Crash of a Bae 4121 Jetstream 41 in Durban: 1 killed

Date & Time: Sep 24, 2009 at 0757 LT
Type of aircraft:
Operator:
Registration:
ZS-NRM
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Durban - Pietermaritzburg
MSN:
41069
YOM:
1995
Flight number:
LNK911
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2956
Captain / Total hours on type:
751.00
Copilot / Total flying hours:
2002
Copilot / Total hours on type:
1027
Aircraft flight hours:
27429
Circumstances:
During the take-off roll, the cockpit crew of another airliner observed smoke pouring from the right engine of ZS-NRM. They were shocked, yet reluctant to tell the crew of ZS-NRM to abort the take-off as they felt that they might be blamed had the abort gone wrong. Instead, the witnessing pilots enquired from the tower whether the aircraft was aware of the smoke. By the time the ATC responded, the aircraft was already in the air, but with its landing gear not yet retracted. Another aircraft lining up at the holding point informed ZS-NRM that their undercarriage was still extended, and the captain of ZS-NRM then transmitted (instead of using the intercom) an instruction to his co-pilot to raise the gear. During this transmission, the sound of what was possibly a warning sound could be heard in the background. The aircraft became airborne and climbed to approximately 500 ft above mean sea level before losing altitude and making a forced landing on a small field in the Merebank residential area, about 1,4 km from the end of the runway. During the forced landing, a member of the public was struck by the wing of the aircraft and the three crew members were seriously injured in the accident. The captain subsequently died from his injuries.
Probable cause:
Engine failure after takeoff followed by inappropriate crew response, resulting in the loss of both lateral and directional control, the misidentification of the failed engine, and subsequent shutdown of the remaining serviceable engine.
Contributing factors:
- Separation of the second-stage turbine seal plate rim;
- Failure of the captain and first officer to implement any crew resource management procedures as prescribed in the operator’s training manual;
- The crew’s failure to follow the correct after take-off engine failure procedures as prescribed in the aircraft’s flight manual.
Final Report:

Crash of a BAe 4101 Jetstream 41 in Charlottesville

Date & Time: Dec 29, 2000 at 2234 LT
Type of aircraft:
Operator:
Registration:
N323UE
Survivors:
Yes
Schedule:
Washington DC – Charlottesville
MSN:
41059
YOM:
1995
Flight number:
UA331
Crew on board:
3
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4050
Captain / Total hours on type:
1425.00
Copilot / Total flying hours:
4818
Copilot / Total hours on type:
68
Aircraft flight hours:
14456
Circumstances:
The twin-engine turboprop airplane touched down about 1,900 feet beyond the approach end of the 6,000-foot runway. During the rollout, the pilot reduced power by pulling the power levers aft, to the flight idle stop. He then depressed the latch levers, and pulled the power levers further aft, beyond the flight idle stop, through the beta range, into the reverse range. During the power reduction, the pilot noticed, and responded to a red beta light indication. Guidance from both the manufacturer and the operator prohibited the use of reverse thrust on the ground with a red beta light illuminated. The pilot pushed the power levers forward of the reverse range, and inadvertently continued through the beta range, where aerodynamic braking was optimum. The power levers continued beyond the flight idle gate into flight idle, a positive thrust setting. The airplane continued to the departure end of the runway in a skid, and departed the runway and taxiway in a skidding turn. The airplane dropped over a 60-foot embankment, and came to rest at the bottom. The computed landing distance for the airplane over a 50-foot obstacle was 3,900 feet, with braking and ground idle (beta) only; no reverse thrust applied. Ground-taxi testing after the accident revealed that the airplane could reach ground speeds upwards of 85 knots with the power levers at idle, and the condition levers in the flight position. Simulator testing, based on FDR data, consistently resulted in runway overruns. Examination of the airplane and component testing revealed no mechanical anomalies. Review of the beta light indicating system revealed that illumination of the red beta light on the ground was not an emergency situation, but only indicated a switch malfunction. In addition, a loss of the reverse capability would have had little effect on computed stopping distance, and none at all in the United States, where performance credit for reverse thrust was not permitted.
Probable cause:
The captain's improper application of power after responding to a beta warning light during landing rollout, which resulted in an excessive rollout speed and an inability to stop the airplane before it reached the end of the runway.
Final Report:

Crash of a Bae 4101 Jetstream 41 in Columbus: 5 killed

Date & Time: Jan 7, 1994 at 2321 LT
Type of aircraft:
Operator:
Registration:
N304UE
Survivors:
Yes
Site:
Schedule:
Washington DC - Columbus
MSN:
41016
YOM:
1993
Flight number:
UA6291
Crew on board:
3
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
3660
Captain / Total hours on type:
192.00
Copilot / Total flying hours:
2430
Copilot / Total hours on type:
31
Aircraft flight hours:
1069
Aircraft flight cycles:
1000
Circumstances:
The airplane stalled and crashed 1.2 nautical miles east of runway 28L during an ILS approach. The captain initiated the approach at high speed & crossed the FAF at a high speed without first having the airplane properly configured for a stabilized approach. The airspeed was not monitored nor maintained by the flightcrew. The airline had no specified callouts for airspeed deviations during instrument approaches. The captain failed to apply full power & configure the airplane in a timely manner. Both pilots had low flight time and experience in in the airplane and in any EFIS-equipped airplane. Additionally, the captain had low time and experience as a captain. Inadequate consideration was given to the possible consequences of pairing a newly upgraded captain, on a new airplane, with a first officer who had no airline experience in air carrier operations, nor do current FAA regulations address this issue.
Probable cause:
The accident was the consequence of the following factors:
(1) An aerodynamic stall that occurred when the flightcrew allowed the airspeed to decay to stall speed following a very poorly planned and executed approach characterized by an absence
of procedural discipline;
(2) Improper pilot response to the stall warning, including failure to advance the power levers to maximum, and inappropriately raising the flaps;
(3) Flightcrew inexperience in 'glass cockpit' automatic aircraft, aircraft type, and in seat position, a situation exacerbated by a side letter of agreement between the company and its pilots;
(4) The company's failure to provide adequate crew resource management training, and the FAA's failure to require such training;
(5) The company's failure to provide adequate stabilized approach criteria, and the FAA's failure to require such criteria; and
(6) The unavailability of suitable training simulators that precluded fully effective flightcrew training.
Note: Items 1, 2, and 3 were approved by a Board vote of 4-0. Item 5 was adopted 3-1, with the dissenting Member believing the item was a contributory cause. The Board was divided 2-2 on items 4 and 6, two Members believing them causal and two Members, contributory.
Final Report: