Crash of a PAC 750XL in the Pacific Ocean: 1 killed

Date & Time: Dec 26, 2003 at 0601 LT
Operator:
Registration:
ZK-UAC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hamilton – Pago Pago – Christmas Island – Kiribati – Hilo – Oakland
MSN:
103
YOM:
2003
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
16564
Captain / Total hours on type:
180.00
Aircraft flight hours:
65
Circumstances:
The pilot was ferrying the aircraft from Hamilton, New Zealand to Davis, California, via Pago Pago, American Samoa; Christmas Island, Kiribati; and Hilo, Hawaii. On the final leg, following a position report 858 nm from San Francisco, he reported a problem with his fuel system, indicating a probable ditching. Under the observation of a US Coast Guard HC-130 crew, the pilot ditched the aircraft at 1701 UTC, 341 nm from San Francisco, the aircraft nosing over on to its back as it touched down. The pilot did not emerge as expected and was later found by rescue swimmers, deceased, still in the cockpit. His body could not be recovered and was lost with the aircraft.
Probable cause:
The following findings were reported:
- The pilot was appropriately licensed, rated and experienced for the series of flights undertaken.
- The aeroplane had a valid airworthiness certificate and had been released to service.
- There was nothing (other than the item in 3.5) to suggest that the aeroplane was operating abnormally on the final flight.
- The aeroplane was being operated at 14 000 feet pressure altitude without supplementary oxygen as required by CAR 91.209 and 91.533.
- The left front fuel filler orifice was observed to be leaking fuel before departure.
- There was no attempt made to further investigate or correct this fuel leak and the pilot stated that it would stop once he departed.
- On most other aircraft this would be true, once the fuel level dropped away from the filler orifice and was no longer affected by aerodynamic suction.
- On the 750XL, the fuel system design was such that the front tanks were continuously topped up.
- The fuel loss would continue until all fuel in the rear tanks and the ferry system was consumed.
- The front fuel caps are thus critical items to be checked before flight.
- The fuel quantity uplifted at Hilo indicated that the problem had existed on the previous leg with a loss rate of up to 125 litres (33.2 US gallons) per hour.
- A comparison of the uplift figure with the expected consumption on the previous leg should have provided sufficient warning to the pilot that a problem existed.
- The existence of the problem could have been detected on the final flight by the shortened top-up intervals and by comparing fuel used by the engine with fuel remaining.
- Cumulative delays, especially including the longer than normal final refuelling time, probably influenced the pilot’s decision to depart without further checking the reason for the fuel leak or the apparent discrepancy between fuel figures.
- Cumulative fatigue, circadian rhythm and hypoxia were probably significant factors in the pilot’s failure to detect the fuel problem in flight, in time to make a safe return.
- By the time the pilot announced that he had a fuel problem, the only course of action open to him was ditching the aeroplane.
- The search and rescue facilities were activated appropriately, and had the potential to effect a successful rescue.
- The water entry impact on ditching was reasonably severe and probably incapacitated the pilot before he could vacate the cockpit.
Final Report:

Crash of a Tupolev TU-154M in the in Black Sea: 78 killed

Date & Time: Oct 4, 2001 at 1344 LT
Type of aircraft:
Operator:
Registration:
RA-85693
Flight Phase:
Survivors:
No
Schedule:
Tel Aviv - Novosibirsk
MSN:
91A866
YOM:
1991
Flight number:
SBI1812
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
66
Pax fatalities:
Other fatalities:
Total fatalities:
78
Aircraft flight hours:
16705
Aircraft flight cycles:
7281
Circumstances:
While cruising at an altitude of 36,000 feet over the Black Sea on a weekly schedule service from Tel Aviv to Novosibirsk, the aircraft disappeared from radar screens at 1344LT. The crew did not send any distress call. The aircraft entered an uncontrolled descent and crashed in the sea about 185 km off Adler, and sank to a depth of 2,000 metres. All 78 occupants were killed. Ten days after the crash, the President of Ukraine confirmed officially that the aircraft has been shot down by a surface-to-air missile (Type S200) as the Ukrainian Army was completing exercices off Feodosia, south Crimea.
Probable cause:
The catastrophe involving Tu-154M RA-85693 occurred during the execution, by crew of the Sibir airline, of passenger charter flight # 1812 from Tel Aviv to Novosibirsk. During travel along international flight path B-145 at an altitude of 11,100 m, the aircraft was struck by the 5B14Sh warhead of a 5B28 missile from an S-200B surface-to-air missile system, launched from a position near the town of Feodosia on the Crimean Peninsula, with coordinates 45°03'48"N. Lat. and 36°05'07"E. Long.

Crash of an Antonov AN-2 in the Gulf of Mexico: 1 killed

Date & Time: Sep 19, 2000
Type of aircraft:
Operator:
Flight Phase:
Flight Type:
Survivors:
Yes
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The pilot Angel Lenin Iglesias Hernández stole the aircraft at Pinar del Río Airport, took off with nine of his family members and elected to reach Florida. En route, the aircraft ran out of fuel and crashed in the Gulf of Mexico about 145 km southwest of Key West. A passenger was killed while nine other occupants were rescued by the crew of the bulk carrier christened 'Chios Dream'.
Probable cause:
Engine failure due to fuel exhaustion.

Crash of a Beechcraft 200 Super King Air in the Pacific Ocean

Date & Time: May 23, 2000 at 1945 LT
Registration:
N24CV
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Parker – Carlsbad
MSN:
BB-1524
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1659
Captain / Total hours on type:
1058.00
Aircraft flight hours:
1350
Circumstances:
En route from Arizona to California, the pilot became nauseous and began to vomit. The pilot advised air traffic that he was sick and radio contact was lost. The airplane had descended from 16,500 feet msl and was on an established course to his destination and level at 10,500 feet msl being flown by the autopilot. The last thing that he recalled was approaching his destination. When the pilot regained consciousness he looked outside the airplane to determine where he was. The surface was obscured in cloud cover. On his left side was a Navy F18 fighter plane, and they briefly communicated by hand signals. The F18 pilot indicated he should turn around towards land. The accident pilot determined that he was 186 nautical miles southwest of his destination and over the ocean. He reversed his course. The pilot attempted to contact air traffic without success; another aircraft relayed the pilot's message to air traffic. The pilot declared a medical emergency and advised that because of low fuel he would not be able to return to land. Within 10 minutes the fuel onboard was exhausted and the pilot configured the airplane for the best angle of glide and ditching at sea. Subsequently, the pilot descended through low stratus and ditched the airplane in the ocean at dusk. The pilot exited the airplane with a hand held VHF radio, two flashlights, a cell phone, and a trash bag for flotation; he climbed onto the top of the fuselage to await rescue. At this time it was dark. After about 30 minutes a Navy S3B circled the downed plane until a rescue helicopter arrived and rescued him. While at the pilot's Arizona residence he sprayed for bugs and insects using the pesticide 'Dursban.' During the process he opened the spray container to replenish the pesticide and the built-up pressure sprayed the vapor into his face. He cleaned himself up and then departed for the airport and the return flight to Palomar. He had bought food to eat during the flight, and shortly thereafter, he became sick in flight. The EPA as of June 8, 2000, has banned Dursban from the commercial market.
Probable cause:
Physical incapacitation of the pilot from improper handling of a pesticide.
Final Report:

Crash of a PZL-Mielec AN-2T on the North Pole

Date & Time: May 15, 2000
Type of aircraft:
Registration:
N72KS
Flight Type:
Survivors:
Yes
Schedule:
Longyearbyen - Barrow
MSN:
1G237-32
YOM:
1989
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was engaged in an expedition over the Arctic and was completing a flight from Longyearbyen (Spitzberg Islands) to Barrow, Alaska, with another Cessna 185. The crew of the Cessna landed first to check the ice thickness. When the AN-2 landed, the ice started to crack. The pilot attempted to takeoff but the undercarriage went through the ice and the aircraft came to rest partially submerged in water. All five occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Cessna 401A in the Pacific Ocean: 2 killed

Date & Time: May 9, 2000
Type of aircraft:
Registration:
CC-CBX
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Santiago - Robinson Crusoe Island
MSN:
401A-0121
YOM:
1969
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
En route from Santiago-Los Cerrillos Airport to Robinson Crusoe Island, the twin engine airplane crashed in unknown circumstances in the Pacific Ocean. Both pilots were killed.
Crew:
Luis Bochetti Melo,
Luis Bochetti del Canto.

Crash of a Boeing 767-366ER in the Atlantic Ocean: 217 killed

Date & Time: Oct 31, 1999 at 0152 LT
Type of aircraft:
Operator:
Registration:
SU-GAP
Flight Phase:
Survivors:
No
Schedule:
Los Angeles – New York – Cairo
MSN:
24542
YOM:
1989
Flight number:
MS990
Country:
Region:
Crew on board:
15
Crew fatalities:
Pax on board:
202
Pax fatalities:
Other fatalities:
Total fatalities:
217
Captain / Total flying hours:
14384
Captain / Total hours on type:
6356.00
Copilot / Total flying hours:
12538
Copilot / Total hours on type:
5191
Aircraft flight hours:
33354
Aircraft flight cycles:
7594
Circumstances:
EgyptAir Flight 990 departed Los Angeles International Airport, destined for Cairo, with a scheduled intermediate stop at New York-JFK. The aircraft landed at JFK about 23:48 EDT and arrived at the gate about 00:10 EDT. Two designated flight crews (each crew consisting of a captain and first officer) boarded the aircraft at JFK. The aircraft taxied to runway 22R and was cleared for takeoff at 01:19. Shortly after liftoff, the pilots of EgyptAir flight 990 contacted New York Terminal Radar Approach (and departure) Control (TRACON). New York TRACON issued a series of climb instructions and, at 01:26, instructed the flight to climb to FL230 and contact New York Air Route Traffic Control Center (ARTCC). At 01:35, New York ARTCC instructed EgyptAir flight 990 to climb to FL330 and proceed directly to DOVEY intersection. About 01:40 the relief first officer suggested that he relieve the command first officer at the controls. The command first officer agreed and left the flightdeck. The airplane leveled at FL330 four minutes later. At 01:48, the command captain decided to go to the toilet and left the flightdeck. At 01:48:30, about 11 seconds after the captain left the cockpit, the CVR recorded an unintelligible comment. Ten seconds later, the relief first officer stated quietly, "I rely on God." There were no sounds or events recorded by the flight recorders that would indicate that an airplane anomaly or other unusual circumstance preceded the relief first officer's statement. At 01:49:18, the CVR recorded the sound of an electric seat motor and 27 seconds later the autopilot was disconnected. At 01:49:48, the relief first officer again stated quietly, "I rely on God." At 01:49:53, the throttle levers were moved from their cruise power setting to idle, and, one second later, the FDR recorded an abrupt nose-down elevator movement and a very slight movement of the inboard ailerons. Subsequently, the airplane began to rapidly pitch nose down and descend. Between 0149:57 and 0150:05, the relief first officer quietly repeated, "I rely on God," seven additional times. During this time, as a result of the nose-down elevator movement, the airplane's load factor decreased from about 1 to about 0.2 G (almost weightlessness). Then the elevators started moving further in the nose-down direction. Immediately thereafter the captain entered the flightdeck and asked loudly, "What's happening? What's happening?". As he airplane's load factor reached negative G loads (about -0.2 G) the relief first officer stated for the tenth time, "I rely on God." At 01:50:08, as the airplane exceeded its maximum operating airspeed (0.86 Mach), a master warning alarm began to sound and the relief first officer stated quietly for the eleventh and final time, "I rely on God," and the captain repeated his question, "What's happening?" At 0150:15, as the airplane was descending through about 27,300 feet the airplane's rate of descent began to decrease. About 6 seconds later the left and right elevator surfaces began to move in opposite directions. The engine start lever switches for both engines then moved from the run to the cutoff position. At 01:50:24 the throttle levers started to move from their idle position to full throttle, and the speedbrake handle moved to its fully deployed position. The captain again asked "What is this? What is this? Did you shut the engine(s)?" At 01:50:26, the captain stated, "Get away in the engines ... shut the engines". The relief first officer replied "It's shut". Between 01:50:31 and 01:50:37, the captain repeatedly stated, "Pull with me." However, the elevator surfaces remained in a split condition (with the left surface commanding nose up and the right surface commanding nose down) until the FDR and CVR stopped recording. at 0150:36.64 and 0150:38.47, respectively. The height estimates based on primary radar data from the joint use FAA/U.S. Air Force (USAF) radar sites indicated that the airplane's descent stopped about 01:50:38 and that the airplane subsequently climbed to about 25,000 feet msl and changed heading from 80º to 140º before it started a second descent, which continued until the airplane impacted the ocean.
Probable cause:
The National Transportation Safety Board determines that the probable cause of the EgyptAir flight 990 accident is the airplane's departure from normal cruise flight and subsequent impact with the Atlantic Ocean as a result of the relief first officer's flight control inputs. The reason for the relief first officer's actions was not determined.
Final Report:

Crash of a Rockwell Grand Commander 680 in the Atlantic Ocean: 1 killed

Date & Time: Apr 9, 1998
Operator:
Registration:
4X-CCS
Flight Phase:
Flight Type:
Survivors:
No
MSN:
680-1731-138
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The pilot, sole on board, departed Southend on a ferry flight to Canada with an intermediate stop in Greenland. En route, he reported to ATC severe icing conditions. Shortly later, the aircraft entered an uncontrolled descent and crashed in the Atlantic Ocean about 167 km southeast of the Greenland coast. The pilot was killed.

Crash of a Lockheed C-141B Starlifter in Atlantic Ocean: 9 killed

Date & Time: Sep 13, 1997 at 1710 LT
Type of aircraft:
Operator:
Registration:
65-9405
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Windhoek - Georgetown - McGuire AFB
MSN:
6142
YOM:
1965
Flight number:
REACH4201
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
9
Aircraft flight hours:
36430
Circumstances:
Some 65 nautical miles west off the Namibian coast, a US Air Force Lockheed C-141B Starlifter collided with a German Air Force Tupolev 154M in mid-air. Both aircraft crashed, killing all 33 occupants. The Tupolev 154M (11+02), call sign GAF074, operated on a flight from Cologne/Bonn Airport in Germany to Kaapstad, South Africa. En route refueling stops were planned at Niamey, Niger and Windhoek, Namibia. On board were ten crew members and 14 passengers. The C-141B, (65-9405), call sign REACH 4201, had delivered UN humanitarian supplies to Windhoek and was returning to the U.S. via Georgetown on Ascension Island in the South Atlantic Ocean. On board were nine crew members. GAF074 departed Niamey, Niger at 10:35 UTC. REACH 4201 took off from Windhoek at 14:11 UTC and climbed to its filed for and assigned cruise level of 35,000 feet (FL350). At the same time, GAF074 was not at its filed for cruise level of FL390 but was still at its initially assigned cruise level FL350. Windhoek ATC was in sole and continuous radio contact with REACH 4201, with no knowledge of GAF 074's movement. Luanda ATC was in radio contact with GAF074, but they were not in radio contact with REACH 4201. Luanda ATC did receive flight plans for both aircraft but a departure message for only REACH 4201. At 15:10 UTC both aircraft collided at FL350 and crashed into the sea.
Probable cause:
The primary cause of this accident, in my opinion, was GAF 074 flying a cruise level (FL350) which was not the level they had filed for (FL390). Neither FL350 nor FL390 were the correct cruise levels for that aircraft's magnetic heading according to International Civil Aviation Organization regulations. The appropriate cruise level would have been FL290, FL330, FL370, FL410, etc. A substantially contributing factor was ATC agency Luanda's poor management of air traffic through its airspace. While ATC communications could be improved, ATC agency û Luanda did have all the pertinent information it needed to provide critical advisories to both aircraft. If ATC agency Luanda was unable to contact GAF 074, it should have used other communication means (HF radio, telefax or telephone) to contact REACH 4201 through ATC agency Windhoek, as outlined in governing documents. Another substantially contributing factor was the complicated and sporadic operation of the Aeronautical Fixed Telecommunications Network (AFTN). Routing of messages to affected air traffic control agencies is not direct and is convoluted, creating unnecessary delays and unfortunate misroutings. Specifically, ATC agency Windhoek did not receive a flight plan or a departure message on GAF 074, which could have been used by the controllers to identify the conflict so they could have advised REACH 4201. In my opinion, the absence of TCAS was not a cause or substantially contributing factor, but the presence of a fully operational TCAS could have prevented the accident." (William H.C. Schell, jr., Colonel, USAF President, Accident Investigation Board).

Crash of a Tupolev TU-154M in the Atlantic Ocean: 24 killed

Date & Time: Sep 13, 1997 at 1710 LT
Type of aircraft:
Operator:
Registration:
11+02
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bonn – Niamey – Windhoek – Cape Town
MSN:
89A813
YOM:
1989
Flight number:
GAF074
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
24
Circumstances:
Some 65 nautical miles west off the Namibian coast, a US Air Force Lockheed C-141B Starlifter collided with a German Air Force Tupolev 154M in mid-air. Both aircraft crashed, killing all 33 occupants. The Tupolev 154M (11+02), call sign GAF074, operated on a flight from Cologne/Bonn Airport in Germany to Kaapstad, South Africa. En route refueling stops were planned at Niamey, Niger and Windhoek, Namibia. On board were ten crew members and 14 passengers. The C-141B, (65-9405), call sign REACH 4201, had delivered UN humanitarian supplies to Windhoek and was returning to the U.S. via Georgetown on Ascension Island in the South Atlantic Ocean. On board were nine crew members. GAF074 departed Niamey, Niger at 10:35 UTC. REACH 4201 took off from Windhoek at 14:11 UTC and climbed to its filed for and assigned cruise level of 35,000 feet (FL350). At the same time, GAF074 was not at its filed for cruise level of FL390 but was still at its initially assigned cruise level FL350. Windhoek ATC was in sole and continuous radio contact with REACH 4201, with no knowledge of GAF 074's movement. Luanda ATC was in radio contact with GAF074, but they were not in radio contact with REACH 4201. Luanda ATC did receive flight plans for both aircraft but a departure message for only REACH 4201. At 15:10 UTC both aircraft collided at FL350 and crashed into the sea.
Probable cause:
The primary cause of this accident, in my opinion, was GAF 074 flying a cruise level (FL350) which was not the level they had filed for (FL390). Neither FL350 nor FL390 were the correct cruise levels for that aircraft's magnetic heading according to International Civil Aviation Organization regulations. The appropriate cruise level would have been FL290, FL330, FL370, FL410, etc. A substantially contributing factor was ATC agency Luanda's poor management of air traffic through its airspace. While ATC communications could be improved, ATC agency Luanda did have all the pertinent information it needed to provide critical advisories to both aircraft. If ATC agency Luanda was unable to contact GAF 074, it should have used other communication means (HF radio, telefax or telephone) to contact REACH 4201 through ATC agency Windhoek, as outlined in governing documents. Another substantially contributing factor was the complicated and sporadic operation of the Aeronautical Fixed Telecommunications Network (AFTN). Routing of messages to affected air traffic control agencies is not direct and is convoluted, creating unnecessary delays and unfortunate misroutings. Specifically, ATC agency Windhoek did not receive a flight plan or a departure message on GAF 074, which could have been used by the controllers to identify the conflict so they could have advised REACH 4201. In my opinion, the absence of TCAS was not a cause or substantially contributing factor, but the presence of a fully operational TCAS could have prevented the accident." (William H.C. Schell, jr., Colonel, USAF President, Accident Investigation Board).