Crash of a Cessna 208B Super Cargomaster off Saba Island

Date & Time: Aug 12, 2015 at 1205 LT
Type of aircraft:
Operator:
Registration:
N924FE
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
San Juan – Basseterre
MSN:
208B-0024
YOM:
1987
Flight number:
FDX8124
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot departed San Juan-Luis Muñoz Marín Airport at 1049LT on a cargo flight to Basseterre-Robert L. Bradshaw International Airport, Saint Kitts & Nevis. The flight was performed by Mountain Air Cargo on behalf of FedEx. The pilot continued the flight at FL110 until 1139LT, reduced his altitude down to FL100 and maintained this level until 1153LT. At this moment, the aircraft was descending between 600 and 800 feet per minute and the pilot decided to divert to the Juancho E. Yrausquin Airport located on Saba Island, Dutch Antilles. While approaching to island from the south, the pilot realized he would not make it, so he attempted to ditch the aircraft some 900 metres off shore. The pilot evacuated the cabin and was quickly rescued while the aircraft sank by a depth of about 1,500 feet. According to the pilot, he decided to divert to the nearest airport due to a loss of engine power.

Crash of a Short 360-200 off Sint Maarten: 2 killed

Date & Time: Oct 29, 2014 at 1840 LT
Type of aircraft:
Operator:
Registration:
N380MQ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sint Maarten - San Juan
MSN:
3702
YOM:
1986
Flight number:
SKZ7101
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5318
Captain / Total hours on type:
361.00
Copilot / Total flying hours:
1040
Copilot / Total hours on type:
510
Aircraft flight hours:
25061
Aircraft flight cycles:
32824
Circumstances:
On October 29, 2014, at about 1840 Atlantic Standard Time, a Shorts SD3-60, United States registered N380MQ was destroyed when it crashed into the sea shortly after takeoff from Runway 28 at Princess Juliana International Airport, Sint Maarten, Dutch Antilles, Kingdom of the Netherlands. The two crewmembers on board sustained fatal injuries. The aircraft was operated by SkyWay Enterprises Inc. on a scheduled FedEx contract cargo flight to Luis Munoz Marin International Airport, San Juan, Puerto Rico. At 1839 local, Juliana Tower cleared the aircraft for takeoff Runway 28 - maintain heading 230 until passing 4000 feet. At 1840 local, Tower observed the aircraft descending visually and the radar target and data block disappeared. There were no distress calls. Night conditions and rain prevailed at the time of the accident. Coast Guard search crews discovered aircraft debris close to the shoreline about 1 ½ hours later. The Sint Maarten Civil Aviation Authority initiated an investigation in accordance with ICAO Annex 13. Local investigation authority personnel were joined by Accredited Representatives and advisors from the following states: the USA (NTSB/FAA), United Kingdom (AAIB and Shorts Brothers PLC), and Canada (TSB, TC, PWC). Organization of the investigation included the following groups: Operations, Accident Site and Wreckage, Powerplants, Aircraft Maintenance, Air Traffic Services, Meteorology, and GPS Study. The operator made available personnel for interviews but deferred to participate in the groups. Flight recorders were not installed nor required on this cargo configured aircraft. The original FDR and CVR were removed following conversion to cargo only operations. A handheld GPS recovered from submerged wreckage was successfully downloaded. Data revealed the aircraft past the departure runway threshold on takeoff and attained a maximum GPS recorded altitude of 433 feet at 119 knots groundspeed at 18:39:30. The two remaining data points were over the sea and recorded decreasing altitude and increasing airspeed. The wreckage was recovered from the sea and examined by technical experts. Assessment of the evidence concluded there were no airframe or engine malfunctions that would have affected the airworthiness of the aircraft. The experts concluded that the aircraft struck the sea while under normal engine operation. Operations and human performance investigators evaluated the evidence and analyzed extensive interviews. The investigation concluded that the aircraft departed from the expected flight path in an unusual attitude. The pilot flying most likely experienced a somatographic illusion as a result of a stressful takeoff and acceleration from flap retraction. The pilot’s reaction to pitch down while initiating a required heading change led to an extreme unusual attitude. Circumstances indicate the pilot monitoring did not perceive/respond/intervene to correct the flight path and recover from the unusual attitude. The aircraft exceeded the normal maneuvering parameters, the crew experienced a loss of control, and lacking adequate altitude for recovery, the aircraft crashed into the sea.
Probable cause:
The investigation believes the PF experienced a loss of control while initiating a turn to the required departure heading after take-off. Flap retraction and its associated acceleration combined to set in motion a somatogravic illusion for the PF. The PF’s reaction to pitch down while initiating a turn most likely led to an extreme unusual attitude and the subsequent crash. PM awareness to the imminent loss of control and any attempt to intervene could not be determined. Evidence show that Crew resource management (CRM) performance was insufficient to avoid the crash. Contributing factors to the loss of control were environmental conditions including departure from an unfamiliar runway with loss of visual references (black hole), night and rain with gusting winds.
Final Report:

Crash of a BAe 3101 Jetstream 31 in Punta Cana

Date & Time: Oct 12, 2014 at 2025 LT
Type of aircraft:
Operator:
Registration:
HI816
Survivors:
Yes
Schedule:
San Juan - Punta Cana
MSN:
694
YOM:
18
Crew on board:
3
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3850
Captain / Total hours on type:
3000.00
Aircraft flight hours:
29780
Circumstances:
The twin engine aircraft departed San Juan-Luis Muñoz Marín (Isla Verde) Airport, Puerto Rico, on a charter flight to Punta Cana, carrying two pilots, one flight attendant and 10 crew members from Air Europa positioning to Punta Cana. Following an uneventful flight, the crew completed the approach and landing on runway 08. After a roll of about 1,500 feet, the aircraft deviated to the left, made a 45° turn, veered off runway and came to rest in a wooded area, bursting into flames. All 13 occupants evacuated safely, among them two passengers were slightly injured. The aircraft was destroyed.
Probable cause:
The accident was the consequence of the combination of human and technical factor. During the approach to land, the crew observed a fluctuation in oil pressure in the instrument panel of the #2 (right) engine. After landing, the crew activated the thrust reversers on both engines without waiting for the Beta light, an essential indication to ensure a proper operation of those system. This configuration caused the aircraft to turn sharply to the left at an angle of 45° because the thrust reverser system activated on the left engine only. The fluctuation in the oil pressure observed by the crew on final approach and the malfunction of the right engine was the consequence of an oil leak in flight.
Final Report:

Crash of a Swearingen SA227AC Metro III in La Alianza: 2 killed

Date & Time: Dec 2, 2013 at 2010 LT
Type of aircraft:
Operator:
Registration:
N831BC
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
CSQ405
MSN:
AC-654B
YOM:
1986
Flight number:
Santo Domingo - San Juan
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1740
Captain / Total hours on type:
686.00
Copilot / Total flying hours:
1954
Copilot / Total hours on type:
92
Aircraft flight hours:
33888
Circumstances:
The captain and first officer were conducting an international cargo flight in the twin-engine turboprop airplane. After about 40 minutes of flight during night visual meteorological conditions, an air traffic controller cleared the airplane for a descent to 7,000 ft and then another controller further cleared the airplane for a descent to 3,000 ft and told the flight crew to expect an ILS (instrument landing system) approach. During the descent, about 7,300 ft and about 290 kts, the airplane entered a shallow left turn, followed by a 45-degree right turn and a rapid, uncontrolled descent, during which the airplane broke up about 1,500 ft over uneven terrain. The moderately loaded cargo airplane was not equipped with a flight data recorder or cockpit voice recorder (CVR) (although it previously had a CVR in its passenger configuration) nor was it required by Federal Aviation Administration (FAA) regulations. There were also no avionics on board with downloadable or nonvolatile memory. As a result, there was limited information available to determine what led to the uncontrolled descent or what occurred as the flight crew attempted to regain control of the airplane. Also, although the first officer was identified in FAA-recorded radio transmissions several minutes before the loss of control and it was company policy that the pilot not flying make those transmissions, it could not be determined who was at the controls when either the loss of control occurred or when the airplane broke up. There was no evidence of any in-flight mechanical failures that would have resulted in the loss of control, and the airplane was loaded within limits. Evidence of all flight control surfaces was confirmed, and, to the extent possible, flight control continuity was also confirmed. Evidence also indicated that both engines were operating at the time of the accident, and, although one of the four propeller blades from the right propeller was not located after separating from the fractured hub, there was no evidence of any preexisting propeller anomalies. The electrically controlled pitch trim actuator did not exhibit any evidence of runaway pitch, and measurements of the actuator rods indicated that the airplane was trimmed slightly nose low, consistent for the phase of flight. Due to the separation of the wings and tail, the in-flight positions of the manually operated aileron and rudder trim wheels could not be determined. Other similarly documented accidents and incidents generally involved unequal fuel burns, which resulted in wing drops or airplane rolls. In one case, the flight crew intentionally induced an excessive slide slip to balance fuel between the wings, which resulted in an uncontrolled roll. However, in the current investigation, the fuel cross feed valve was found in the closed position, indicating that a fuel imbalance was likely not a concern of the flight crew. In at least two other events, unequal fuel loads also involved autopilots that reached their maximum hold limits, snapped off, and rolled the airplane. Although the airplane in this accident did not have an autopilot, historical examples indicate that a sudden yawing or rolling motion, regardless of the source, could result in a roll, nose tuck, and loss of control. The roll may have been recoverable, and in one documented case, a pilot was able to recover the airplane, but after it lost almost 11,000 ft of altitude. During this accident flight, it was likely that, during the descent, the flight crew did regain control of the airplane to the extent that the flight control surfaces were effective. With darkness and the rapid descent at a relatively low altitude, one or both crewmembers likely pulled hard on the yoke to arrest the downward trajectory, and, in doing so, placed the wings broadside against the force of the relative wind, which resulted in both wings failing upward. As the wings failed, the propellers simultaneously chopped through the fuselage behind the cockpit. At the same time, the horizontal stabilizers were also positioned broadside against the relative wind, and they also failed upward. Evidence also revealed that, at some point, the flight crew lowered the landing gear. Although it could not be determined when they lowered the gear, it could have been in an attempt to slow or regain control of the airplane during the descent. Although reasons for the loss of control could not be definitively determined, the lack of any preexisting mechanical anomalies indicates a likelihood of flight crew involvement. Then, during the recovery attempt, the flight crew's actions, while operating under the difficult circumstances of darkness and rapidly decreasing altitude, resulted in the overstress of the airplane.
Probable cause:
The flight crew's excessive elevator input during a rapid descent under night lighting conditions, which resulted in the overstress and breakup of the airplane. Contributing to the
accident was an initial loss of airplane control for reasons that could not be determined because postaccident examination revealed no mechanical anomalies that would have
precluded normal operation.
Final Report:

Ground accident of a Douglas C-54G Skymaster in San Juan

Date & Time: Mar 22, 2012 at 1915 LT
Type of aircraft:
Registration:
N406WA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Christiansted – San Juan
MSN:
35944
YOM:
1945
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful cargo flight from Christiansted-Henry E. Rohlsen Airport, the crew completed the landing normally at San Juan-Luis Muñoz Marin Airport. While taxiing to the ramp, the nose gear collapsed and the aircraft came to rest. Both pilots escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
No investigations were conducted by the NTSB.

Crash of a Convair CV-440-38 in San Juan: 2 killed

Date & Time: Mar 15, 2012 at 0738 LT
Operator:
Registration:
N153JR
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
San Juan - Sint Marteen
MSN:
117
YOM:
1953
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
22586
Captain / Total hours on type:
9000.00
Copilot / Total flying hours:
2716
Copilot / Total hours on type:
700
Circumstances:
The airplane, operated by Fresh Air, Inc., crashed into a lagoon about 1 mile east of the departure end of runway 10 at Luis Muñoz Marín International Airport (SJU), San Juan, Puerto Rico. The two pilots died, and the airplane was destroyed by impact forces. The airplane was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 1251 as a cargo flight. Visual meteorological conditions prevailed at the time of the accident, and a visual flight rules flight plan was filed. The flight had departed from runway 10 at SJU destined for Princess Juliana International Airport, St. Maarten. Shortly after takeoff, the first officer declared an emergency, and then the captain requested a left turn back to SJU and asked the local air traffic controllers if they could see smoke coming from the airplane (the two tower controllers noted in postaccident interviews that they did not see more smoke than usual coming from the airplane). The controllers cleared the flight to land on runway 28, but as the airplane began to align with the runway, it crashed into a nearby lagoon (Laguna La Torrecilla). Radar data shows that the airplane was heading south at an altitude of about 520 ft when it began a descending turn to the right to line up with runway 28. The airplane continued to bank to the right until radar contact was lost. The estimated airspeed at this point was only 88 knots, 9 knots below the published stall speed for level flight and close to the 87-knot air minimum control speed. However, minimum control speeds increase substantially for a turn into the inoperative engine as the accident crew did in the final seconds of the flight. As a result, the airplane was operating close to both stall and controllability limits when radar contact was lost. Pilots flying multiengine aircraft are generally trained to shut down the engine experiencing a problem and feather that propeller; thus, the flight crew likely intended to shut down the right engine by bringing the mixture control lever to the IDLE CUTOFF position and feathering the right propeller, as called out in the Engine Fire In Flight Checklist. This would have left the flight crew with the left engine operative to return to the airport. However, postaccident examinations revealed that the left propeller was found feathered at impact, with the left engine settings consistent with the engine at takeoff or climb setting. The right engine settings were generally consistent with the engine being shut down; however, the right propeller’s pitch was consistent with a high rotation/takeoff power setting. The accident airplane was not equipped with a flight data recorder or a cockpit voice recorder (nor was it required to be so equipped); hence, the investigation was unable to determine at what point in the accident sequence the flight crew shut down the right engine and at what point they feathered the left propeller, or why they would have done so. Post accident examination of the airplane revealed fire and thermal damage to the airframe on the airplane’s right wing rear spar, nacelle aft of the power section, and in the vicinity of the junction between the augmentor assemblies and the exhaust muffler assembly. While the investigation was unable to determine the exact location of the ignition source, it appears to have been aft of the engine in the vicinity of the junction between the augmentor assemblies and exhaust muffler assembly. The investigation identified no indication of a fire in the engine proper and no mechanical failures that would have prevented the normal operation of either engine.
Probable cause:
The flight crew's failure to maintain adequate airspeed after shutting down the right engine due to an in-flight fire in one of the right augmentors. The failure to maintain airspeed resulted in either an aerodynamic stall or a loss of directional control.
Final Report:

Ground fire of a Douglas DC-3C in San Juan

Date & Time: Apr 26, 2009 at 0428 LT
Type of aircraft:
Operator:
Registration:
N136FS
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
San Juan - Charlotte Amalie
MSN:
10267
YOM:
1943
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
50233
Captain / Total hours on type:
7000.00
Copilot / Total flying hours:
957
Copilot / Total hours on type:
204
Aircraft flight hours:
19952
Circumstances:
During taxi to a runway, the instrument panel and cockpit floor erupted in flames. Examination of the wreckage revealed that the majority of the wires contained inside the main junction box had very little damage except for two wires that had insulation missing. The damage appeared to be associated with the routing of the two wires. Both wires were connected to the battery relay and ran through wires in and around the exposed terminal studs. Heat damage was noted on the insulation of wires and other components that were in contact with the exposed wires. The wires ran from the battery relay to the forward section of the cockpit, where the fire started. Due to the fire damage that consumed the cockpit, the examination was unable to determine what system the wires were associated with. Further examination revealed that the fuel pressure was a direct indicating system. Fuel traveled directly to the instruments in the cockpit via rigid aluminum lines routed on the right lower side of the fuselage, where more severe fire damage was noted. Review of maintenance records did not reveal any evidence of the fuel pressure indicating system lines and hoses having ever been replaced; however, they were only required to be replaced on an as-needed basis. The electrical system, instrument lines, and hoses through the nose compartment were required to be inspected on a Phase D inspection; the airplane's last Phase D inspection was completed about 9 months prior to the accident and the airplane had accrued 313.1 hours of operation since that inspection.
Probable cause:
Worn electrical wires and a fuel pressure indicating system hose, which resulted in a ground fire during taxi.
Final Report:

Crash of a Rockwell Grand Commander 690B in the El Yunque National Forest: 3 killed

Date & Time: Dec 3, 2008 at 1205 LT
Operator:
Registration:
N318WA
Flight Phase:
Survivors:
No
Site:
Schedule:
Tortola – San Juan
MSN:
690-11444
YOM:
1978
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
9600
Aircraft flight hours:
5286
Circumstances:
The charter flight departed for the destination, where the passengers would connect with another airline flight. The instrument-rated pilot may have felt pressured as the flight departed late. The accident airplane approached the destination airport from the east, descending at 250 knots ground speed from 8,800 feet above mean sea level (msl), on a 270 degree assigned heading, and was instructed to enter the right downwind for runway 10. The airplane's altitude readout was then observed by the approach controller to change to "XXX." The pilot was queried regarding his altitude and he advised that he was descending to 3,200 feet msl. The pilot was asked to confirm that he was in visual flight rules (VFR) conditions and was advised that the minimum vectoring altitude (MVA) for the area was 5,500 feet msl. The pilot responded that “We just ahh,” at which time the controller advised that she missed his transmission and asked him to repeat it. The pilot stated “Ahh roger, could we stay right just a little, we are in and out of some clouds right now.” The controller advised the pilot to “Maintain VFR” and again of the MVA. The controller then made multiple attempts to contact the pilot without result. The wreckage was discovered on the side of a mountain, where the airplane impacted after entering instrument meteorological conditions. Because aircraft operating in VFR flight are not required to comply with minimum instrument altitudes, aircraft receiving VFR radar services are not automatically afforded Minimum Safe Altitude Warning services except by pilot request. The controller's query to the pilot about his altitude and flight conditions was based on her observation of the loss of altitude reporting information. The pilot had not indicated any difficulty in maintaining VFR flight or terrain clearance up to that point. His comment that the aircraft was "in and out of some clouds" was her first indication that the pilot was not operating in visual conditions, and came within seconds of impact with the terrain. The controller was engaged in trying to correct the situation, and despite having been advised of the minimum vectoring altitude, the pilot continued to descend. The airplane was equipped with a terrain avoidance warning system but it could not be determined if it was functional. The pilot owned the charter operation. Documents discovered in the wreckage identified the pilot and airplane as operating for a different company since the pilot did not have the permissions necessary to operate in the United Kingdom Overseas Territories.
Probable cause:
The pilot's continued visual flight into instrument meteorological conditions, which resulted in an in-flight collision with terrain.
Final Report:

Crash of a Douglas DC-3C off Charlotte Amalie

Date & Time: Jul 19, 2006 at 0720 LT
Type of aircraft:
Operator:
Registration:
N782T
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Charlotte Amalie - San Juan
MSN:
4382
YOM:
1942
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15750
Copilot / Total flying hours:
305
Aircraft flight hours:
32278
Circumstances:
The captain stated that the accident flight was a return flight to San Juan, Puerto Rico, after delivering U.S. Mail. The airplane was empty of cargo at the time of the accident. The first officer was flying the airplane. The takeoff roll and rotation at 84 knots was uneventful until about 100 feet above the ground when the gear was called out to be retracted. At that time, the left engine's rpm dropped from 2,700 to 1,000. He communicated to the first officer that he would be assuming control of the airplane. He then proceeded with verifying that the left engine had failed. Once confirmed, he proceeded with the failed engine check list and feathering the propeller. They advised air traffic control (ATC) of the situation and informed them that they were returning to land. The airplane would not maintain altitude and the airspeed dropped to about 75 knots. The captain stated that he knew the airplane would not make it back to the airport. Instructions were given to the two passengers to don their life vests and prepared for a ditching. The captain elected to perform a controlled flight into the water. All onboard managed to exit the airplane through the cockpit overhead escape hatch onto the life raft as the airplane remained afloat. About ten minutes later the airplane sank nose first straight down. The airplane came to rest at the bottom of the ocean, in about 100 feet of water. The airplane was not recovered. Underwater photos provided by the operator showed the nose and cockpit area caved in, the left engine's propeller was in the feathered position, and the right engine's propeller was in a low pitch position.
Probable cause:
The airplane's inability to maintain altitude for undetermined reasons, following a loss of power from the left engine.
Final Report:

Crash of a Rockwell Shrike Commander 500S in San Juan

Date & Time: Feb 28, 2005 at 1120 LT
Operator:
Registration:
N97VB
Flight Phase:
Survivors:
Yes
Schedule:
San Juan – Tortola
MSN:
500-3233
YOM:
1975
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1038
Captain / Total hours on type:
282.00
Aircraft flight hours:
6943
Circumstances:
The non-Spanish speaking commercial pilot was preparing for a Title 14, CFR Part 135 on-demand charter flight in a twin-engine airplane with gasoline engines. A non-English speaking fuel truck operator inadvertently serviced the accident airplane with 120 gallons of Jet-A turbine fuel. In the pilot's written statement he reported that just after takeoff, with six passengers aboard, both engines began to lose power, and the airplane subsequently descended and collided with tree-covered terrain at the departure end of the runway. An on-site examination of the fuel vender's Jet-A fuel truck disclosed that the dispensing nozzle installed on the truck was the same nozzle as a typical gasoline nozzle. An examination of the accident airplane's fuel caps and fueling ports disclosed that the accident airplane was equipped with round, fuel tank inlet restrictors, that would prevent fueling from a jet fuel nozzle of the appropriate size, but the fueling ports were not placarded with the required statement indicating that only gasoline (av-gas) should be used.
Probable cause:
The fuel truck operator's improper refueling of a gasoline engine powered airplane with jet (turbine) fuel, and the pilot's inadequate preflight, which resulted in a loss of power in both engines and subsequent collision with trees. Factors associated with the accident were the unclear communications between the Spanish-speaking fuel truck operator and the English speaking pilot, and the uel truck operator's lack of familiarity with the accident airplane's fueling requirements. An additional factor was the absence of the required placards adjacent to the fuel filler caps indicating that only gasoline (av-gas) should be used.
Final Report: