ASN Wikibase Occurrence # 140324
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| Date: | Saturday 10 December 2011 |
| Time: | 14:15 LT |
| Type: |  Beechcraft 65-80 Queen Air |
| Owner/operator: | Aviation Technology Innovators |
| Registration: | RP-C824 |
| MSN: | LD-21 |
| Fatalities: | Fatalities: 3 / Occupants: 3 |
| Other fatalities: | 11 |
| Aircraft damage: | Written off (damaged beyond repair) |
| Category: | Accident |
| Location: | Dona Soledad Subdivision, Better Living, Parañaque City -
 Philippines
|
| Phase: | Initial climb |
| Nature: | Cargo |
| Departure airport: | Manila-Ninoy Aquino International Airport (MNL/RPLL) |
| San Jose-McGuire Field (SJI/RPUH) | |
| Confidence Rating: |  Information verified through data from accident investigation authorities |
A Beechcraft 65-80 Queen Air crashed into a school building of the Felixberto Serrano Elementary school, Dona Soledad Subdivision, Better Living, Parañaque City, after take-off. All three occupants of the aircraft and at least eleven residents of the neighborhood around the school were killed. The pilot reported mechanical trouble before the crash, and was attempting to return to the airport when it crashed. The planned route of the aircraft was Manila - Ninoy Aquino International (MNL / RPLL) to McGuire Field, San Jose, Mindoro Occidental (RPUH) where it was supposed to fetch a cargo of fish.
The Aircraft Accident Investigation and Inquiry Board determined that the probable cause of
this accident was:
Immediate Cause
(1) Pilot’s Lack of event proficiency in emergency procedures for one (1) engine in-operative condition after-off. Pilot Error (Human Factor) While a one engine in-operative condition during take-off after V1 is a survivable emergency event during training, the pilot failed to effectively maintain aircraft control
the aircraft due to inadequate event proficiency.
Contributing Cause
(1) Left engine failure during take-off after v1. (Material Factor) The left engine failed due to oil starvation as indicated by the severely burnt item 7 crankshaft assembly and frozen connecting rods 5 & 6. This triggered the series of events that led to the failure of the pilot to manage a supposedly survivable emergency event.
Underlying Causes
(1) Inadequate Pilot Training for Emergency Procedure. Human Factor
Emergency event such as this (one engine inoperative event – twin engine aircraft) was not actually or properly performed (discussed only) in actual training flights/check-ride and neither provided with corresponding psycho-motor training on a simulator. Hence, pilot’s motor skill/judgment recall was not effective (not free-flowing) during actual emergency event.
(2) Inadequate engine overhaul capability of AMO. Human Factor
There was no document to prove that engine parts scheduled to be overhauled aboard were complied with or included in the overhaul activity. The presence unauthorized welding spot in the left-hand engine per teardown inspection report manifested substandard overhaul activity.
(3) Inadequate regulatory oversight (airworthiness inspection) on the overhaul activity of the AMO (on engine overhaul). Human Factor
The airworthiness inspection on this major maintenance activity (engine overhaul) failed to ensure integrity and quality of replacement parts and work done (presence of welding spots).
(4) Unnecessary Deviation by ATC from the AIP provision on Runway 13 Standard VFR Departure Southbound.
The initiative of the AY+TC for an early right turn southbound after airborne was not in accord with the standard departure in the AIP which provides the safest corridor for takeoff and the ample time to stabilize aircraft parameters in case of a one engine inoperative emergency event for a successful re-land or controlled emergency landing.
Sources:
http://news.abs-cbn.com/nation/metro-manila/12/10/11/light-plane-crashes-para%C3%B1aque-report
https://ph.news.yahoo.com/14-killed-plane-crashes-slum-area-175022879.html
https://www.huffingtonpost.com/huff-wires/20111210/as-philippines-plane-crash
http://www.therepublic.com/view/story/ae3c286a0b3d4f6388e90dd23cdac64b/AS--Philippines-Plane-Crash/
https://www.pprune.org/rumours-news/471395-13-killed-philippines-plane-crash.html
https://www.philstar.com/nation/article.aspx?publicationsubcategoryid=63&articleid=757069
http://www.gmanetwork.com/news/news/metro/241307/death-toll-in-paranaque-city-plane-crash-rises-to-14/story/
http://web.archive.org/web/20120108233526/http://www.monstersandcritics.com:80/news/asiapacific/news/article_1680034.php/3ND-LEAD-Fourteen-dead-as-plane-crashes-in-Manila
https://web.archive.org/web/20111219181121/http://www.ndrrmc.gov.ph/attachments/article/356/NDRRMC%20Update%20Plane%20Crash%20as%20of%2012%20Dec%202011,%208AM.pdf
https://www.baaa-acro.com/sites/default/files/2021-08/RP-C824.pdf
https://abpic.co.uk/images/images/1048243F.jpg (photo)
Media:
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 10-Dec-2011 01:08 | Dmitriy | Added |
| 10-Dec-2011 01:33 | Dmitriy | Updated [Total fatalities, Total occupants, Other fatalities, Destination airport, Source, Narrative] |
| 10-Dec-2011 04:40 | Alpine Flight | Updated [Aircraft type, Departure airport, Destination airport, Narrative, Plane category, ] |
| 10-Dec-2011 04:40 | Alpine Flight | Updated [Aircraft type] |
| 10-Dec-2011 05:10 | RobertMB | Updated [Aircraft type, Source, Narrative] |
| 10-Dec-2011 08:25 | BenK | Updated [Other fatalities, Phase, Narrative] |
| 10-Dec-2011 08:58 | BenK | Updated [Source] |
| 10-Dec-2011 16:56 | RobertMB | Updated [Total fatalities, Total occupants, Other fatalities, Nature, Source, Narrative] |
| 12-Dec-2011 01:17 | RobertMB | Updated [Time, Location, Source, Narrative] |
| 12-Dec-2011 01:17 | harro | Updated [Embed code] |
| 12-Dec-2011 01:20 | RobertMB | Updated [Time, Location, Source, Embed code, Narrative] |
| 13-Dec-2011 00:39 | Anon. | Updated [Phase, Embed code] |
| 16-Dec-2011 12:01 | Anon. | Updated [Embed code] |
| 05-Oct-2013 07:31 | pilot_jhun | Updated [Narrative] |
| 21-Sep-2014 11:02 | Aerossurance | Updated [Source, Narrative] |
| 01-Jul-2022 16:36 | Aerossurance | Updated [Embed code] |
| 01-Jul-2022 16:39 | Aerossurance | Updated [Source, Narrative] |
| 17-Nov-2022 06:08 | Ron Averes | Updated [Aircraft type, Departure airport, Destination airport] |
| 02-Dec-2022 06:56 | Ian | Updated [Source] |
| 02-Dec-2022 06:58 | harro | Updated [Aircraft type, Narrative] |
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