from Mombasa to Mogadishu, while in cruising altitude over the Indian Ocean, the crew contacted ATC and declared an emergency following an explosion in the cargo compartment. The crew initiated an emergency descent and elected to divert to the nearest airport when control was lost. The aircraft crashed in the sea about 200 metres offshore, some 7 km from Malindi. Six crew members were rescued while eight others were killed.
Probable cause:
A 105 mm shell exploded in a gun barrel for unknown reasons.

Crash of a Cessna 425 Conquest off Altenrhein: 5 killed

Date & Time: Jan 24, 1994
Type of aircraft:
Operator:
Registration:
D-IEFW
Survivors:
No
Schedule:
Riga - Prague - Altenrhein - Paris
MSN:
425-0228
YOM:
1985
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The twin engine aircraft was completing a charter flight from Riga to Paris-Le Bourget with intermediate stops in Prague and Altenrhein. On approach to Altenrhein Airport, the aircraft lost height and crashed in the Constance Lake (Bodensee) about 4 km short of runway 10, off Rorschach. Three dead bodies were found few days later and the wreckage was located at a depth of 160 metres on February 7 only. The bodies of the pilot, a female passenger and a dog were never recovered.
Probable cause:
The exact cause of the accident could not be determined. The aircraft quickly lost altitude on final for unknown reasons.

Crash of a Consolidated PBY-5A Catalina in the Pacific Ocean

Date & Time: Jan 15, 1994
Type of aircraft:
Registration:
N5404J
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Los Angeles - Hilo - Papeete
MSN:
22022
YOM:
1943
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was transferred from Los Angeles to New Zealand via Hilo and Papeete, Tahiti. En route, while cruising at the altitude of 1,500 metres, the crew encountered technical problems with the left engine and decided to divert to Christmas Island. The left engine eventually failed and as the crew as unable to maintain a safe altitude because the aircraft was heavy (load of fuel to cross the Pacific), he decided to ditch the aircraft about 150 km north of Christmas Island. The aircraft sank four hours later and was lost. All eight occupants were rescued by the crew of a merchant ship eight hours later.
Probable cause:
Failure of the left engine for unknown reasons.

Crash of a Rockwell Grand Commander 690 off Sydney: 1 killed

Date & Time: Jan 14, 1994 at 0114 LT
Registration:
VH-BSS
Flight Type:
Survivors:
No
Schedule:
Canberra - Sydney
MSN:
690-11044
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1800
Captain / Total hours on type:
50.00
Aircraft flight hours:
7975
Circumstances:
On 14 January 1994 at 0114, Aero Commander 690 aircraft VH-BSS struck the sea while being radar vectored to intercept the Instrument Landing System approach to runway 34 at Sydney (Kingsford-Smith) Airport, NSW. The last recorded position of the aircraft was about 10 miles to the south-east of the airport. At the time of the accident the aircraft was being operated as a cargo charter flight from Canberra to Sydney in accordance with the Instrument Flight Rules. The body of the pilot who was the sole occupant of the aircraft was never recovered. Although wreckage identified as part of the aircraft was located on the seabed shortly after the accident, salvage action was not initially undertaken. This decision was taken after consideration of the known circumstances of the occurrence and of the costs of salvage versus the potential safety benefit that might be gained from examination of the wreckage. About 18 months after the accident, the wing and tail sections of the aircraft were recovered from the sea by fishermen. As a result, a detailed examination of that wreckage was carried out to assess the validity of the Bureau’s original analysis that the airworthiness of the aircraft was unlikely to have been a factor in this accident. No evidence was found of any defect which may have affected the normal operation of the aircraft. The aircraft descended below the altitude it had been cleared to by air traffic control. From the evidence available it was determined that the circumstances of this accident were consistent with controlled flight into the sea.
Probable cause:
Findings
1. The pilot held a valid pilot licence, endorsed for Aero Commander 690 aircraft.
2. The pilot held a valid multi-engine command instrument rating.
3. There was no evidence found to indicate that the performance of the pilot was adversely affected by any physiological or psychological condition.
4. The aircraft was airworthy for the intended flight, despite the existence of minor anomalies in maintenance and serviceability of aircraft systems.
5. The aircraft carried fuel sufficient for the flight.
6. The weight and balance of the aircraft were estimated to have been within the normal limits.
7. Recorded radio communications relevant to the operation of the aircraft were normal.
8. Relevant ground-based aids to navigation were serviceable.
9. At the time of impact the aircraft was capable of normal flight.
10. The aircraft was fitted with an altitude alerting system.
11. The aircraft was not fitted with a ground proximity warning system.
12. The aircraft was equipped with a transponder which provided aircraft altitude information to be displayed on Air Traffic Control radar equipment.
3.2 Significant factors
1. The pilot was relatively inexperienced in single-pilot Instrument Flight Rules operations on the type of aircraft being flown.
2. The aircraft was being descended over the sea in dark-night conditions.
3. The workload of the pilot was significantly increased by his adoption of a steep descent profile at high speed, during a phase of flight which required multiple tasks to be completed in a limited time prior to landing. Radio communications with another company aircraft during that critical phase of flight added to that workload.
4. The pilot probably lost awareness of the vertical position of the aircraft as a result of distraction by other tasks.
5. The aircraft was inadvertently descended below the altitude authorized by Air Traffic Control.
6. The secondary surveillance radar system in operation at the time provided an aircraft altitude readout which was only updated on every sixth sweep of the radar display.
7. The approach controller did not notice a gross change of aircraft altitude shortly after a normal radio communication with the pilot.
Final Report:

Crash of a Beechcraft 65-90 King Air off Marseille

Date & Time: Jan 13, 1994
Type of aircraft:
Registration:
N46WA
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
LJ-65
YOM:
1965
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot, sole on board, was completing a ferry flight from Germany to the US via Lisbon and the Azores Islands. While cruising at FL130 off Martigues, smoke spread in the cockpit. The pilot started en emergency descent and eventually ditched the aircraft in the Gulf of Lion off Marseille. The pilot was rescued while the aircraft sank and was lost.

Crash of a Piper PA-31-310 Navajo C in Lourdes-de-Blanc-Sablon: 2 killed

Date & Time: Jan 11, 1994 at 1854 LT
Type of aircraft:
Operator:
Registration:
C-GDOU
Flight Type:
Survivors:
No
Schedule:
Saint Anthony - Lourdes-de-Blanc-Sablon
MSN:
31-7612033
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8000
Captain / Total hours on type:
1550.00
Copilot / Total flying hours:
1079
Copilot / Total hours on type:
650
Aircraft flight hours:
11050
Circumstances:
On 11 January 1994, the crew were on a chartered round-robin flight on a PA-31 Navajo, between Lourdes-de-Blanc-Sablon airport, Quebec, and St. Anthony, Newfoundland, in accordance with visual flight rules (VFR) . During the return flight, at night, the crew advised the St. Anthony flight service station (FSS) that they departed at 1813 Newfoundland standard time (NST). At 1846 NST, the crew transmitted that they were flying at 2,500 feet and that they were 32 nautical miles (nm) and 13 minutes southeast of Blanc-Sablon. Seven minutes later, the crew called the Sept-Iles FSS through the Blanc-Sablon repeater. They requested airport information and reported being 16 nm and six minutes from the airport. After receiving information on the winds and the altimeter setting, the crew reported that they would use runway 05 and would call back on final. No further transmissions were received from the crew. Fishermen found the wreckage seven months later.
Probable cause:
The cause of the occurrence could not be determined; however, it is probable that the pilots did not monitor the altimeter properly and allowed the aircraft to descend until it struck the surface of the ice.
Final Report: