Crash of an ATR42-312 near Paranapanema: 2 killed

Date & Time: Sep 14, 2002 at 0540 LT
Type of aircraft:
Operator:
Registration:
PT-MTS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
São Paulo – Londrina
MSN:
026
YOM:
1986
Flight number:
TTL5561
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6627
Captain / Total hours on type:
3465.00
Copilot / Total flying hours:
2758
Copilot / Total hours on type:
1258
Aircraft flight hours:
33371
Aircraft flight cycles:
22922
Circumstances:
The twin engine airplane departed São Paulo-Guarulhos Airport at 0440LT on a postal service (flight TTL5561) to Londrina with two pilots on board. About an hour into the flight, while cruising at an altitude of 18,000 feet, the autopilot disconnected while the crew was encountering technical problems with the elevator trim system. The captain asked the copilot to pull out the circuit breaker but this instruction was not understood immediately. Nevertheless, the copilot executed this request few seconds later. Shortly later, the aircraft nosed down and the Vmo alarm sounded, indicating to the crew that the aircraft's speed was above the maximum operating speed. The crew reduced the engine power to 10% but the aircraft entered an uncontrolled descent and crashed at a speed of 366 knots in an open field located 38 km south of Paranapanema. The aircraft was totally destroyed upon impact and both pilots were killed. Some debris were found at a depth of three metres.
Probable cause:
The following findings were identified:
- The pilots' perception about the situation was affected by lack of specific training and procedures, which, coupled with the limited time available for action and lack of clarity in communications, influenced the time elapsed for taking corrective actions.
- Communication between the crew was not clear at the time of emergency, making the co-pilot did not understand at first, the action to be performed, which increased the time spent to disarm the CB. Such facts, however, can not be separated from the situation experienced by pilots with inadequate training for emergency and in a short time to identify the problem and take the corrective actions.
- The company had not provided a regular CRM training to pilots. Furthermore, the captain did not receive simulator training for over one year. It was impossible to determine, however, if the regular training and updating of the CRM simulator training of the pilot would have prevented the accident.
- The removal of the pilot from his seat at the time of the emergency may have increased the time spent in identifying the crash and taking corrective actions, but it was not possible to establish whether the accident would be avoided if he would have been in the cockpit. The copilot was slow to understand the situation and initiate corrective actions, although the alarm 'whooler' has sounded, also increasing the elapsed time.
- The operational testing under J IC 27-32-00 allowed the partial completion of the procedures due to lack of clarity, which allowed the release of the aircraft for flight with a defective relay.
Furthermore, although the elevator trim system has been certified, no procedure for emergency triggering of the compensator in the manuals provided by the manufacturer, no replacement intervals of the components of the elevator trim system in "Time Limits" systems normal and reserves were not independent and the system had a low tolerance for errors.
Final Report:

Crash of an Avro 748 in George: 3 killed

Date & Time: Jun 1, 2002 at 0715 LT
Type of aircraft:
Operator:
Registration:
ZS-OJU
Flight Type:
Survivors:
No
Site:
Schedule:
Bloemfontein - George
MSN:
1782
YOM:
1980
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
20963
Captain / Total hours on type:
1819.00
Copilot / Total flying hours:
1099
Copilot / Total hours on type:
518
Aircraft flight hours:
14226
Aircraft flight cycles:
19789
Circumstances:
The aircraft was on a scheduled freight flight from Bloemfontein to George. Poor weather conditions prevailed over the George area and the pilots had to execute an instrument guided approach for the landing. The ground based Instrument Landing System (ILS) on Runway 29 at George Aerodrome was intermittently unreliable during the approach. The pilots decided to execute a missed approach. During the missed approach the pilots did not comply with the published missed approach procedure and with a combination of strong winds and possible erroneous heading indications they lost situational awareness. They flew the aircraft into a valley and crashed into the side of the mountains North-East of the George Aerodrome. The passenger was Hansie Cronje, a former South African cricket captain who had missed a South African Airlines flight.
Probable cause:
The crew deviated from the prescribed missed approach procedure during an attempted Instrument Landing System landing on Runway 29 at George in Instrument Meteorological Conditions and lost situational awareness aggravated by the presence of strong upper SouthWesterly winds. They allowed the aircraft to drift off course resulting in a controlled impact with terrain 6.7 nm North-East of the aerodrome. Contributing factors to the probable cause were the weather conditions, the intermittent unreliability of the Instrument Landing System, the serviceability of the directional gyro and the uncleared defects.
Final Report:

Crash of a Swearingen SA227AC Metro III in Goose Bay

Date & Time: Mar 4, 2002 at 0456 LT
Type of aircraft:
Operator:
Registration:
C-FITW
Flight Type:
Survivors:
Yes
Schedule:
Saint John's - Goose Bay
MSN:
AC-638
YOM:
1986
Flight number:
PB905
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was on a scheduled courier flight from St. John=s, Newfoundland and Labrador, to Goose Bay. The aircraft touched down at 0456 Atlantic standard time and, during the landing roll on the snow-covered runway, the aircraft started to veer to the right. The captain's attempt to regain directional control by the use of full-left rudder and reverse on the engines was unsuccessful. The aircraft continued to track to the right of the centreline, departed the runway, and struck a hard-packed snow bank. There were no injuries to the two crew members. The aircraft was substantially damaged.
Probable cause:
Findings as to Cause and Contributing Factors:
1. Aircraft directional control was lost, likely because of negative castering of the nosewheel when snow piled up in front of the nosewheel assembly.
Findings as to Risk:
1. The crew members were not aware of negative castering; the aircraft flight manual and emergency checklists do not address negative castering.
2. The emergency response to the occurrence was delayed by four minutes because of the lack of communication from the aircraft to the tower.
Final Report:

Crash of an Embraer EMB-820C Navajo in Varginha

Date & Time: Feb 22, 2001 at 1935 LT
Operator:
Registration:
PT-LFP
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Varginha – Belo Horizonte
MSN:
820-038
YOM:
1977
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1959
Captain / Total hours on type:
213.00
Copilot / Total flying hours:
658
Copilot / Total hours on type:
276
Circumstances:
The twin engine aircraft departed Varginha-Major-Brigadeiro Trompowsky Airport on a mail flight to Belo Horizonte-Pampulha Airport with two pilots on board. After takeoff, while in initial climb, the right engine lost power. The aircraft lost height and crash landed in an open field. It slid for about 100 metres before coming to rest, bursting into flames. Both pilots escaped with minor injuries and the aircraft was destroyed by fire.
Probable cause:
Loss of power on the right engine for undetermined reasons. The following findings were identified:
- Poor flight preparation on part of the crew,
- The crew did not know the exact weight of the mail/cargo,
- The crew did not have sufficient training/instruction regarding a possible loss of engine power at takeoff,
- Poor engine maintenance as the right engine had experienced power issues in the past that had not been resolved,
- Poor crew coordination,
- When the loss of power occurred on the right engine, the captain asked the copilot to raise the landing gear and preferred to resolve the emergency situation alone,
- Poor evaluation of the aircraft performances on part of the crew in regard of the weight and balance values and CofG.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Val d'Or

Date & Time: Feb 20, 2001 at 1900 LT
Operator:
Registration:
C-GNIE
Flight Type:
Survivors:
Yes
Schedule:
Rouyn – Val d’Or – Saint-Hubert
MSN:
31-7552047
YOM:
1975
Flight number:
APO1023
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
900
Captain / Total hours on type:
30.00
Circumstances:
A Piper PA-31-350, registration C-GNIE, serial number 31-7552047, was on a scheduled (APO1023) instrument flight rules mail service flight between Rouyn Airport, Quebec, and Val-d'Or Airport, Quebec, at approximately 1845 . After checking for prevailing weather conditions at the destination airport, the pilot decided to make a visual approach on runway 36. The pilot reported by radio at two miles on final approach for runway 36 and then stated that he was going to begin his approach again after momentarily losing visual contact with the runway. This was the last radio contact with the aircraft. No emergency locator transmitter signal was received by the flight service station specialist. Emergency procedures were initiated, and searches were conducted. The aircraft was found by a search and rescue team about three hours after the crash. The aircraft was lying about two miles southeast of the end of runway 36; it was substantially damaged. The pilot suffered serious injuries.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The environmental conditions and loss of visual ground references near Val-d'Or Airport were conducive to spatial disorientation. Because of a lack of instrument flight experience, the pilot probably became disoriented during the overshoot and was unable to regain control of the situation.
2. During the approach, the pilot did not plan to and did not pull up towards the centre of the airport, thereby contributing to spatial disorientation.
3. Although the pilot-in-command received training required by Transport Canada, Aéropro did not ensure that the pilot-in-command completed the required Pilot Proficiency Check (PPC) and was adequately supervised and experienced to conduct a night IFR flight safely as pilot-in-command.
Final Report:

Crash of a Grumman G-159 Gulfstream I in Linneus: 2 killed

Date & Time: Jul 19, 2000 at 0031 LT
Type of aircraft:
Registration:
C-GNAK
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Moncton - Montreal
MSN:
154
YOM:
1965
Flight number:
AWV9807
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6000
Captain / Total hours on type:
500.00
Copilot / Total flying hours:
600
Copilot / Total hours on type:
300
Aircraft flight hours:
22050
Aircraft flight cycles:
15452
Circumstances:
The airplane was in cruise flight at 16,000 feet, in instrument meteorological conditions. About two minutes after the crew ceased cross-feeding due to a fuel imbalance, the left engine experienced a total loss of power. About one minute later, the co-pilot indicated to the pilot-in-command (PIC) that the airplane was losing airspeed, and about 15 seconds later, the co-pilot remarked "keep it up, keep it up." Shortly thereafter, the airplane departed controlled flight and impacted terrain. The airplane was destroyed by fire and impact forces. Examination of the left engine revealed no evidence of any pre-impact failures that would have accounted for an uncommanded in-flight shut-down. A SIGMET for potential severe clear icing was effective for airplane's flight path; however, the flight crew did not report or discuss any weather related problems around the time of the accident. At the time of the accident, the airplane was above its single-engine service ceiling. The PIC had accumulated approximately 6,000 hours of total flight experience, of which, about 500 hours were as PIC in make and model. The co-pilot had approximately 600 hours of total fight experience, of which, 300 hours were in make and model.
Probable cause:
The pilot-in-command's failure to maintain minimum control airspeed, which resulted in a loss of control. Factors in this accident were clouds, and a loss of engine power for undetermined reasons, while in cruise flight above the airplane's single engine service ceiling.
Final Report:

Crash of a Cessna 402C II off Vieques: 1 killed

Date & Time: Jul 8, 2000 at 0455 LT
Type of aircraft:
Registration:
N405MN
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
San Juan - Christiansted
MSN:
402C-0221
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2400
Captain / Total hours on type:
235.00
Aircraft flight hours:
13702
Circumstances:
After departure from San Juan, the pilot of N405MN contacted the FAA San Juan Approach Control, was identified on radar by the controller, and told to climb to 7,000 feet. About 1 minute later, the pilot is told to proceed direct to St. Croix. About 4 minutes later, the pilot requested radar vectors to St. Croix, and was told to fly heading 140 degrees. Radar data showed the flight leveled at the cruise altitude of 7,000 feet at about 0444. At about 0453:36, the pilot requested a lower altitude, and was cleared to 2,000 feet. The pilot acknowledged the clearance, and no further transmissions were received from the pilot. The flight began descent from 7,000 feet at about 0454. At 0454:29, the aircraft's transponder reports the flight is at 6,500 feet. At 0454:41, the transponder reports the flight is at 5,600 feet, and at 0454:49, at 4,000 feet. At 0454:53, the transponder reports the flight is at 1,100 feet. The flight is not observed on radar after this. No other aircraft or radar returns are observed near the flight as it began it's descent. One main landing gear tire, wheel, and brake assembly; the left wing lower skin from the area above the wing flap; the left wing baggage compartment door; the right nose baggage compartment door; the cabin floor cover; and some items from the U.S. mail cargo, were recovered floating in the ocean, at points north of the last observed radar contact with the airplane, on the day of the accident and in the days after the accident. The recovered components had damage from being separated from the airplane. None of the recovered components had any fire, heat, or soot damage. The remainder of the airplane was not located and recovered. The depth of the sea in the area of the accident site was reported by the Coast Guard to be about 6,000 feet. U.S. Post Office personnel reported the flight carried 1,517 pounds of U.S. mail. No hazardous materials were in the mail. A 75-pound pouch of mail was recovered from the ocean and identified as having been placed on N405MN. The weather at the time of the accident was reported to scattered clouds with visibility 10 miles.
Probable cause:
The airplanes entry into an uncontrolled descent for undetermined reasons from which it crashed into the ocean.
Final Report:

Crash of a Cessna 208B Grand Caravan in Lerwick

Date & Time: Sep 6, 1999 at 1034 LT
Type of aircraft:
Registration:
LN-PBB
Flight Type:
Survivors:
Yes
Schedule:
Kirkwall - Lerwick
MSN:
208B-0302
YOM:
1992
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1780
Captain / Total hours on type:
500.00
Circumstances:
The operating company were involved in a Royal Mail contract to deliver mail from Aberdeen to Shetland Islands each day. The crew involved in the accident had flown LN-PBB from Stauning Airport in Denmark to Aberdeen in preparation for a two week period of duty delivering the mail; they arrived at Aberdeen at 1700 hrs on 5 September 1999. The next morning, the crew arrived for duty at approximately 0540 hrs and completed their normal checks of LN-PBB. Shortly after this, the mail arrived and was escorted to the aircraft by the company ground crew. The mail bags were sorted and loaded into the aircraft by the flight and ground crew under the supervision of the commander; the mail had been weighed by Royal Mail and the commander was given written confirmation of the total weight of 1,196 kg. At the completion of the loading, the commander was satisfied that the load was secure and correctly distributed. Prior to departure for Sumburgh Airport, the commander had checked the weather and was aware that it was 'poor' at Sumburgh but the indications were that it would improve; additionally, the weather at Kirkwall Airport was clear if they needed to divert. The aircraft appeared fully serviceable during start, taxi and take off from Aberdeen at 0640 hrs; for the flight to Sumburgh, the commander was the handling pilot. Cruise was at Flight Level (FL)90and, about half way to Sumburgh, ATC advised the crew of the latest weather at Sumburgh which indicated that they would not be able to land there. However, there was a preceding aircraft heading for the same destination and the commander elected to continue towards Sumburgh. Then, once the preceding aircraft crew had declared that they were diverting to Aberdeen, the commander decided to divert to Kirkwall. The diversion was uneventful and the aircraft landed at 0807 hrs. At Kirkwall, the crew uplifted sufficient fuel to bring the total up to the same with which they had left Aberdeen (1,200lb) and waited for a weather improvement at Sumburgh. By approximately 0930hrs, the crew were advised by Kirkwall ATC that the weather had improved at Sumburgh and they prepared the aircraft for departure. Take off was at 0950 hrs with the co-pilot as handling pilot. Cruise was at FL 70 and was uneventful up to the approach and landing. The airport was using Runway 27 as that is the only runway with full ILS. The ATIS information at 1020 hrs was broadcasting the following information: surface wind 340°/07 kt; 9,000 metres in rain; cloud few at 300 feet, scattered at 1,000 feet and broken at 1,600 feet; temperature 12°, dew point 12°; tempo cloud broken 1,500 feet with a wet runway. In accordance with ATC instructions, the crew commenced their descent to 2,000 feet amsl where they were instructed to intercept the ILS from a heading of 300°. Once fully established on the ILS, the commander noted that the co-pilot was having a little difficulty maintaining the aircraft on both the localizer and glide slope. The co-pilot was not sure of the height at which they broke cloud but the commander estimated that they were at 500 feet agl. At this point, the co-pilot considered that they were slightly high and fast; subsequently, the commander estimated the aircraft airspeed as 140 kt as they became visual with the runway. During the final approach, the air traffic controller gave three separate wind reports of 010°/11 kt, 010°/11 kt and010°/10 kt; these reports were based on the two minute mean surface winds. As the aircraft crossed the runway threshold, the co-pilot called out that he had too much speed and that "it wasn't going to work". With no reply from the commander, the co-pilot took this lack of response as an indication that the commander was content. For his part, the commander was concentrating on the runway aspect and, although he heard a comment from the co-pilot, did not make any response. The crew considered that touchdown was approximately halfway down the runway and the co-pilot was aware of the aircraft bouncing before a second touchdown; neither pilot could recall the speed at touchdown. Both pilots applied full foot braking but with little apparent result in retardation. Then, as the aircraft approached the end of the runway, the commander took control and applied full power; this was because he was aware of the concrete blocks positioned off the end of the runway as a sea defence and wished to clear them. The aircraft was now yawed slightly left and positioned to the left of the runway centreline. It left the runway surface, travelled across grass and a public road and came to rest on the concrete blocks.
Probable cause:
The aircraft overran the end of Runway 27 at Sumburgh following a touchdown which was too fast and well down the runway. There was insufficient runway remaining for the aircraft to stop. The landing resulted from a poor approach and no apparent co-operation between the crew. A positive decision from the co-pilot, or better monitoring and an active input from the commander, should have resulted in a go-around and a further approach or a diversion. While this crew may be unusual, it would be appropriate for the operating company to review their procedures to ensure that their crews are operating in a safe manner. The investigation also reviewed the rules under which the flight was conducted. Examination of the weather information available to the crew indicate doubts as to whether the flight could have been completed within the limitations contained within company manuals. Additionally, Article 32A of the UK ANO is not clear; it could be interpreted as only prohibiting flights when the weather conditions are not met at all of the relevant aerodromes. It would be appropriate for the CAA to review the content of Article 32A to ensure that the intent is clear.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in King Island-Currie: 1 killed

Date & Time: Feb 8, 1996 at 0507 LT
Operator:
Registration:
VH-KIJ
Flight Type:
Survivors:
No
Schedule:
Melbourne - King Island
MSN:
31-7405222
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5519
Captain / Total hours on type:
106.00
Circumstances:
A witness heard the aircraft pass King Island aerodrome at 0455 EST at the same time as he noticed the pilot-activated 10/28 runway lights illuminate. The pilot reported to Melbourne Control that he would be completing a runway 10, non-directional beacon (NDB) approach. A short time later he broadcast that the aircraft was at the minimum descent altitude, which is 640 feet above mean sea level (AMSL) for a runway 10 NDB approach. He also broadcast that there was a complete cloud cover. The aircraft did not enter a missed approach procedure but was heard to fly towards the south-east from overhead the NDB, which is located 1.3 km south-south-west of the centre of runway 10/28. A second witness, located near the NDB site, reported observing the aircraft's lights to the south-east. At 0507 a farmer heard the aircraft pass low over his house shortly before it crashed into trees, 3.5 km south-east of the aerodrome. The first responders arrived at the accident site at about 0530. The pilot had not survived.
Probable cause:
The pilot continued a visual approach in conditions which prevented him from maintaining adequate visual clearance from the ground or obstacles and which made visual judgement of the approach difficult. Also, the pilot probably did not recognise that the conditions were not suitable for a visual approach.
Final Report:

Crash of a Cessna 402B in Kamuela: 1 killed

Date & Time: Jan 29, 1996 at 0435 LT
Type of aircraft:
Registration:
N999CR
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Kamuela - Honolulu
MSN:
402B-0616
YOM:
1974
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3434
Captain / Total hours on type:
1250.00
Aircraft flight hours:
19764
Circumstances:
The aircraft departed at night from runway 4R on a flight to transport mail. The pilot-in-command (PIC) was in the left seat, a pilot-rated cargo loader was in the right seat, and another cargo loader was aboard the aircraft, but was not in a seat. During takeoff, the aircraft entered a turn and flew into gradually rising terrain. The initial impact point was about 15 feet higher than the runway elevation and about 0.3 miles abeam the departure end of the runway. Investigation revealed that the company allowed pilot-rated cargo loaders to fly the aircraft from the right seat during positioning and ferry flight segments (to build multiengine flight time) as part of their compensation. There was evidence that at the time of the accident, the aircraft was being piloted on this flight from the copilot's position. The right side of the instrument panel was equipped with only EGT gauges (no flight instruments on the copilot's side). There were cloud layers in the vicinity, no moon illumination, and no visible ground lighting in the direction of flight. No preimpact mechanical malfunction or failure was identified during the investigation. Except at the pilot and copilot positions, the airplane had no other seat and/or restraint system. The operator stated that the pilot was not authorized to carry company personnel or passengers without the required seating.
Probable cause:
Failure of the copilot (pilot-rated cargo loader, who was flying the aircraft) to establish and maintain a positive rate of climb after taking off at night; and inadequate supervision by the pilot-in-command (PIC), by failing to ensure that proper altitude was obtained and maintained during the departure. Factors relating to the accident were: darkness; the lack of visual cues; and the resultant visual illusion, which the copilot failed to recognize during the night departure. Also, the lack of a restraint system (seat belt and/or shoulder harness) for the passenger was a possible related factor.
Final Report: