Crash of a De Havilland DHC-6 Twin Otter 200 in Sechelt: 2 killed

Date & Time: Sep 30, 1979 at 1300 LT
Registration:
C-FWAF
Survivors:
Yes
Schedule:
Vancouver – Sechelt – Powell River
MSN:
122
YOM:
1968
Flight number:
106
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
13815
Circumstances:
Flight 106 was a schedule service from Vancouver to Powell River with an intermediate stop at Sechelt. The flight to Sechelt was uneventful. While approaching Porpoise Bay at Sechelt, at an altitude of 200 feet, the twin engine airplane rolled to the right in an angle of 90° then nosed down and crashed on the east shore of the bay, about 50 meters from the water. The captain and a passenger were killed while 14 other occupants were injured, four of them seriously.
Probable cause:
The right-hand aileron bellcrank-to-aileron rod had separated from the bellcrank end fitting due to an extensive stress corrosion crack. This allowed the right-hand aileron to move up, causing asymmetric lift and irretrievable loss of control. The specified visual inspection of the rods was inadequate to detect stress corrosion cracking. Previous similar failures of flap rods on the DHC-6 had led to airworthiness action by the manufacturer and the DOT but these measures were not applied to the aileron rods which are of similar construction.

Crash of a De Havilland DHC-6 Twin Otter 300 in Frobisher Bay: 9 killed

Date & Time: Aug 29, 1979 at 2300 LT
Operator:
Registration:
C-GROW
Survivors:
No
Schedule:
Brevoort Island - Frobisher Bay
MSN:
415
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Aircraft flight hours:
5286
Circumstances:
The airplane was being used for a series of flights between Frobisher (YFB) and Brevoort Island, a distance of 119 nm. These flights were conducted under visual flight rules (VFR) with a Flight Notification filed at Frobisher. Two return flights were accomplished without incident and the aircraft was flown back to Brevoort for another round trip. On the final flight the aircraft, with the same two pilots and with seven passengers, left Brevoort at 21:57 hours local time enroute to Frobisher. The pilots contacted Frobisher Flight Service Station (FSS) at 22:31 reporting at 6000 feet altitude estimating Frobisher in 15 minutes. Upon receiving the latest weather indicating conditions below VFR limits, they requested clearance for "Special VFR". This clearance was granted. Another weather report was transmitted by the Frobisher FSS giving the 22:44 observation in which the ceiling had lowered to 400 ft with the visibility at 8 miles and the wind from 190 deg M at 22 knots. The pilot stated they would make a front course ILS approach to runway 36 with a landing on 18. At 22:58 they were issued a clearance for an ILS approach. They subsequently reported outbound at procedure turn altitude and at that time confirmed their planned approach for runway 36 with circling for 18. This was the last radio transmission from C-GROW. The Twin Otter was seen flying north along the runway. It then struck high ground about 1200 feet east of the runway and about 100 feet above runway level. The aircraft was destroyed and all nine occupants were killed.
Probable cause:
The exact cause of the accident could not be determined with certainty. However, it is quite possible that there was low cloud over the terrain east of the runway; when the aircraft had nearly completed its turn, it entered low cloud and the crew lost visual contact; the crew continued the right turn probably expecting to become visual again because they knew that good visibility existed over the runway; they did not regain contact with the ground and runway environment however and impacted the higher ground to the east of the runway.

Crash of a De Havilland DHC-6 Twin Otter 300 in Hyannis: 1 killed

Date & Time: Jun 17, 1979 at 2248 LT
Operator:
Registration:
N383EX
Survivors:
Yes
Schedule:
New York-LaGuardia – New Bedford – Hyannis
MSN:
245
YOM:
1969
Flight number:
NE248
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
25101
Captain / Total hours on type:
951.00
Copilot / Total flying hours:
4362
Copilot / Total hours on type:
102
Aircraft flight hours:
17058
Circumstances:
Before loading the aircraft for takeoff from LaGuardia, the flight crew checked the enroute weather for the return flight to Hyannis and learned that a landing at the en route stop at New Bedford might not be possible. When they were advised of the weather situation, the passengers destined for New Bedford decided to remain in LaGuardia. At 2132, flight 248 departed LaGuardia for Hyannis on the last leg of the day. There were eight passengers and two flight crew members aboard. According to the first officer's and a passenger's testimony at the public hearing during the investigation of the accident, flight 248 was normal until the approach for landing at Hyannis. At 2234:08, flight 248 contacted Otis Approach Control and reported level at 5,000 feet. At 2239:05, the flight was given the current Hyannis weather which included an indefinite ceiling of 200 feet, sky obscured, visibility 3/4 mile in fog, wind 210° at 10 knots. It also included a visibility of 1 1/8 in light drizzle on runway 24. At 2244:36, flight 248 was 4 nmi north-northeast of the outer marker when Otis Approach Control gave the flight a vector of 210° to intercept the localizer at 1,700 feet for an ILS approach to runway 24 at the Barnstable Airport. At 2245:34, flight 248 was instructed to contact the Barnstable Airport tower. About 2247, the flight complied with this request and reported crossing the outer marker. The flight was cleared to land, however, no further transmissions were heard form the aircraft. The Boston Air Route Traffic Control Center (Boston Center) was able to track flight 248 to within 2.8 nmi of the intended touchdown point on runway 24. Boston Center's computer printout showed the flight's position at 2246:51 about 0.35 nmi northeast of the ILS outer marker at 1,700 feet. It also showed the flight about 0.15 nmi southwest of the outer marker at 1,500 feet at 2247:03. The last radar position shown for the flight was about 1.1 nmi southwest of the outer marker at 2247:27 at 1,100 feet. The first officer stated that the captain was flying the aircraft during the approach to Hyannis. He said that he made the following callouts: localizer alive, outer marker, 500 feet above, 200 feet above, 100 feet above, minimums, and 100 feet below. He said that the captain did not acknowledge any of these calls. The first officer said that when he called 'minimums', the aircraft was one dot below the ILS glidepath. The first officer said that it appeared that the aircraft was in a continual descent without any excessive sink rates or descent angles from 5,000 feet until impact, with the airspeed near 130 knots for the entire approach. He stated that, as he called '100 feet below', he looked outside the cockpit because he believed that the captain had the approach lights in sight. The first officer said that he did not see the ground before the aircraft crashed about 2248 into a heavily wooded area located 1.5 nmi from the approach end of runway 24, on the runway centerline extended. The accident occurred during the hours of darkness. The captain was killed while all other occupants were injured, some of them seriously.
Probable cause:
The National Transportation Safety Board determines that the probable cause of the accident was the failure of the flightcrew to recognize and react in a timely manner to the gross deviation from acceptable approach parameters, resulting in a continuation of the descent well below decision height during a precision approach without visual contact with the runway environment. Although the Board was unable to determine conclusively the reason for the failure to recognize and react to the gross deviation, it is believed that the degraded physiological condition of the captain seriously impaired his performance. Also, the lack of adequate crew coordination practices and procedures contributed to the first officer's failure to detect and react to the situation in a timely manner.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter in Rockland: 17 killed

Date & Time: May 30, 1979 at 2055 LT
Operator:
Registration:
N68DE
Survivors:
Yes
Schedule:
Boston - Rockland
MSN:
229
YOM:
1969
Flight number:
DE46
Crew on board:
2
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
17
Captain / Total flying hours:
5050
Captain / Total hours on type:
603.00
Copilot / Total flying hours:
2580
Copilot / Total hours on type:
46
Aircraft flight hours:
21050
Circumstances:
About 2055LT, Downeast Airlines flight 46 crashed into a heavily wooded area about 1,2 mile south-southwest of the Knox County Regional Airport in Rockland, Maine. The crash occurred during a non-precision instrument approach to runway 03 in instrument meteorological conditions. Of the 16 passengers and 2 crew members aboard, only one passenger survived the accident. The aircraft was destroyed.
Probable cause:
The National Transportation Safety Board determines that the probable cause of the accident was the failure of the flightcrew to arrest the aircraft's descent at the minimum descent altitude for the non-precision approach, without the runway environment in sight, for unknown reasons. Although the Safety Board was unable to determine conclusively the reason(s) for the flightcrew's deviation from standard instrument approach procedures, it is believed that inordinate management pressures, the first officer's marginal instrument proficiency, the captain's inadequate supervision of the flight, inadequate crew training and procedures, and the captaints chronic fatigue were all factors in the accident.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 200 in Yarra Creek

Date & Time: Feb 13, 1979
Operator:
Registration:
VH-PAQ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
King Island - Wynyard
MSN:
227
YOM:
1969
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The airplane departed King Island-Currie Airport on a cargo flight to Wynyard-Burnie Airport, carrying one pilot and a load of meat. Weather conditions worsened and the pilot was unable to locate the destination airport so he decided to divert to Devonport Airfield. Unfortunately, the visibility was too low and he eventually decided to return to King Island. While approaching the coast, both engines failed due to fuel exhaustion. The pilot attempted an emergency landing when the airplane crashed in a prairie located in Yarra Creek, on the east coast of the island. The pilot was injured and the aircraft was destroyed.
Probable cause:
Double engine failure in flight due to fuel exhaustion.

Crash of a De Havilland DHC-6 Twin Otter in Steamboat Springs: 2 killed

Date & Time: Dec 4, 1978 at 1945 LT
Operator:
Registration:
N25RM
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Steamboat Springs - Denver
MSN:
387
YOM:
1973
Flight number:
JC217
Crew on board:
2
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7340
Captain / Total hours on type:
3904.00
Copilot / Total flying hours:
3816
Copilot / Total hours on type:
320
Aircraft flight hours:
15145
Circumstances:
The flight departed Steamboat Springs-Bob Adams Airport at 1855LT on a scheduled flight to Denver-Stapleton, carrying 20 passengers and a crew of two. After takeoff, while climbing, the crew encountered severe icing conditions and was cleared to return when the flight crashed into a mountain at the 10,530 feet level. Rescuers arrived on scene the following morning. A pilot and a passenger died while 20 other occupants were injured, most of them seriously. According to official observations, the weather at Steamboat Springs about 25 minutes before the accident consisted of an estimated 2,000 feet overcast ceiling and 6 miles visibility in freezing rain. According to surviving passengers, after the accident, snow was falling at the crash site and a strong wind was blowing and gusting from the west.
Probable cause:
The probable cause of the accident was severe icing and strong downdrafts associated with a mountain wave which combined to exceed the aircraft's capability to maintain flight. Contributing to the accident was the captain's decision to fly into probable icing conditions that exceeded the conditions authorised by company directive.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 off Marie-Galante: 15 killed

Date & Time: Nov 18, 1978
Operator:
Registration:
F-OGHD
Survivors:
Yes
Schedule:
Pointe-à-Pitre - Marie-Galante
MSN:
469
YOM:
1975
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
15
Circumstances:
The twin engine airplane departed Pointe-à-Pitre on a schedule flight to the Island of Marie-Galante, carrying 19 passengers and one pilot. Weather conditions deteriorated en route and while approaching Marie-Galante, the ceiling was very low, about 200 feet above water with rain falls, turbulences and stormy conditions. While completing a slight turn to the left, the left wing tip struck the water surface. The aircraft crashed into the sea and sank by a depth of 13 meters few hundred meters offshore. Five passengers were rescued while 15 other occupants, among them the pilot, were killed. The wreckage was recovered. The aircraft was not equipped with a flight data recorder or an autopilot system.
Probable cause:
In the absence of a flight data recorder (not compulsory on this type of aircraft), investigators stated that their examination of the wreck showed no evidence of a technical failure of the aircraft or of its engines or equipment prior to impact, and that the probable cause of the accident was the decision taken by the pilot to descend in cloud to try to establish visual contact with the ground or the sea. The absence of an autopilot system (it was not installed in the aircraft) was acknowledge by the commission. It was reported that the airline had requested and obtained from the French CAA an exemption to fly this aircraft with only one pilot, but the said exemption mentioned that an operative autopilot system was compulsory for all flights, which was not the case for this aircraft. Prior to the accident, the Pilot's Association had officially protested in writing about the total lack of implementation of these provisions by the airline, about the pressures exerted onto the pilots to accept such flights in the absence of ATC radar coverage, of airborne weather radar, DME and transponder equipment, together with inadequate maintenance practices.

Crash of a De Havilland DHC-6 Twin Otter 200 in Barrow: 1 killed

Date & Time: Oct 13, 1978 at 1644 LT
Registration:
N4048B
Survivors:
Yes
Schedule:
Anaktuvuk Pass - Barrow
MSN:
125
YOM:
1968
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4302
Captain / Total hours on type:
892.00
Circumstances:
The twin engine airplane was completing a taxi flight from Anaktuvuk Pass to Barrow. On final approach to Barrow Airport in icing conditions, the airplane stalled and crashed in flames short of runway. The aircraft was destroyed, the pilot was killed and the passenger was seriously injured.
Probable cause:
Stall on final approach after the pilot continued VFR flight into adverse weather conditions. The following contributing factors were reported:
- Inadequate maintenance and inspection on part of the maintenance personnel,
- Airframe - flight controls surfaces: other, improperly installed,
- The pilot failed to use or incorrectly used miscellaneous equipment,
- Improper operation of anti-icing/deicing equipment or failed to use,
- The pilot misused or failed to use flaps,
- Inadequate flight training procedures on part of the operational supervisory personnel,
- Deficiency, company maintained equipment, services, regulation on part of the operational supervisory personnel,
- Icing conditions including sleet, freezing rain,
- Improper installed deice boots on horizontal stabilizer.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter near Mexico City: 19 killed

Date & Time: Sep 9, 1978
Registration:
XA-BOP
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Mexico City - Morelia
MSN:
18
YOM:
1966
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
19
Circumstances:
While cruising in marginal weather conditions, the twin engine airplane struck the slope of a mountain shrouded by clouds and located about 65 km west of Mexico City. A pilot and a passenger survived while 19 other occupants were killed.

Crash of a De Havilland DHC-6 Twin Otter 200 off Vancouver: 11 killed

Date & Time: Sep 3, 1978 at 1742 LT
Operator:
Registration:
C-FAIV
Survivors:
Yes
Schedule:
Victoria - Vancouver
MSN:
215
YOM:
1969
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
11
Captain / Total flying hours:
6000
Captain / Total hours on type:
3600.00
Copilot / Total flying hours:
450
Circumstances:
Twin Otter C-FAIV, operating as a scheduled VFR flight, departed Victoria Harbour at 1718LT with Vancouver Harbour water-aerodrome as destination. The estimated time en route was 20 minutes. The flight proceeded normally and reported by Active Pass at 2,000 feet. This altitude was maintained in order to cross the Vancouver Control Zone in accordance with standard procedure; once out of the control zone, a slow descent was begun towards Vancouver Harbour. Normal radio procedures were followed as the flight reported by standard visual reporting points. Just before joining final approach, the transmission, "AIV, Third Beach", was made and landing clearance was given to the flight by the Harbour Tower. The approach continued, and when the aircraft reached approximately 175 feet above the surface, nine ground witnesses heard a loud noise from the aircraft. Two surviving witnesses also heard a noise. Power was subsequently applied and C-FAIV yawed left, rolled in the same direction and plunged into the harbour in a left-wing and nose-down attitude, 2 500 feet from the intended landing area. An ELT (Emergency Locator Transmitter) tone was heard by the tower controller 54 seconds after the radio call at Third Beach. The controller called the aircraft several times but there was no response. The flight had been of 24 minutes duration. Both pilots and nine passengers were killed while two others were injured. The aircraft was destroyed.
Probable cause:
The following findings were determined:
- The final approach to land was normal until an unusual noise occurred followed by loss of control,
- The aircraft dived into the water with left wing down, nose down and with some sideslip. Value of roll, pitch and yaw, at impact could not be estimated with useful accuracy,
- At impact, the complete left flap system was in the retracted position,
- The inboard span-wise push-pull flap control rod (inboard bell-crank to inboard rod, PT # C6CW-1029-1), was severely stress-corroded and had at least three longitudinal cracks; the rod had separated from its inboard fitting,
- It was deduced t h a t t h e in-flight failure of the left-hand inboard flap control rod led to sudden retraction of the complete left-hand flap system and sudden loss of control.
- The passengers had not been briefed in evacuation procedures,
- The crew was qualified for the type of operation in accordance with Transport Canada regulations. After the failure of the left flap control rod, no action by the pilot could have averted the accident.
Final Report: