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Accident reviews on this page:

Beech C90

Beech 300 KADS

Boeing 737-200

Boeing 747-258F

Boeing 747-400 ERF


Cessna 310

Cessna 404

DC-10 Faro

DHC-6 Twin Otter


Jetstream 4100

Lockheed C-130H

Mitsubishi MU-2B

Piper PA-31

Piper PA-31P

Piper PA 44-180

Saab SF-340B

Accidents in Dutch

Engine Failure Related Accidents

Accidents after engine failure continue to happen. A list with more than 500 reported accidents with multi-engine airplanes since Jan. 1996 can be downloaded here; more than 4,000 people lost their lives during these unnecessary accidents.  Unnecessary? Yes, most of them definitely, because if pilots would have been made aware of the limitations that apply for controlling their airplanes while an engine is inoperative and the power setting of the remaining engine is high,  these accidents would not have happened.

Regrettably, flight manuals of most multi-engine airplanes and courseware for a multi-engine rating present definitions of the minimum control speed VMC(A) and engine emergency procedures that are not in agreement anymore with airplane design methods and flight-test techniques.

AvioConsult reviewed more than 400 accident investigation reports and concluded that none of them presented the real cause of the accidents and hence did not recommend the appropriate improvements to really improve aviation safety, see below.  It became clear that neither the mishap pilots nor the accident investigators and in some cases not even the writers of airplane flight manuals and courseware knew about the real value and the limitations of air minimum control speed VMCA (and of takeoff safety speed V2) for the controllability and performance of their airplane following an engine failure or while an engine was inoperative.  A number of training manuals were also reviewed and are also briefly discussed. 

The sole purpose of publishing the comments below is to help prevent accidents after engine failure from happening again.  Please feel free to read or download and learn from these comments.  Please do not hesitate to ask any questions remaining.
All of the theory that is needed to understand the comments presented below can be found in the Paper Airplane Control and Accident Investigation after Engine Failure by AvioConsult. Please refer to the Downloads page.
Formal FAA and EASA documents, Test Pilot School course books and references to Aeronautical Universities can be found in the References table on the Downloads page and on the Links page.

On the Downloads page, free papers explaining the controllability and performance while one of the engines of a multi-engine airplane is inoperative are presented, as well as a link to an interesting on-line One Engine Inoperative Trainer of the University of North Dakota. Click here for direct access to this trainer.

Please read the copyright and liability disclaimers here first. 
Unless specifically stated otherwise, you may download one copy of the content for informational, non-commercial and personal use only, provided you keep intact all copyright notices and do not modify the content. 

Reviews of accident investigation reports

A limited number of investigation reports were reviewed by AvioConsult. Please refer to the links in the list in the left column, or browse further down.

If you would like an accident to be reviewed, please don't hesitate to ask.

If you would like to learn how to control an airplane after engine failure, or how to analyze engine failure related accidents using Flight Data Recorder data, click here.

Textron Aviation B-300, KADS, 30 June 2019

After liftoff, power of the left engine decreased. The resulting yaw was not adequately counteracted and the airplane continued to roll to the left and impacted an airport hangar. All 10 crew and pax were fatally injured. Inadequate rudder to maintain straight flight and not maintaining a favorable bank angle of 5° into the good engine increased VMCA to a lot higher value than the POH-published VMCA; the large resulting sideslip caused much drag preventing the airspeed from increasing to V2. The actual VMCA increased above the calibrated airspeed, after which control was lost.
The NTSB reported that the pilot initially commanded a left rudder input, which was the conclusion of calculating the sideslip with only one of three lat-dir simultaneous equations of motion, which is not a good engineering practice, because other sources of sideslip were left out.
It is hard to believe that a pilot would apply rudder into the yaw due to asymmetrical thrust at low altitude, thus enhancing the yaw rate.
AvioConsult was asked to write a post on the crash on the BeechTalk/ Crash Talk forum, subject: Plane Down in KADS...(page 77, 21 July 2019). Click here or download the pdf version below.
In anticipation of more questions, AvioConsult reviewed NTSB studies in the accident docket as they appeared and wrote notes to the NTSB Lead Investigator to help improve the final report, because engineering errors were made in calculating the sideslip. In addition, the engine emergency procedure in the B-300 POH was not quite complete. Regrettably, these notes were not used. The pilot was blamed, while his training and the FAA review of the POH were obviously inadequate. In addition, the NTSB report was inadequate as well (as most, if not all engine failure accident reports).
Download the annotated studies and the notes sent to the NTSB in one document.

Another post was written and posted on the BeechTalk forum on 24 Nov. 2022, page 111.
Download a pdf with both posts on the BeechTalk Forum    |   Top

Incident with Boeing 747-400 ERF, Maastricht Aachen Airport, 17 nov. 2017

When takeoff thrust was being set, the thrust of engine #4 suddenly reduced to 20%, most probably due to a compressor stall. The airspeed was about 30 kt. The captain, as pilot flying, used nose wheel steering, differential braking and even reverse thrust trying to prevent the airplane from vacating the runway. He of course, was not successful. The throttles were not closed at once and the airplane was not brought to an immediate stop when diverting from the runway centerline. The errors by the crew raised doubts about their training.
The Dutch TSB reported that "there are no certification requirements for situations in which a critical engine becomes inoperative during takeoff below VMCG". Well, there are, as (nearly) all multi-engine rated pilots know: the certification requirement is that the minimum control speed on the ground (VMCG) must be determined and decision speed V1 made available. If any engine fails during takeoff when VMCG or V1 has not yet been reached, the takeoff must be aborted expeditiously. The report by the Dutch TSB is really embarrasing, therefore, as an apology to readers worldwide, AvioConsult annotated the original report and makes it available for download.
Download the original annotated report     |   Top

A limited review in the Dutch language is available here.

DC-10, Faro Portugal, 21 Dec. 1992

At the request of 30+ victims and next of kin of the deceased of this fatal accident, AvioConsult critically reviewed the formal accident investigation report and the contribution of the Dutch Aviation Safety Board as accredited representative.
This resulted in the involvement as an expert witness in two court cases that ended 8 Jan 2020 with the verdict that the cause of the accident, that took the lives of 57, was not windshear, as was 'determined' by the Dutch Board. The court passed sentence that the crew did not follow procedures and made several errors. The initiated go-around just before touchdown failed because the engines rpm had decreased to flight idle as the throttles were already closed and held back at 150 ft against the fully functioning autothrottle system.

The detailed analysis of the last 80 seconds of flight, written by AvioConsult using flight data recorder and other data, and experimental flight-test expertise, is available for download.
Download The Last 80 Seconds of Flight MP495 (2017).

The first report, written in 2012 with very limited means and data, includes the dubious role of the Dutch Aviation Safety Board and is also available for download. 
Download Analysis DC-10 Faro accident, version 2012, revised 2017.

A few more downloads:
The Portuguese accident report (7 MB).
The reports of the National Aerospace Laboratory (NLR) and Review (12 MB).
The AIR Inc. en Gillespie reports and Review (7 MB).
Review of the Draft (Interim) Report V17 of Court-experts (2016) (5,6 MB).
Final Report of Court-experts with annotated Comments (2017) (3,5 MB).
Review of the Final Report of Court-experts (2017) (1,5 MB).

These reports prove that experienced airline pilots may be very well educated, trained and experienced to operate airplanes, but should — without proper engineering education — never be assigned as (independent or sole) accident investigator. Analyzing FDR data requires airplane systems knowledge as well, as became clear in the report The Last 80 Seconds ... referenced above. Windshear was not the cause of this accident, but numerous consecutive pilot errors were.

Other data are available on the Dutch downloads page     |   Top

Britten Norman BN-2, Bonaire, 22 Oct. 2009

A BN-2 ditched very close to the destination island Bonaire (Caribean) following an engine failure shortly after takeoff from Curaçao.  The passengers could escape and were rescued; the pilot regrettably died in the accident. The accident investigation was conducted by the Dutch Safety Board.
It seems that the pilot was never made aware of the technique to achieve maximum performance (minimum drag) while one engine is inoperative, most probably because neither his training manuals, nor the BN-2 flight manual did provide this life-saving information. The accident investigators were obviously not aware of this either. Refer to the Downloads page for papers on this subject. 

The accident investigation report with many comments, written by AvioConsult using experimental flight-test expertise, is available for download:

Download the Safety Board Report with comments of AvioConsult     |   Top

Lockheed C-130H, Netherlands, 15 July 1996

A C-130H Hercules crashed at Eindhoven Airbase in the Netherlands following the failure of engines #1 and #2 due to bird ingestion during a go-around that was initiated just prior to touchdown. Engine #3 was was shutdown by the crew, either before the approach or just before #1 and #2 failed.
The go-around was initiated at an airspeed below 97 kt, which is far below the flight manual required go-around airspeed of VMCA2 (134 kt in this case). The flight manual requires acceleration to VMCA2 (VMCA for n - 2) before selecting full go-around power to be able to maintain control and in anticipation of another engine to fail on the same wing. If two engines fail on the same wing and the power setting on the other engines is high, the airplane will be uncontrollable at speeds below VMCA2.
In this case, the airplane lost the thrust of three engines (# 1, 2 and 3). Only #4 was operating at max. thrust following the bird ingestion. In this very special case, the actual minimum control speed, however, was VMCA1 (one asymetrical outboard engine). As the airspeed was a little below VMCA1, the airplane started to slowly roll and slide away in a direction away from the operating engine, until it impacted the ground.

The pilots of the airplane and the accident investigators did not know about the real value of the minimum control speeds of the airplane, not about the factors that influence VMCA, not how the magnitude of VMCA can be 'controlled' by the pilots and not what VMCA really means for the controllability and safety of flight before and after engine failure, despite the fact that Lockheed provided good VMCA data and explanations, including control limitations, in the airplane flight manual as well as in a very good publication 'C-130 low speed flying qualities' that is available to all C-130 pilots.

The Flight and Performance Manuals of the C-130H airplane present numerous warnings, cautions and notes on propulsion system malfunctions, explain the reduced controllability after engine failure and present recommended flight techniques and the consequences if these are not adhered to. Lockheed did a good job, but the warnings, cautions and notes are regrettably not understood by most pilots.

Cause of the accident
The cause of the accident was that the pilots were not (made) aware of the go-around speed warnings in the Flight Manual. They initiated a go-around at a speed 37 knots(!) below the Flight Manual required go-around speed when an engine fails or is inoperative.
The Dutch Aviation Safety Board refused to re-investigate the accident following the publication of a book on the accident, at the request of the survivors and relatives of the victims (2010).

Download the analysis of the accident (Dutch language) here    |    Top

Cessna 404, Australia, 11 Aug. 2003

Shortly after liftoff, while still over the runway, the right engine failed. The pilot retracted the landing gear, selected flaps up and feathered the right propeller and then, at very low altitude, turned left, into the operating engine, to return for landing. One of the conclusions in the report was: The aircraft was manoeuvred, including turns and banks, at low altitude resulting in a decrease in airspeed below that required to maximise one-engine inoperative performance.
While on the left hand downwind leg, the airspeed decayed, the altitude could not be maintained and the airplane descended and impacted with the ground. Weight and cg were within limits.

Cause of the accident
The pilot did not maintain 5 degrees of bank after engine failure as required in step 6 in the engine failure procedure in the flight manual, but initiated a turn at too low an altitude (100 ft AGL) while the airspeed was too low. Control was not lost immediately, because the turn was in the direction of the operating engine, which is the favorable direction for keeping actual VMCA low, i.e. below the published VMCA.

The accident investigation report did not include the effect of bank angle on VMCA and the necessity for a 5 degree bank angle into the good engine as a life-saving factor that influences both the controllability and the one engine inoperative climb performance. Pilot and accident investigators were obviously not familiar with the effect of bank angle on both VMCA and the airplane performance, may be because it was never taught to them.

A supplemental analysis to the formal accident investigation report, written by AvioConsult, using experimental flight-test expertise, is available for download:
Download this analysis   |   Top

Beech C90, Australia, 27 Nov. 2001

Just prior to, or at about the time the aircraft became airborne, the left engine failed. After liftoff, the aircraft remained airborne for about 20 seconds. The aircraft was rolling through about 90 degrees left bank, it struck power lines about 10 m above ground level and about 560 m beyond the end of the runway. It then continued to roll left and impacted the ground inverted in a steep nose-low attitude.

Cause of the accident
The accident was caused because of an incomplete and deficient engine emergency procedure. In addition, the real value and meaning of VMCA was neither clear to the pilot, nor to the accident investigators.

AvioConsult wrote a letter to the CEO of Raytheon Aircraft Company on 8 August 2006 expressing concerns about the definitions and the engine emergency procedures in the operator manual of the Beech King Air C90 and to present recommendations to improve. Ratheon never responded.

A supplemental analysis to the formal accident investigation report, written by AvioConsult, using experimental flight-test expertise, is available for download:
Download this analysis     |    Top

Boeing 737-200, Algeria, 6 March 2003

Just after passing V1, an engine failed. Almost immediately after liftoff, control of the airplane was lost and the airplane crashed, killing all but one on-board.
AvioConsult reviewed the accident investigation report and concluded that the engine emergency procedures in the Flight Crew Training Manual were inappropriate because the recommended control inputs were not leading to the 10% airspeed safety margin over VMCA that aviation regulations require when an engine fails during takeoff.
When using the recommended control inputs (for keeping the wings level), the actual minimum control speed that the airplane experiences right after liftoff, will be much higher than the minimum control speed that was determined during flight-testing and that is used to calculate both VR and V2.Actual VMCA was most probably even a little higher than V2 at the moment of liftoff; because the airplane continued a slow roll into the dead engine.

Cause of the accident
The accident was caused by inappropriate engine emergency procedures. The pilots are not to be held responsible.

AvioConsult recommended Boeing in July 2005 to improve the procedures, but Boeing responded that 'there was no compelling reason to change the procedures'.

An analysis of the Engine Failure Takeoff Procedures in the Boeing 737-200/300/400 Flight Crew Training Manual is available for download:
Download this analysis     |    Top

Piper PA-31, New Zealand, 17 Dec 2002

Shortly after takeoff, the left engine quit operating for unknown reasons. The pilot feathered the propeller and returned to the airport for landing.
During the final turn, control was lost and the airplane crashed.

The analysis of this accident is included in the paper Airplane Control and Accident Investigation after Engine Failure, please refer to the Downloads page.   |    Top

Piper PA-31P, Australia, 15 June 2010

While passing 7000 ft, the right engine failed and was shutdown. The airplane returned to the departure airport, but crash landed a few miles short of the airport on a road.
Download the original report with comments added

Piper PA-44-180, Netherlands, 14 August 2002

A Piper PA-44-180 Seminole, owned and operated by Martinair Flight School in The Netherlands, crashed in a lake, killing an instructor and two students during a demonstration of flight with an inoperative engine.  The Dutch Transport Safety Board thoroughly investigated the accident and concluded that following the intentional shut down of the left engine, the fuel valve of the right engine was inadvertently closed rather than the valve of the left engine, after which the right engine quit as well and an emergency landing became unavoidable, according to the report. The report also concludes that the airspeed decreased below the stall speed, after which control of the airplane was lost at an altitude from which recovery was not possible.

But to the opinion of AvioConsult, this was not the cause of the accident. Neither the pilots nor the investigators did know about the limitations of a minimum control speed. A VMCA, although never determined, also exists due to asymmetrical drag (yawing moment) caused by one feathered propeller and the other not feathered.

The analysis (in Dutch language) with comments on the formal accident investigation report is available for download:
Download this analysis      |     Top

Documentation review PA-44-180. The formal accident investigation report did not report on the training documentation used by the flight school. AvioConsult therefore asked, and received permission, to review the airplane and training documents. Many errors and deficiencies were found.

A limited analysis of the PA-44 documents, as used by the flight school (and also by other PA-44 owners) in the English language, is available for download:
Download this analysis       |    Top

This analysis will also be useful to operators of other multi-engine airplane types.

AvioConsult wrote a letter to the CEO of The New Piper Aircraft, Inc. on 9 August 2006 expressing concerns about the imperfections in the Pilot's Information Manuals of Piper Aircraft and to present recommendations for improvement.
The company never responded.

Mitsubishi MU-2B, USA, 10 Dec. 2004

Shortly after takeoff, the left engine failed. The pilot returned for landing via a left-hand circuit; the left propeller was feathered. The airplane did overshoot the final approach of runway 35R and was cleared to the next runway 28. The landing lights were then seen turning down toward the terrain. The airplane crashed; the two souls onboard were fatally injured.

The analysis of this accident is included in the paper Airplane Control and Accident Investigation after Engine Failure, please refer to the Downloads page.

Boeing 747-258F, Netherlands, 4 October 1992

Shortly after takeoff, both engines on the right wing (#3 and #4) separated from the wing due to a fuse pin failure in pylon #3. The pilots decided to return to the airport immediately and initiated a right hand turn (in the direction of the 'dead' engines). The asymmetrical loss of weight of engines and pylons could obviously be compensated for by the ailerons and a high enough airspeed. During the second right hand turn, required to position for the requested runway, the airspeed was decreased, obviously to a value below the actual lateral or directional minimum control speed VMCA2, the minimum control speed if two engines are inoperative, upon which control of the airplane was lost and the airplane crashed in a residential area in Amsterdam.
In civil aviation regulations (part 25.149), only VMCA exists (for one engine inoperative). VMCA2 was deleted from the civil regulations, but still exists in military regulations, and definitely also in-flight, and causes catastrophes if not observed, like in this accident.
The formal accident investigation report does neither discuss the air minimum control speed for one inoperative engine (VMCA) nor for two engines inoperative (VMCA2).

Why were the pilots and the accident investigators not aware of the real value of these minimum control speeds? And why didn't they know that turning away from straight flight, while maintaining a small bank angle away from the inoperative engine(s) as required for VMCA's to be valid, increases the actual VMCA considerably and becomes almost certainly deadly when the power setting on the remaining engines is (increased to) maximum and the airspeed is (getting) low? Most probably because the engine emergency procedures and VMCA definitions in airplane flight and operating manuals are incorrect or inappropriate / deficient, or because the engine-out pilot and investigator training is inappropriate and incomplete. It seems that the manuals- and training-approving-authorities were not aware either. Test Pilot Schools though, still teach engine-out flight in theory and in-flight; experimental test pilots are thoroughly made aware of the do's and don'ts after engine failure and do not crash.
Refer to the Paper Airplane Control and Accident Investigation after Engine Failure that AvioConsult presents on the Downloads page of this website to learn about improving procedures, definitions and engine-out training.

The huge effect of bank angle on VMCA and VMCA2 was neither considered by the pilots, nor by the accident investigators. They might have never been taught that an airplane is only certified for straight flight when one or more engines are inoperative while the airspeed is low, and the thrust setting on the opposite engine(s) is (increased to) maximum. During turns, the sideslip increases and cannot be counteracted by vertical tail with rudder, because the regulations do not require to size the vertical tail large enough for making turns. In addition, a bank angle larger than 10° may lead to a fin stall, causing the loss of directional control. The effect of bank angle is calculated and illustrated in Paper The Effect of Bank Angle and Weight on VMCA that is also available for download:
Download this paper     |    Top

Please also refer to the comments on the Boeing 737 FCTM above.

Saab SF-340B, Netherlands, 4 April 1994

Ten minutes after takeoff from runway 24, an oil pressure warning of the right engine (#2) made the captain decide to return to the airport. He left the affected engine #2 idling; its propeller was not-feathered. The wind was 270/ 11 kt when the captain accepted landing runway 06. On short final, with an actual wind of 280/ 8 kt, the airplane was displaced to the right. At 45 ft Radar Altitude, the captain therefore decided to go-around using the thrust of the left engine only; the right engine was kept idling. The airplane crashed 13 seconds later, far to the right of the runway.

Download this paper and learn about investigating engine failure related accidents.   |  Top

The analysis of this accident is also included in the paper Airplane Control and Accident Investigation after Engine Failure, please refer to the Downloads page.

DHC-6-100 Twin Otter, USA, 29 July 2006

A De Havilland DHC-6-100 airplane carrying skydivers crashed into trees and terrain after takeoff. Witnesses at the airport reported that, shortly after the airplane lifted off from the runway, flames emitted from the airplane’s right engine.

The analysis of this accident is included in the paper #3 Airplane Control and Accident Investigation after Engine Failure, please refer to the Downloads page.    |   Top

EMB-120ER, Australia, 22 March 2010

During the takeoff of an EMB-120ER twin-turboprop airplane for a revalidating command instrument rating, the training and checking captain retarded the left power lever to zero torque just after liftoff.  The airplane crashed, both pilots died in the accident.

The Safety Report was reviewed and many suggestions for improvement were included. This review is to learn more about airplane control after engine failure.

Download the safety report with review and learn more about investigating engine failure related accidents.

The analysis of this accident is included in the YouTube video (downloads page) and in the paper Airplane Control and Accident Investigation after Engine Failure, please refer to the Downloads page.       |      Top

Jetstream 4100, South Africa, 24 September 2009

During takeoff, at about the instant of rotation, 5 sec. before liftoff, the right (#2) engine failed; the takeoff was continued. Control was lost shortly after liftoff, the airplane crashed.

The thorough analysis of this accident on control after engine failure is included in the paper Airplane Control and Accident Investigation after Engine Failure, please refer to the Downloads page     |     Top

Cessna 310Q, UK, 15 November 2013

During final approach, a go-around was initiated. The left engine failed, after which control was lost. The airplane crashed, killing both persons on board.

The accident report was reviewed, and comments and recommendation for improvement of Airplane and Training Manuals are presented.      |     Top

Download the safety report with comments      |     Top

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