Status: | Accident investigation report completed and information captured |
Date: | Thursday 9 August 2007 |
Time: | 12:01 |
Type: | de Havilland Canada DHC-6 Twin Otter 300 |
Operator: | Air Moorea |
Registration: | F-OIQI |
MSN: | 608 |
First flight: | 1979 |
Total airframe hrs: | 30833 |
Cycles: | 55044 |
Engines: | 2 Pratt & Whitney Canada PT6A-27 |
Crew: | Fatalities: 1 / Occupants: 1 |
Passengers: | Fatalities: 19 / Occupants: 19 |
Total: | Fatalities: 20 / Occupants: 20 |
Aircraft damage: | Destroyed |
Aircraft fate: | Written off (damaged beyond repair) |
Location: | 1,5 km (0.9 mls) off Moorea-Temae Airport (MOZ) ( French Polynesia)
|
Phase: | Initial climb (ICL) |
Nature: | Domestic Scheduled Passenger |
Departure airport: | Moorea-Temae Airport (MOZ/NTTM), French Polynesia |
Destination airport: | Papeete-Faaa Airport (PPT/NTAA), French Polynesia |
Flightnumber: | 1121 |
Narrative:A DHC-6 Twin Otter operated by Air Moorea as flight 1121, departed Moorea-Temae Airport in French Polynesia.
After a normal takeoff, the flaps were retracted at around 350 feet. The pilot then lost pitch control of the aeroplane, which adopted a steep nose-down attitude. The pilot was unable to regain control of the aircraft and the Twin Otter struck the sea, broke up and sank.
Probable Cause:
The accident was caused by the loss of airplane pitch control following the failure, at low height, of the elevator pitch-up control cable at the time the flaps were retracted.
This failure was due to a sequence of the following:
- Large wear of a cable to the right of a rope guide;
- External phenomenon, probably jet blast, causing the rupture of several strands;
- Failure of the last strands as a result of strain during the flight when using the elevator.
The following factors contributed to the accident:
- The absence of information and training for pilots on the loss of pitch control;
- The operator´s omission of special inspections ;
- The failure by the manufacturer and the aviation authorities to fully take into account the wear phenomenon;
- The failure by the aviation authorities, airport authorities and operators risk to fully take into account the risks associated with jet blast;
- The rules for replacement of stainless steel cables on a calendar basis, without taking into account the activity of the airplane in relation to its type of operation.
Accident investigation:
|
Investigating agency: | BEA France |
Status: | Investigation completed |
Duration: | 1 year and 4 months | Accident number: | BEA f-qi070809 | Download report: | Final report
|
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Classification:
Loss of control
Sources:
» Air Moorea plane crashes after Moorea takeoff; 14 bodies recovered (Tahitipresse 9-8-2007)
» Air Moorea Communique
» BEA
Follow-up / safety actions
BEA issued 7 Safety Recommendations
Issued: 09-OCT-2007 | To: Transport Canada; EASA | F-OIQI (1) |
Require operators to perform an inspection as soon as possible on stainless steel stabilizer control cables installed on DHC-6 Twin Otter airplanes, with particular attention being paid to chafing areas in contact with cable guides. |
Issued: 09-OCT-2007 | To: Transport Canada; EASA | F-OIQI (2) |
Consider extending these inspections to carbon steel cables that may also be installed on the stabilizer control system of this airplane. |
Issued: 04-DEC-2008 | To: Transport Canada; EASA | F-OIQI (3) |
That stainless steel control surface cables be forbidden on the DHC6, at least until improved knowledge on their behaviour makes it possible to determine new regulatory requirements and to establish appropriate maintenance procedures; |
Issued: 04-DEC-2008 | To: Transport Canada; EASA | F-OIQI (4) |
That a review be undertaken, in the light of the lessons learned in this investigation, of the design and in-service experience of other aircraft on which stainless steel cables are used for the primary controls so as to determine the measures that may prove useful to safety. |
Issued: 04-DEC-2008 | To: DGAC | F-OIQI (5) |
DGAC encourage operators to transmit to manufacturers all information on technical anomalies detected that are not included in the maintenance documentation. |
Issued: 04-DEC-2008 | To: DGAC | F-OIQI (6) |
DGAC organise an information campaign among aerodrome and aircraft operators so as to make them aware of the risks associated with jet blast from airplanes; |
Issued: 04-DEC-2008 | To: EASA | F-OIQI (7) |
EASA consider the appropriateness of taking jet blast into account in the process of aircraft certification. |
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Photos
F-OIQI
F-OIQI
F-OIQI
accident date:
09-08-2007type: de Havilland Canada DHC-6 Twin Otter 300
registration: F-OIQI
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Moorea-Temae Airport to Papeete-Faaa Airport as the crow flies is 18 km (11 miles).
Accident location: Exact; as reported in the official accident report.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.