Crash of a Convair CV-340 in Pretoria: 1 killed

Date & Time: Jul 10, 2018 at 1639 LT
Type of aircraft:
Operator:
Registration:
ZS-BRV
Flight Type:
Survivors:
Yes
Schedule:
Pretoria - Sun City
MSN:
215
YOM:
1954
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
18240
Captain / Total hours on type:
63.00
Copilot / Total flying hours:
19616
Aircraft flight hours:
18115
Circumstances:
On Tuesday 10 July 2018, at approximately 1439Z, two crew members and 17 passengers took off on a ZS-BRV aircraft for a scenic flight from Wonderboom Aerodrome (FAWB) destined for Pilanesberg Aerodrome (FAPN) when the accident occurred. During take-off, the left engine caught fire, however, the crew continued with the flight. They declared an emergency by broadcasting ‘MAYDAY’ and requesting to return to the departure aerodrome. The crew turned to the right with the intention of returning to the aerodrome. However, the left engine fire intensified, causing severe damage to the left wing rear spar and left aileron system, resulting in the aircraft losing height and the crew losing control of the aircraft and colliding with power lines, prior to crashing into a factory building. The footage taken by one of the passengers using their cellphone showed flames coming from the front top side of the left engine cowling and exhaust area after take-off. The air traffic control (ATC) on duty at the time of the accident confirmed that the left engine had caught fire during take-off and that the crew had requested clearance to return to the aerodrome. The ATC then activated the crash alarm and the aircraft was prioritized for landing. During the accident sequence that followed, one passenger (engineer) occupying the jump seat in the cockpit was fatally injured and 18 others sustained injuries. The investigation revealed that during take-off, the left engine had caught fire and the crew had continued with the flight without securing the left engine as prescribed in the aircraft flight manual (AFM). The crew had then declared an emergency and attempted to return to the aerodrome, however, they lost control of the aircraft and collided with power lines prior to crashing into a factory building. Owned by Rovos Air (part of the South African Rovos Rail Group), the aircraft was donated to the Dutch Museum Aviodrome based in Lelystad and has to be transferred to Europe with a delivery date on 23 July 2018. For this occasion, the aircraft was repaint with full Martin's Air Charter colorscheme. Part of the convoy program to Europe, the airplane was subject to several test flights, carrying engineers, technicians, pilots and also members of the Aviodrome Museum.
Probable cause:
During take-off, the left engine caught fire and the crew continued with the flight without securing the left engine as prescribed in the aircraft flight manual (AFM). The crew declared an emergency and attempted to return to the aerodrome, however, they lost control of the aircraft and collided with power lines prior to crashing into a factory building. The following contributing factors were reported:
- Pre-existing damage to the cylinder No 13 piston and ring pack deformation and, most probably, the cylinder No 7’s fractured exhaust valve head that were not detected during maintenance of the aircraft,
- Substandard maintenance for failing to conduct compression tests on all cylinders during the scheduled maintenance prior to the accident,
- Misdiagnosis of the left engine manifold pressure defect as it was reported twice prior to the accident,
- The crew not aborting take-off at 50 knots prior to reaching V1; manifold pressure fluctuation was observed by the crew at 50 knots and that should have resulted in an aborted take-off,
- Lack of crew resource management; this was evident as the crew ignored using the emergency checklist to respond to the in-flight left engine fire,
- Lack of recency training for both the PF and PM, as well as the LAME,
- Non-compliance to Civil Aviation Regulations by both the crew and the maintenance organisation.
Final Report:

Crash of a Convair CV-340-70 in Miami

Date & Time: Dec 4, 2004 at 0851 LT
Type of aircraft:
Operator:
Registration:
N41626
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Miami – Nassau
MSN:
274
YOM:
1955
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3100
Captain / Total hours on type:
2400.00
Copilot / Total flying hours:
9169
Copilot / Total hours on type:
964
Aircraft flight hours:
18465
Circumstances:
The pilot stated that when the airplane was 3 miles east of the shoreline, at 3,000 feet, he felt a short tremor in the left engine followed by loss of power from the left engine. The pilot elected to return to the departure airport while declaring an emergency to air traffic control. During the process of securing the left engine the pilot noticed the propeller did not feathered and the airplane was descending quickly. He maneuvered the airplane and ditched in a lake. On September 26, 2003 engine s/n: 34592 was removed from the accident airplane due to high oil consumption with 1,225 hours of time in service. It was reportedly preserved and stored at the operator's warehouse. The mechanic who reportedly preserved the engine stated he followed the steps in the manual that was provided by the operator. On October 27, 2004 the left engine, s/n: NK510332, which was producing metal for months, was removed and engine s/n: 34592 was taken out of preservation and installed in the left position on the accident airplane with a new overhauled propeller assembly. On November 06, 2004, the left engine's, s/n: 34592, propeller governor was replaced due to the left propeller slow to response to power setting. During the post accident engine examination, the engine's main oil screen was observed with deposits of metal flakes and fragments, the oil scavenge pump would not rotate and had deposits of metal fragments internally; the engine was seized and wound not rotate. Catastrophic damage was observed to the accessories drive gears, oil transfer tube, and protection covers in the front accessory area. It was observed during a visual inspection of the crankshaft and bearings, including the front journal and front crankpin had damaged and sections of their respective bearings missing. The master rod bearing had incurred a catastrophic failure. Several cylinders skirts were found with impact marks from piston rods. Before removing the propeller assembly from the engine, the propeller feather system was flush with fresh oil and pressured with a feathering pump; the propeller blades were observed moving toward the feather position. Examination of the propeller assembly revealed metal contamination throughout the system; the propeller's governor screen gasket was clogged with metal contamination. The maintenance manual provided by the operator used for the engine preservation details several tasks required to be accomplished to the engine for proper engine preservation (i.e. thrust bear, cylinder, and propeller shaft treatments), which the mechanic did not mention he performed. No documentation for inspection and condition status of the dehydrator plugs were available. Documentation for flushing of contamination from the metal producing engine, s/n NK510332, was not available nor knowledge by the operator if since a process was preformed to the left engine's oil tank and its system before installation of engine s/n: 34592. An FAA review of the cargo manifest discovered two different manifest weights. The cargo manifest obtained at the accident scene showed a total of 267 pieces of cargo annotated at a total weight of 10, 837 lbs. The sealed cargo manifest package showed a total of 267 pieces of cargo annotated at a total weight of 14,182 lbs. The maximum payload weight for the accident airplane is 13,586 lbs.
Probable cause:
The improper maintenance of the left engine by company maintenance personnel (failure to flush metal from the oil system and failure to properly preserve the engine for storage) resulting in a total failure of the master rod bearing and contamination of the engine oil system with metal, which prevented the left propeller from feathering. This resulted in the airplane being unable to maintain altitude following loss of engine power and subsequent ditching in a lake. A factor in this accident is the aircraft operator and flight crew exceeding the maximum allowable takeoff weight for the airplane.
Final Report:

Crash of a Convair CV-340-38 in Elma

Date & Time: Mar 21, 1978 at 0145 LT
Type of aircraft:
Registration:
N4807C
Survivors:
Yes
Schedule:
Saint Louis - Minneapolis
MSN:
84
YOM:
1953
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9000
Captain / Total hours on type:
5500.00
Circumstances:
En route from Saint Louis to Minneapolis, while cruising at an altitude of 6,000 feet, the right engine caught fire. The copilot declared an emergency and was cleared to divert to Elma Airport. Shortly later, the right engine detached. The crew completed an emergency descent but made a forced landing off airport on land. All four occupants evacuated safely while the aircraft was considered as damaged beyond repair.
Probable cause:
Engine failure in flight due to master and connecting rods failure. The following contributing factors were reported:
- Material failure,
- Fire in engine,
- Oil exhaustion - engine lubrication system,
- Separation in flight,
- Complete engine failure,
- Force landing off airport on land,
- Engine separated from aircraft in flight due to fire damage.
Final Report:

Crash of a Convair CV-340-68B in Sana'a

Date & Time: Feb 4, 1972
Type of aircraft:
Operator:
Registration:
HZ-AAT
Survivors:
Yes
Schedule:
Najran – Sanaa – Ta’izz – Aden
MSN:
174
YOM:
1954
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was completing a flight from Najran to Aden with intermediate stops in Sana'a and Ta'izz. On approach to Sana'a Airport, the crew encountered technical problems and the captain decided to attempt an emergency landing on a road located few km from the airport. All occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Unknown technical problems on final approach, forcing the crew to attempt an emergency landing.