Crash of a Dassault Falcon 20E in Peterborough

Date & Time: Jun 13, 2000 at 2250 LT
Type of aircraft:
Operator:
Registration:
N184GA
Flight Type:
Survivors:
Yes
Schedule:
Louisville – Marion – Detroit – Peterborough
MSN:
266
YOM:
1972
Flight number:
GAE184
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11800
Captain / Total hours on type:
9400.00
Copilot / Total flying hours:
2300
Copilot / Total hours on type:
150
Aircraft flight hours:
15798
Circumstances:
The Dassault-Breguet Falcon 20E aircraft was on an unscheduled charter cargo flight from Detroit Willow Run, Michigan, USA, to Peterborough, Ontario. The flight was being conducted at night and under instrument flight rules in instrument meteorological conditions. Nearing the destination, the flight crew received a clearance to conduct a non-directional beacon runway 09 approach at Peterborough Airport. The flight crew did not acquire the runway environment during this approach and conducted a missed approach procedure. They obtained another clearance for the same approach from Toronto Area Control Centre. During this approach, the flight crew acquired the runway environment and manoeuvred the aircraft for landing on runway 09. The aircraft touched down near the runway midpoint, and the captain, who was the pilot flying, elected to abort the landing. The captain then conducted a left visual circuit to attempt another landing. As the aircraft was turning onto the final leg, the approach became unstabilized, and the flight crew elected to overshoot; however, the aircraft pitched nose-down, banked left, and struck terrain. As it travelled 400 feet through a ploughed farm field, the aircraft struck a tree line and came to rest about 2000 feet before the threshold of runway 09, facing the opposite direction. The aircraft was substantially damaged. No serious injuries occurred.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The captain's attempt to continue the landing during the second approach was contrary to company standard operating procedures and Federal Aviation Regulations, in that the approach was unstable and the aircraft was not in a position to land safely.
2. Following the aborted landing, the flight crew proceeded to conduct a circling approach to runway 09, rather than the missed approach procedure as briefed.
3. The pilot lost situational awareness during the overshoot after the third failed attempt to land, likely when he was subjected to somatogravic illusion.
4. Breakdown in crew coordination after the aborted landing, lack of planning and briefing for the subsequent approach, operating in a dark, instrument meteorological conditions environment with limited visual cues, and inadequate monitoring of flight instruments contributed to the loss of situational awareness.
Final Report:

Crash of a Swearingen SA226AC Metro II in Montreal: 11 killed

Date & Time: Jun 18, 1998 at 0728 LT
Type of aircraft:
Operator:
Registration:
C-GQAL
Survivors:
No
Schedule:
Montreal - Peterborough
MSN:
TC-233
YOM:
1977
Flight number:
PRO420
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
11
Captain / Total flying hours:
6515
Captain / Total hours on type:
4200.00
Copilot / Total flying hours:
2730
Copilot / Total hours on type:
93
Aircraft flight hours:
28931
Circumstances:
On the morning of 18 June 1998, Propair 420, a Fairchild-Swearingen Metro II (SA226-TC), C-GQAL, took off for an instrument flight rules flight from Dorval, Quebec, to Peterborough, Ontario. The aircraft took off from Runway 24 left (L) at 0701 eastern daylight time. During the ground acceleration phase, the aircraft was pulling to the left of the runway centreline, and the right rudder was required to maintain take-off alignment. Two minutes later, Propair 420 was cleared to climb to 16 000 feet above sea level (asl). At 0713, the crew advised the controller of a decrease in hydraulic pressure and requested to return to the departure airport, Dorval. The controller immediately gave clearance for a 180° turn and descent to 8000 feet asl. During this time, the crew indicated that, for the moment, there was no on-board emergency. The aircraft initiated its turn 70 seconds after receiving clearance. At 0713:36, something was wrong with the controls. Shortly afterward came the first perceived indication that engine trouble was developing, and the left wing overheat light illuminated about 40 seconds later. Within 30 seconds, without any apparent checklist activity, the light went out. At 0718:12, the left engine appeared to be on fire, and it was shut down. Less than one minute later, the captain took the controls. The flight controls were not responding normally: abnormal right aileron pressure was required to keep the aircraft on heading. At 0719:19, the crew advised air traffic control (ATC) that the left engine was shut down, and, in response to a second suggestion from ATC, the crew agreed to proceed to Mirabel instead of Dorval. Less than a minute and a half later, the crew informed ATC that flames were coming out of the 'engine nozzle'. Preparations were made for an emergency landing, and the emergency procedure for manually extending the landing gear was reviewed. At 0723:10, the crew informed ATC that the left engine was no longer on fire, but three and a half minutes later, they advised ATC that the fire had started again. During this time, the aircraft was getting harder to control in roll, and the aileron trim was set at the maximum. Around 0727, when the aircraft was on short final for Runway 24L, the landing gear lever was selected, but only two gear down indicator lights came on. Near the runway threshold, the left wing failed upwards. The aircraft then rotated more than 90° to the left around its longitudinal axis and crashed, inverted, on the runway. The aircraft immediately caught fire, slid 2500 feet, and came to rest on the left side the runway. When the aircraft crashed, firefighters were near the runway threshold and responded promptly. The fire was quickly brought under control, but all occupants were fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
- The crew did not realize that the pull to the left and the extended take-off run were due to the left brakes' dragging, which led to overheating of the brake components.
- Dragging of the left brakes was most probably caused by an unidentified pressure locking factor upstream of the brakes on take-off. The dragging caused overheating and leakage, probably at one of the piston seals that retain the brake hydraulic fluid.
- When hydraulic fluid leaked onto the hot brake components, the fluid caught fire and initiated an intense fire in the left nacelle, leading to failure of the main hydraulic system.
- When the L WING OVHT light went out, the overheating problem appeared corrected; however, the fire continued to burn.
- The crew never realized that all of the problems were associated with a fire in the wheel well, and they did not realize how serious the situation was.
- The left wing was weakened by the wing/engine fire and failed, rendering the aircraft uncontrollable.
Findings as to Risk:
- Numerous previous instances of brake overheating or fire on SA226 and SA227 aircraft had the potential for equally tragic consequences. Not all crews flying this type of aircraft are aware of its history of numerous brake overheating or fire problems.
- The aircraft flight manual and the emergency procedures checklist provide no information on the possibility of brake overheating, precautions to prevent brake overheating, the symptoms that could indicate brake problems, or actions to take if overheated brakes are suspected.
- More stringent fire-blocking requirements would have retarded combustion of the seats, reducing the fire risk to the aircraft occupants.
- A mixture of the two types of hydraulic fluid lowered the temperature at which the fluid would ignite, that is, below the flashpoint of pure MIL-H-83282 fluid.
- The aircraft maintenance manual indicated that the two hydraulic fluids were compatible but did not mention that mixing them would reduce the fire resistance of the fluid.
Other Findings:
- The master cylinders were not all of the same part number, resulting in complex linkage and master cylinder adjustments, complicated overall brake system functioning, and difficult troubleshooting of the braking system. However, there was no indication that this circumstance caused residual brake pressure.
- The latest recommended master cylinders are required to be used only with specific brake assembly part numbers, thereby simplifying adjustments, functioning, and troubleshooting.
- Although the emergency checklist for overheating in the wing required extending the landing gear, the crew did not do this because the wing overheat light went out before the crew initiated the checklist.
- The effect of the fire in the wheel well made it difficult to move the ailerons, but the exact cause of the difficulty was not determined.
Final Report:

Crash of a Pilatus PC-6/B2-H2 Turbo Porter near Peterborough

Date & Time: Dec 18, 1983 at 1042 LT
Operator:
Registration:
G-BIZP
Flight Phase:
Survivors:
Yes
Schedule:
Peterborough - Peterborough
MSN:
812
YOM:
1981
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2350
Captain / Total hours on type:
700.00
Circumstances:
The aircraft took off on the first flight of the day with eight parachutists, and a reported fuel load of 70 US gallons. At an altitude of approximately 11,000 feet it was decided that the cloud cover at that time was obscuring the dropping zone to an unacceptable degree, and so the detail was cancelled. During the subsequent descent, on rolling out of a left turn at about 4,500 feet, a bang was heard, and the left aileron was seen to have become partially detached. After a violent lateral oscillation of the control column lasting a few seconds, the right aileron also became partially detached. At this stage the parachutists successfully abandoned the aircraft on the orders of the pilot. The aircraft then adopted an angle of bank to the right of approximately 45° despite the application of full left rudder. The descent was continued until the pilot realized that the aircraft was approaching the village of Yarwell; he therefore applied engine power to ensure that the aircraft would clear the houses. The bank angle then increased to 60° and the aircraft struck the ground right wing low, coming to rest upright, and facing the opposite direction. The pilot sustained minor injuries, and there was no fire.
Probable cause:
Subsequent examination showed that, on each aileron, the centre of the three attachments to the wing had suffered an in-flight failure, leading to the subsequent detachment of one half of each aileron control surface. Detailed inspection revealed the presence of fatigue in each of the rear angle brackets, located within the wing, to which are attached the aileron supports. Preliminary indications are that the point of primary failure occurred at the left aileron rear angle bracket; the remaining brackets had failed subsequently as a result of overload.
Final Report:

Crash of a Lockheed C-141A-LM Starlifter near Peterborough: 18 killed

Date & Time: Aug 28, 1976 at 1240 LT
Type of aircraft:
Operator:
Registration:
67-0006
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
McGuire - Mildenhall - Torrejón
MSN:
300-6259
YOM:
1967
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
18
Aircraft flight hours:
14989
Circumstances:
The Starlifter registered 67-0006 had a recent history of weather radar problems. It had been written up by crew members eight times previously. On the day of the accident the maintenance crewman, unaware of the previous problems, checked the radar. It seemed to be working, so it was signed off as "Ops Check Okay". Shortly after takeoff from McGuire AFB, the crew noticed that the radar was inoperative. Since severe weather was not forecast, they elected to continue to RAF Mildenhall, UK. Two hours after takeoff, British forecasters issued a SIGMET for "Moderate to occasional severe clear air turbulence from FL240 to FL400", but the crew never got this report. Four hours after takeoff the crew updates the weather forecast. They receive a weather forecast of "3/8 at 3000 feet, 4/8 at 4000 feet with an intermittent condition of wind 030/12 gusting 22, visibility five miles in thunderstorms, 2/8 at 2000 feet 5/8 at 2500 feet". The crew then attempted to get an update one hour from Mildenhall, but was unable to contact the base. Another station reported "4/8 Thunderstorms tops to FL260". During the enroute decent they entered the clouds. At FL150, they requested vectors around the weather. Because the primary radar was inoperative, the controller advised that he would have difficulty providing avoidance vectors. The aircraft then entered the leading edge of a very strong line of thunderstorm cells. One estimate indicated they encountered a 100 mph downward vertical airshaft. The right wing had failed, followed quickly by the upper half of the vertical stabilizer, and the four engines.
Source: C-141 Lifetime Mishap Summary / Lt. Col. Paul M. Hansen
Probable cause:
Loss of control due to severe atmospheric turbulences in thunderstorm activity.

Crash of a Beechcraft C18 Expeditor near Peterborough: 2 killed

Date & Time: Oct 18, 1958
Type of aircraft:
Operator:
Registration:
1420
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Camp Borden – Trenton
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was completing a VFR flight from Camp Borden to Trenton when the twin engine aircraft crashed in unknown circumstances. Both pilots were killed.
Crew:
S/L Eric Robert McDowall,
F/Lt Edward Arthur Elson.

Crash of a Boeing B-17F Flying Fortress in Whaplode Drove: 5 killed

Date & Time: Jan 7, 1944
Operator:
Registration:
42-29821
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
4935
YOM:
1942
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
En route, went out of control, dove into the ground and crashed in an open field located in Whaplode Drove, some 20 km northeast of Peterborough. Five crew were killed while five other were injured.
Probable cause:
The loss of control was caused by an in-flight structural failure.

Crash of a De Havilland DH.80 Puss Moth in Peterborough

Date & Time: Aug 21, 1935
Operator:
Registration:
179
Flight Type:
Survivors:
Yes
Schedule:
Camp Borden - Peterborough
MSN:
DHC.210
YOM:
1930
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing, the aircraft went out of control and came to rest. The pilot was unhurt and the aircraft was damaged beyond repair.

Crash of an Avro 504K in Peterborough: 3 killed

Date & Time: Jun 24, 1920
Type of aircraft:
Operator:
Registration:
G-EADR
Flight Type:
Survivors:
Yes
Schedule:
Bournemouth - Peterborough
MSN:
D6245
YOM:
1919
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
While on approach to Peterborough Airport, the single engine aircraft suffered a wing failure and crashed in a field. The aircraft was destroyed and all three occupants were killed.
Crew:
Donald Hastings Sadler, pilot.
Passengers:
Mr. Charles Guest,
Mr. Philip Warwick Rinquest.
Probable cause:
Loss of control on approach following a structural failure on both wings.