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Crash of a Piper PA-42-720 Cheyenne III off Grand Case: 4 killed

Date & Time: May 5, 2012 at 0240 LT
Type of aircraft:
Registration:
F-GXES
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Grand Case - Fort-de-France
MSN:
42-8001043
YOM:
1980
Flight number:
TIF520
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3950
Captain / Total hours on type:
513.00
Aircraft flight hours:
7593
Aircraft flight cycles:
7830
Circumstances:
The twin engine aircraft was engaged in an ambulance flight between Grand Case and Fort-de-France and was carrying a pilot, a nurse, a doctor and a patient, a Greek citizen in honeymoon in Saint Martin who suffered a heart attack. He normally should be transferred to Fort-de-France from Saint Martin-Princess Juliana Airport with another Operator but the aircraft suffered technical problem prior to departure and the patient was transferred to Grand Case Airport. Piper PA-42 left Grand Case-L'Espérance runway 12 at 02H39. One minute later, during initial climb, it lost height and crashed into the Caribbean Sea, some three NM off the airport, off Tintamarre Island. Around 1000LT in the morning, a wheel and some others debris were found floating in water and no trace of the four occupants was found. They were later considered as deceased.
Probable cause:
The French BEA said in its final report that no technical anomaly to affect significantly the performance of the airplane or its pitch control could be demonstrated. It appears that the pilot had consumed alcohol before the flight and was awake since 0630LT and did not sleep over 20 hours, which could affect his capabilities. In conclusion, the investigation did not determine the cause of the accident, but the following factors may have contributed:
- aircraft's operation with one pilot only,
- absence of regulation does not allow the Civil Aviation Authority to ensure the adequacy of the operational objectives of an operator and its capacity to maintain its activity. This failure could not ensure that the pilot was able to conduct the flight.
- the presence of a flight recorder would probably help to understand the circumstances of the accident with more precision. Important data failed to the investigation, which was not able to identify all possible measures to avoid a similar accident in the future.
Final Report:

Crash of a McDonnell Douglas MD-82 in Machiques: 160 killed

Date & Time: Aug 16, 2005 at 0300 LT
Type of aircraft:
Operator:
Registration:
HK-4374X
Flight Phase:
Survivors:
No
Schedule:
Panama City - Fort-de-France
MSN:
49484
YOM:
1986
Flight number:
YH708
Location:
Country:
Crew on board:
8
Crew fatalities:
Pax on board:
152
Pax fatalities:
Other fatalities:
Total fatalities:
160
Captain / Total flying hours:
5942
Captain / Total hours on type:
1128.00
Copilot / Total flying hours:
1341
Copilot / Total hours on type:
862
Aircraft flight hours:
49494
Aircraft flight cycles:
24312
Circumstances:
The MD-82 arrived at Panama City-Tocumen after a flight from Medellín-José María Córdova Airport (MDE). The plane was then prepared to carry out a flight to the Caribbean island of Martinique. Flight WCW 708 departed Panama City at about 06:00 UTC and climbed to its cruising altitude of FL310. This altitude was reached at about 06:25 UTC. Sixteen minutes later the airplane began a normal climb to FL330. At 06:49 the speed began to steadily decrease from Mach 0.76. The horizontal stabilizer moved from about 2 units nose up to about 4 units nose up during this deceleration. At 06:51 UTC the crew reported at FL330 over the SIDOS waypoint, over the Colombian/Venezuelan border, and requested a direct course to the ONGAL waypoint. The controller instructed the crew to continue on the present heading and to await further clearance direct to ONGAL. The flight crew meanwhile discussed weather concerns that included possible icing conditions and the possible need to turn on engine and airfoil anti-ice. At 06:57 UTC the flight crew requested permission to descend to FL310, which was approved. The autopilot was disconnected and the airplane started to descend. As the airplane descended past about FL315, the airspeed continued to decrease and the engine EPR decreased to about flight idle. Two minutes later a further descent to FL290 was requested, but the controller at Maiquetía did not understand that this was a request from flight 708 and asked who was calling. Flight 708 responded and immediately requested descent to FL240. The controller inquired about the state of the aircraft, to which they responded that both engines had flamed out. The controller then cleared the flight to descent at pilot's discretion. In the meantime, the altitude alert warning had activated, followed by the stick shaker and the aural stall warning alert. The airspeed had reached a minimum of about 150 indicated air speed (IAS) knots at about FL250. The crew reported descending through FL140 and reported that they were not able to control the airplane. The aircraft descended at 7,000 ft/min, and finally crashed in a swampy area. The aircraft disintegrated on impact and all 160 occupants were killed. Debris were found on an area of 205 metres long and 110 metres wide. The entire descent from FL330 had taken approximately 3 minutes and 30 seconds.
Probable cause:
Given the aerodynamic and performance conditions, the aircraft was taken to a critical state, which led to a loss of lift. Consequently, the cockpit resource management (CRM) and decision-making during the development of emergency were misguided. This was caused by the following:
a) Awareness of environment (or situational awareness) insufficient or improper that allowed the cockpit crew, not being full and timely aware of what was happening regarding the performance and behavior of the aircraft.
b) Lack of effective communication between the cockpit crew that limited, within the decision making process, the possibility to timely choose appropriate alternatives and options and to set respective priorities in the actions taken at the time when it was established that there was a critical or emergency situation (stall condition at high altitude).
It is found that the cause of the accident is determined by the absence of appropriate action to correct the stall of the aircraft, and also in the emergency up to the impact with the ground, at an inappropriate hierarchy of priorities in implementing the procedures. Subsequently, the operations were conducted outside of the limits and parameters set by the manufacturer's manual performance, together with an inadequate flight planning by failing to consider meteorological aspects, in addition a misinterpretation and late of the energy state of the aircraft by the flight crew. Therefore, the evidence shows the classification of "Human Factor" as a cause of this accident.
Final Report:

Ground fire of a Transall C-160 in Fort-de-France

Date & Time: May 6, 2004 at 1358 LT
Type of aircraft:
Operator:
Registration:
R100/F-RAZR
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Fort-de-France - Fort-de-France
MSN:
F100
YOM:
1970
Country:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4306
Copilot / Total flying hours:
2564
Aircraft flight hours:
18530
Circumstances:
The aircraft was engaged in a local post maintenance test flight at Fort-de-France-Le Lamentin Airport, carrying five technicians and three crew members on behalf of the Escadron de Transport Outremer 58. After engine startup, the crew started to taxi when a fire erupted. The aircraft was stopped on the ramp and all eight occupants escaped uninjured. Within three minutes, fire bombers were on site and extinguished the fire. Nevertheless, the aircraft was damaged beyond repair.
Probable cause:
The accident was caused by electrical arcing at the power cable to a submersible fuel pump. This arcing occurred above the kerosene liquid inside the tank full of fuel vapors. The cable type used was chosen at the time of the design of the aircraft. Atmospheric conditions on the apron of Fort de France have raised the temperature of the reservoir beyond the flash point kerosene. The vapors contained in this tank were explosive, and the arc was enough to initiate the blast. As such, atmospheric conditions are a certain cause of environmental origin of the accident. The appearance of the arc is, in turn, has only technical causes:
- The quality of cable used and age are in fact responsible for the creation of the electric arc.
- The formation of the insulating sheath of this type of cable is not likely to ensure an absolute seal. This quality is also not claimed by its manufacturer.
Indeed, the analysis carried out show a porosity of electrical cable, even nine, therefore that it is soaked in kerosene. The presence of kerosene increases the phenomenon of porosity of old cables. Degradation characteristics of dielectric strength of the cable insulation explains the appearance of the arc. The accident occurred while the cable was over 19 years old. The fuel pumps wiring has never been a problem. But there has not been a cable that had reached the age of 19 years. The aging of the cable could still degrade the seal. Finally, maintaining this type of cable on the first C160 series until this accident was part of a complex process in which traceability has not been formally established. Doubts indeed appeared in 1969 on the quality of these cables, doubts that can be considered today as precursors. Measures had been adopted precisely to overcome these deficiencies. In this regard, the replacement of the fuel pump wiring of the second series C 160 of these cables with a newer type and considered more efficient is particularly significant. Its extension to the first series aircraft might have seemed relevant, and would probably have prevented the accident. The reasons which led to the maintenance of such cables on the C 160 series first held in both the human factor (underestimation of risk, lack of global view on the issue) and organizational factors, which can be seen as a lack of traceability of technical and logistic actions, a lack of consistency of the measures adopted, and probable deficiencies in the information flow.
Final Report:

Crash of a Britten-Norman BN-2B-21 Islander near Fort-de-France: 6 killed

Date & Time: Jul 17, 1994 at 2145 LT
Type of aircraft:
Operator:
Registration:
8P-TAD
Survivors:
No
Site:
Schedule:
Bridgetown - Fort-de-France
MSN:
2152
YOM:
1983
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
2000
Captain / Total hours on type:
1400.00
Circumstances:
On Monday July 18 1995 at 00h45 UTC, expressed in local time as Sunday July 17 at 20h45, the Trans Island Air Britten-Norman BN2B registered as 8P-TAD, took off from Grantley Adams airport (Barbados) bound for Fort de France (Martinique) with one pilot and five passengers on board. The flight had been preceded by another aircraft, registered as 8P-TAC, of the same type and belonging to the same company, flying the same route. These flights were undertaken on a charter basis on behalf of Société Nouvelle Air Martinique. They were carrying passengers originally scheduled to fly on a Dornier 228 which was out of service, and which was supposed to undertake scheduled flight PN403. At 01h39, at the request of the approach controller, the pilot announced his estimated arrival time over the FOF beacon at 01h47. At 01h40 the pilot said that he was at 2700 feet, thus at the minimum arrival altitude in that sector, still on the 150 radial from FOF; he stated that he had the field in sight and requested permission to make a visual approach. At 01h42, at the request of the controller, the pilot confirmed that he had the field in sight and obtained clearance for a visual approach. At 01h45, the pilot of 8P-TAD transmitted for the last time. At 01h48, he no longer responded to the controller's calls. At 01h58, the DETRESFA phase of the search and rescue procedure was initiated. On July 19 1994 at around 08h30, a day and a half after the accident, the wreckage of the aircraft was found in the Carbet hills, near Piton Lacroix in the
commune of Bellefontaine.
Probable cause:
The accident was caused by the pilot's failure to identify the airdrome installations before the start of the night visual approach procedure under an IFR flight plan. The probable failure of the onboard DME and the imprecise navigation contributed to the accident.
Final Report:

Crash of a Lockheed L-1049H Super Constellation in Fort-de-France

Date & Time: Jun 3, 1975
Registration:
N6931C
Flight Type:
Survivors:
Yes
Schedule:
Fort-de-France - Fort Lauderdale
MSN:
4813
YOM:
1957
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After takeoff from Fort-de-France-Le Lamentin Airport, the crew informed ATC about technical problems and was cleared to return for an emergency landing. Following an unstable approach, the four engine airplane landed hard. The crew was able to stop the airplane in timely manner and while all three crew members were uninjured, the airplane was damaged beyond repair.

Crash of a Boeing 707-121B on Mt La Soufrière: 30 killed

Date & Time: Sep 17, 1965 at 0725 LT
Type of aircraft:
Operator:
Registration:
N708PA
Flight Phase:
Survivors:
No
Site:
Schedule:
Fort-de-France – Saint John’s – Christiansted – San Juan – New York
MSN:
17586
YOM:
1957
Flight number:
PA292
Country:
Crew on board:
9
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
30
Captain / Total flying hours:
15355
Captain / Total hours on type:
297.00
Copilot / Total hours on type:
181
Aircraft flight hours:
19127
Circumstances:
PanAm Flight PA292 was a scheduled service from Fort-de-France, Martinique to New York with en route stops at Saint John's, Antigua, Christiansted, St Croix, and San Juan, Puerto Rico. An IFR flight plan had been filed for the 30-minute leg to Antigua. Cruising altitude would be FL165. The airplane christened 'Clipper Constitution' departed Fort-de-France's runway 27 at 0704LT. Cruising altitude was reached at 0709. The crew established radio contact with the Antigua controller at 0715. The controller cleared the flight to the Coolidge NDB beacon at 2 500 feet and told the crew to report at the beacon outbound leaving 2 500 feet or field in sight. At approximately 0725 the flight reported through FL40 with the field not yet in sight. At the same time the airplane was observed flying along the coast of the island of Montserrat in rain and below the clouds with landing gear down and flaps partially extended. Shortly afterwards the airplane struck a mountain at an elevation of 2 760 feet asl and 242 feet below the summit. The airplane was totally destroyed and all 30 occupants have been killed. Weather was poor at the time of the accident with thunderstorms activity, towering cumulus and heavy rain falls.
Probable cause:
The accident was the result of the aircraft descending below a safe height when its position had not been accurately established.
Final Report:

Crash of a Latécoère 631 into the Atlantic Ocean: 52 killed

Date & Time: Aug 1, 1948 at 2355 LT
Type of aircraft:
Operator:
Registration:
F-BDRC
Flight Phase:
Survivors:
No
Schedule:
Fort-de-France – Port-Etienne – Paris
MSN:
06
YOM:
1947
Flight number:
AF072
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
41
Pax fatalities:
Other fatalities:
Total fatalities:
52
Aircraft flight hours:
185
Circumstances:
The crew was performing a flight from Fort-de-France, Martinique, to Paris, with an intermediate stop in Port-Etienne, Mauritania. While cruising by night over the Atlantic Ocean, about 1,920 km from Port-Etienne (now Nouadhibou), the aircraft crashed into the ocean in unknown circumstances at 2355LT. No message was sent by the crew. SAR operations were jointly conducted by several countries and few debris were found by the crew of USS Campbell three days later, on August 4. Unfortunately, none of the 52 occupants survived the crash of this six-engine aircraft christened 'Henri Guillaumet'.
Crew:
Corentin Kersual, pilot,
Jean Goutay, copilot,
Henri Gloux, radio navigator,
Gontran Ronat, radio navigator,
Henri Cabanes, navigator,
Gaston Le Morvan, mechanic,
Jean Coustaline, mechanic,
Alfred Jaggi, mechanic,
Mr. Arbelot, mechanic,
Mr. Sgourdeos, steward,
Mr. Meunier, steward.
Probable cause:
Due to lack of concrete evidence, it was not possible to determine the exact cause of this tragedy. However, experts did not exclude the hypothesis of a serious technical issue sustained during flight.

Crash of a Sikorsky S-43 off Fort-de-France: 4 killed

Date & Time: Aug 3, 1945 at 1011 LT
Type of aircraft:
Operator:
Registration:
NC15066
Survivors:
Yes
Schedule:
Port of Spain – Fort-de-France
MSN:
4306
YOM:
1936
Flight number:
PA216
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
4298
Captain / Total hours on type:
698.00
Copilot / Total flying hours:
1670
Copilot / Total hours on type:
90
Aircraft flight hours:
12955
Circumstances:
Flight 216 continued at 6,000 feet until radio bearings indicated its position to be opposite the Fort de France radio beacon at which point it turned to the west, away from the island, preparatory to making a let-down. About 10 miles west of Martinique the plane entered an area clear of clouds and descent was started in wide spiral over the open sea. The co-pilot then established radio communications with the company's base station and at 0955 was advised that landing conditions at Fort do France were: wind ESE 20 knots, visibility 2 miles, ceiling 2,000 feet, barometer 1012.2, sea moderate with ground swells. Landing minimums for Pan American at Fort-de-France, approved by the Civil Aeronautics Administration, are: ceiling 1,000 feet, visibility 2 miles. During the let-down to Fort do France the pilot observed that the clouds extended upwards from 800 feet and that very heavy rain underneath the overcast made it impossible to determine accurately the condition of the water surface. Captain Shaw stated that during the let-down the left engine cut out momentarily and then resumed normal operation with indication of the proper manifold pressure. Instead of encountering the weather conditions reported at 0955, the pilot found that low ceiling and heavy rain squalls prevailed with visibility reduced to about 1/2 mile. Proceeding to Fort-de-France under the overcast, Captain Shaw circled the company station at an altitude of 500 feet and rioted that the wind-sock indicated a southwest surface wind instead of the previously reported east-southeast wind. Remarking to the co-pilot that he was afraid they would "lose" the left engine and, being apprehensive of single-engine performance of the Sikorsky S-43, the pilot elected to risk a landing under his emergency authority. At this moment the company radio advised that the weather was closing in rapidly and a landing should be made as soon as possible. Heading into the southwest wind an approach with full flaps was made toward a portion of Fort-de-France harbor seldom used for landing. Captain Shaw stated that during the latter part of his approach intense rain precluded forward vision through the windshield and only by opening a side window in the cockpit was he able to see the surface of the water just before the plane landed on the crest of a 4 to 6-foot swell. On contact with the water and alarmed by the size of the surface swells, the pilot attempted to take off, using full throttles, but he stated that the left engine failed to respond. The bow submerged and the plane yawed to the right, shearing off the left wing float and permitting that wing to submerge. As the left wing went down the aircraft rolled over on its back, rapidly filling with water. Quick action on the part of the crew resulted in the saving of all but four of the ten passengers, several of whom had to be taken from the plane through the submerged hatch. Survivors were picked up by the company service launch and a private fishing boat. The crash occurred at about 1011 and the plane sank within 10 minutes.
Probable cause:
On the basis of the foregoing the Board determines that the probable cause of this accident was the attempt by the pilot to land the aircraft in conditions of water surface not suitable for landing of a flying boat.
Final Report: