These documents are in Adobe® Portable Document Format (PDF) and require a copy of Adobe Reader® to view them. If you do not have a copy of Adobe Reader, you can download and install a free copy from Adobe.
December 2004
Rapid Ice Buildup Triggers Stall and In-flight Breakup 6 pages. [PDF 61K]
While being flown in an area of severe icing conditions in New Zealand, the Convair 580 freighter stalled and entered a spiral dive from which the flight crew was not able to recover. The aircraft broke up and struck water nearly vertically and at a high rate of speed.
November 2004
Nonadherence to Approach Procedure Cited in Falcon 20 CFIT in Greenland 6 pages. [PDF 116K]
Investigators believe that the flight crew observed airport lights during a nighttime nonprecision instrument approach and, to save time, proceeded visually toward the airport. The crew encountered the black-hole effect1 and were not aware of the airplane’s height above terrain.
October 2004
Crew’s Failure to Maintain Airspeed Cited in King Air Loss of Control 8 pages. [PDF 129K]
Investigation of the accident that killed a U.S. senator and seven others leads to calls for increased surveillance of on-demand aircraft operators, implementation of crew resource management training programs for two-pilot flight crews and development of low-airspeed-alert systems.
September 2004
Airframe Icing, Low Airspeed Cause Stall During Nonprecision Approach 6 pages. [PDF 97K]
The Saab 340B’s autopilot was in the altitude-hold mode and the engines were producing near-flight-idle power during a circling approach. The stall-warning system did not activate before the aircraft stalled. The flight crew recovered control of the aircraft 112 feet above the ground.
August 2004
Improvised GPS Approach Procedure And Low Visibility Set Stage for CFIT 8 pages [PDF 283K]
The flight crew of the Ilyushin IL-76TD freighter conducted two approaches based on a user-defined global positioning system waypoint that incorrectly depicted the location of the runway threshold. The first approach led to a go-around. The second approach was not stabilized; the descent rate was high when the airplane struck rising terrain.
July 2004
Improper Response to Stall Warning Cited in A310 CFIT off Ivory Coast 4 pages. [PDF 93K]
The pilot flying applied forward pressure on the control column but did not increase power when the stall-warning system activated during takeoff. The airplane descended into water soon thereafter. The controlled-flight-into-terrain (CFIT) accident occurred on a dark night with limited external visual references available for the flight crew.
June 2004
Failure to Comply With Nonprecision Approach Procedure Sets Stage for Regional Jet CFIT at Zürich 8 pages. [PDF 107K]
The flight crew did not have visual contact with the runway or with the approach lights when they continued descent below the published minimum descent altitude. The airplane struck terrain soon after the crew began a missed approach.
May 2004
Misrigged Elevator and Aft Loading Cause Loss of Control of Raytheon Beech 1900D 8 pages. [PDF 101K]
Limited nose-down elevator travel and an excessive aft center of gravity rendered the twin-turboprop airplane uncontrollable in pitch on takeoff from Charlotte, North Carolina, U.S. The accident report cited incorrect rigging of the elevator-control system and deficiencies in maintenance oversight and in calculation of passenger weights and baggage weights.
April 2004
Low Visibility and Citation Crew’s Deviation From Taxi Instructions Lead to Collision With MD-87 6 pages. [PDF 101K]
Runwa/ap/ap_apr04.pdfy visual range was about 200 meters/700 feet when the crew of a Cessna Citation CJ2 taxied on the wrong taxiway and into the path of a Boeing MD-87 that was taking off on the active runway at Milan, Italy.
March 2004
Electrical Arc Identified as Likely Source of In-flight Fire Aboard Swissair MD-11 8 pages. [PDF 120K]
Inadequate material-flammability-certification standards and the absence of training and procedures for in-flight fire fighting were among the factors cited in the propagation of a fire that became uncontrollable and caused a loss of control of the airplane off the coast of Nova Scotia, Canada.
February 2004
Erroneous Roll-attitude Indication Cited in Loss of Control of B-747 Freighter 6 pages. [PDF 104K]
During an instrument departure from London, England, the captain and the first officer received warnings about roll indications from the attitude-comparator system and from the flight engineer. The airplane was in a left turn, banked nearly 90 degrees, when it descended and struck the ground.
January 2004
Loss of Engine Power Sets Stage for Ditching on a Moonless Night 8 pages. [PDF 156K]
The left engine failed and the right engine malfunctioned when a Piper Chieftain was being flown over a gulf in Australia. The airplane did not have — and was not required to have — life vests aboard for the scheduled flight. None of the eight occupants survived the ditching.
