Crash of a Cessna T207A Turbo Stationair 7 II in Pemberton: 1 killed

Date & Time: May 18, 2006 at 1506 LT
Operator:
Registration:
C-GGQR
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Pemberton – Edmonton
MSN:
207-0499
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1500
Circumstances:
The aircraft departed from Pemberton Airport, British Columbia, at about 1500 Pacific daylight time on a visual flight rules flight to Edmonton, Alberta. The aircraft initially climbed out to the east and subsequently turned northeast to follow a mountain pass route. The pilot was alone on this aircraft repositioning flight. The pilot had been conducting air quality surveys for Environment Canada’s Air Quality Research Section in the Pemberton area. The aircraft was operating on a flight permit and was highly modified to accept various types of probes in equipment pods suspended under the wings, a camera hatch type provision in the centre belly area, and carried internal electronic equipment. About 30 minutes after the aircraft took off, the Coastal Fire Service responded to a spot fire and discovered the aircraft wreckage in the fire zone. A post-crash fire consumed most of the airframe, and the pilot was fatally injured. The accident occurred at about 1506 Pacific daylight time.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot entered the valley at an altitude above ground that did not provide sufficient terrain clearance given the aircraft’s performance.
2. The pilot encountered steeply rising terrain, where false horizon and relative scale illusions in the climb are likely. Realizing that the aircraft would not likely be able to out-climb the approaching terrain, he turned to reverse his course.
3. The aircraft’s configuration, relatively high weight, combined with the effects of increased drag from the equipment, density altitude, down-flowing winds, and manoeuvring resulted in the aircraft colliding with terrain during the turn.
Findings as to Risk:
1. A detailed flight plan was not filed and special equipment, such as laser radiation emitting devices and/or hazardous substances were not reported. The absence of flight plan information regarding these devices could delay search and rescue efforts and expose first responders to unknown risks.
2. Transport Canada (TC) does not issue a rating/endorsement for mountain flying training. There are no standards established to ascertain the proficiency of a pilot in this environment. Pilots who complete a mountain flying course may not acquire the required skill sets.
3. There was no emergency locator transmitter (ELT) signal received. The ELT was destroyed in the impact and subsequent fire. Present standards do not require that ELTs resist crash damage.
4. “Flight permits – specific purpose” are issued for aircraft that do not perform as per the original type design but are deemed capable of safe flight. Placards are not required; therefore, pilots and observers approved to board may be unaware of the limitations of the aircraft and the associated risks.
5. The TC approval process allowed the continued operation of this modified aircraft for sustained environmental research missions under a flight permit authority. This circumvented the requirement to meet the latest airworthiness standards and removed the risk mitigation built into the approval process for a modification to a type design.
Other Findings:
1. The fuel system obstruction found during disassembly was a result of the post-crash fire.
2. The aircraft was operated at an increased weight allowance proposed by the design approval representative (DAR). Such operation was to be approved only in accordance with a suitably worded flight permit and instructions contained in the proposed document CN-MSC-011; however, this increased weight allowance was not incorporated to any flight authority issued by TC.
Final Report:

Crash of a Cessna 207 Skywagon in San Juan de Manapiare: 4 killed

Date & Time: Sep 16, 2005 at 1600 LT
Registration:
YV-412C
Flight Phase:
Survivors:
No
Site:
Schedule:
San Juan de Manapiare – Puerto Ayacucho
MSN:
207-0508
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
Few minutes after takeoff from San Juan de Manapiare, while flying in marginal weather conditions, the single engine aircraft impacted a rocky face of Mt Morrocoy located about 8 km west of San Juan de Manapiare. The aircraft was totally destroyed by impact forces and all four occupants were killed.
Probable cause:
Controlled flight into terrain.

Crash of a Cessna T207 Turbo Skywagon on West Amatuli Island: 3 killed

Date & Time: Jul 1, 2005 at 1200 LT
Operator:
Registration:
N1621U
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Homer - Homer
MSN:
207-0221
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
8432
Aircraft flight hours:
7416
Circumstances:
The airline transport certificated pilot and the two pilot-rated passengers traveled to Alaska for a Title 14, CFR Part 91 personal flying vacation. The pilot received a VFR check-out in a rented airplane, and was the only person authorized by its owner to fly it. The pilot obtained a weather briefing for the day of the accident flight, and queried an FAA automated flight service station (AFSS) specialist about VFR conditions for a sightseeing flight. The FSS specialist stated, in part, "Well, it doesn't really look good probably anywhere today..." The area forecast included areas of marginal VFR and IFR conditions, and an AIRMET for mountain obscuration. The cloud and sky conditions included scattered clouds at 1,500 feet in light rain showers, with areas of isolated ceilings below 1,000 feet, and visibility below 3 statute miles in rain showers and mist. The weather briefing included a report from a pilot who was about 23 miles north of the accident scene about 2 hours before the accident airplane departed. The pilot reported fog and mist to the water, and said he was unable to maintain VFR. Five minutes after receiving the weather briefing, the accident pilot again called the AFSS and requested the telephone number to an automated weather observing system, located south of the point of departure, where VFR conditions were forecast. Local fishing charter captains reported fog in the area of the islands where the accident occurred. One vessel captain reported hearing an airplane in the vicinity of the islands, but could not see it because of the fog. The pilot did not file a flight plan, nor did he indicate any planned itinerary. The airplane was reported overdue two days after departure. The accident wreckage was located an additional two days later on the north cliff face of a remote island. The airplane had collided with the island at high speed, about 800 feet mean sea level, and a post crash fire had incinerated the cockpit and cabin area.
Probable cause:
The pilot's continued VFR flight into instrument meteorological conditions, which resulted in an in-flight collision with an island cliff during cruise flight. A factor contributing to the accident was fog in the area of the accident.
Final Report:

Crash of a Cessna 207 Skywagon in Barradas: 4 killed

Date & Time: May 8, 2005 at 1100 LT
Operator:
Registration:
RP-C3216
Flight Phase:
Survivors:
Yes
Schedule:
Barradas - Barradas
MSN:
207-0333
YOM:
1976
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
Shortly after takeoff from Barradas Airport located near Tanauan (Batangas), while in initial climb, the aircraft suffered an engine failure. It stalled and crashed in a coconut grove located in the village of Santor, near the airfield. The pilot and three passengers were killed while two others were seriously injured. All occupants were completing a local skydiving mission. Witnesses reported that the engine emitted white smoke shortly after rotation.
Probable cause:
Engine failure for unknown reasons.

Crash of a Cessna T207A Skywagon near Henderson: 1 killed

Date & Time: Dec 8, 2004 at 1031 LT
Operator:
Registration:
N1783U
Flight Phase:
Survivors:
No
Site:
Schedule:
Henderson - Henderson
MSN:
207-0383
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1209
Captain / Total hours on type:
117.00
Aircraft flight hours:
12616
Circumstances:
The airplane impacted mountainous terrain in an extreme nose-down attitude following a departure from controlled flight. The purpose of the flight was to check the weather conditions for passenger tour flights that day. The pilot reported about 20 minutes prior to the accident that the ceiling was 6,500 feet mean sea level (msl). Radar data showed that following this weather report, the airplane's radar track continued eastbound and upon its return westbound, at an altitude of about 6,000 feet msl, the airplane entered a series of altitude fluctuations approximately 1 mile west of a ridge that was the location of the accident, descending at 4,000 feet per minute while turning northbound, and then climbing at 3,900 feet per minute while traveling eastbound, prior to disappearing from the radar. The airplane impacted on the eastern side of the ridge. There were no monitored distress calls from the aircraft and no known witnesses to the accident. Prior to the accident, there were reports of vibrations during flight on this aircraft, although many went unreported to maintenance personnel. The day (and flight) prior to the accident, a pilot experienced a vibration during flight with passengers and it was not reported to maintenance personnel because it was logged improperly in the operator's maintenance tracking system. No corrective actions were taken. During the post accident examinations, no portions of the right elevator and trim tab were identified in the wreckage, or at the accident site. The bracket attachment to the right elevator was found loose within the wreckage and was torsionally twisted counterclockwise (aft). Ground and aerial searches for the missing parts based on a trajectory study were unsuccessful. This aircraft was equipped with a foam cored elevator trim tab that was installed during aircraft manufacture. A service difficulty report (SDR) query showed that 47 reports had been issued on elevator trim tab corrosion and many included reports of vibrations during flight. On January 20, 2005, the Federal Aviation Administration (FAA) issued Special Airworthiness Information Bulletin (SAIB) CE-05-27, which addressed potential problems with foam-filled elevator trim tabs in the accident make/model airplane, and Cessna 206 and 210 series airplanes. The SAIB indicated that the foam-filled elevator trim tabs, manufactured until 1985, were reported to have corrosion between the tab and the foam. The SAIB further said, in part, "When the skin of the trim tab becomes thin enough due to the corrosion, the actuator can pull the fasteners through the skin and disconnect. When this occurs, the tab can flutter." Some reports indicated prior instances of "vibrations in the tail section and portions of the elevator tearing away with the trim tab." Prior to the issuance of the SAIB, Cessna Aircraft Company issued a Service Bulletin (SB) SEB85-7 on April 5, 1985, that addressed elevator and trim tab inspection due to corrosion from moisture trapped in the foam cored trim tabs. Based on a review of the airplane's logbooks, the SB was not complied with, nor was the operator required to do so based on the FAA approved maintenance specifications.
Probable cause:
A loss of control due to the in-flight separation of the right elevator and elevator trim tab control surfaces. The precipitating reason for the elevator separation could not be resolved as related to the tab foam core issue with the available evidence.
Final Report:

Crash of a Cessna 207 Skywagon in Urimán

Date & Time: Oct 6, 2004
Operator:
Registration:
YV-217C
Survivors:
Yes
Site:
MSN:
207-0440
YOM:
1978
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Urimán, the single engine aircraft crashed in a wooded area located few km from the destination airport. Both occupants were rescued a day later. The passenger was injured and the pilot was unhurt.

Crash of a Cessna 207 Skywagon in Grants Pass: 2 killed

Date & Time: Apr 9, 2003 at 0850 LT
Registration:
N9785M
Survivors:
No
Site:
Schedule:
North Bend – Grants Pass
MSN:
207-0729
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
34976
Aircraft flight hours:
4516
Circumstances:
During a visual flight rules (VFR) cross-country flight from North Bend, Oregon, to Grants Pass, Oregon, the airplane collided with mountainous terrain approximately seven miles northwest of the pilot's planned destination. Weather data and witness reports outlined areas of low ceilings and low visibility throughout the area during the approximate time of the accident. Post-accident inspection of the aircraft and engine revealed no evidence of a mechanical malfunction or failure.
Probable cause:
The pilot's failure to maintain clearance from mountainous terrain while in cruise flight. Factors include low ceilings and mountainous terrain.
Final Report:

Crash of a Cessna 207A Skywagon in Put-in-Bay

Date & Time: Jan 20, 2003 at 0945 LT
Operator:
Registration:
N9945M
Flight Phase:
Survivors:
Yes
Schedule:
Put-in-Bay – Port Clinton
MSN:
207-0153
YOM:
1970
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4500
Captain / Total hours on type:
405.00
Aircraft flight hours:
6283
Circumstances:
Shortly after takeoff, about 300 feet agl, the engine lost all power. The pilot activated the electric fuel pump, and moved the fuel selector several times. However, the engine did not regain power, and the pilot performed a forced landing into trees. After the accident, the pilot stated to a police officer that he might have departed with the fuel selector positioned to an empty tank. The pilot subsequently stated that both fuel gauges indicated "1/4" full, and he could not remember which tank was selected during the takeoff. Additionally, a passenger stated that he did not smell or observe fuel when he exited the airplane. The passenger added that in the past, the pilot had exhausted one fuel tank, then switched to the other tank and the engine re-started. Examination of the wreckage by an FAA inspector revealed that fuel selector was positioned to the right tank. The right fuel tank contained some fuel, and left fuel tank had ruptured. Following the accident, a successful engine test-run was performed.
Probable cause:
The pilot's inadequate fuel management, which resulted in fuel starvation and a total loss of engine power during the initial climb.
Final Report:

Crash of a Cessna 207 Skywagon in Cradle Mountain

Date & Time: Nov 7, 2002 at 1404 LT
Registration:
VH-EHL
Flight Type:
Survivors:
Yes
Schedule:
Cradle Mountain - Cradle Mountain
MSN:
207-0141
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
730
Captain / Total hours on type:
180.00
Circumstances:
The Cessna 207 aircraft (C207) was engaged on a sightseeing flight from Cradle Mountain, to Lake St. Clair and return. On board were the pilot and 4 passengers. The flight departed Cradle Mountain at approximately 1310 ESuT and tracked direct to Lake St Clair at 7000 ft due to turbulence. The aircraft then returned to Cradle Mountain. At approximately 1404, as the aircraft was approaching the airfield, the pilot configured the aircraft for a straight in approach to strip 02. The pilot had selected two stages of flap, and had reduced power to approximately 19 inches of manifold pressure. He reported that at approximately half a mile from the airfield the engine stopped without any prior warning. After completing trouble checks, the pilot became aware that the aircraft would not reach the airfield. He then manoeuvred the aircraft towards an open area on his right while broadcasting a MAYDAY call. Melbourne air traffic control acknowledged this call. The pilot then completed additional trouble checks and changed the fuel tank selection, but the engine failed to respond. The aircraft touched down heavily on the main wheels and slid approximately 40 metres before coming to a stop. During the touchdown and subsequent ground slide, the nose wheel detached from the aircraft, the propeller was damaged and the right wing was partially separated from the airframe. After the aircraft stopped the pilot checked the passengers and discovered that two of them had suffered serious injuries.
Probable cause:
The pilot reported that he had completed a daily inspection of the aircraft earlier in the morning. That inspection included assessing the fuel quantity on board the aircraft and completing a fuel drain and water check. Both of these checks did not reveal any problem with the fuel. The pilot estimated that there was approximately 185 litres of fuel on board the aircraft, 90 litres in the right tank and 95 litres in the left tank. The aircraft had last been refuelled the day previously from drum stock. The aircraft had completed two flights since that refuelling with no problems being reported. The engineers that recovered the aircraft reported that there was approximately 30 litres of fuel in the left tank and approximately 100 litres of fuel in the right tank. The C207 aircraft has a fuel selector in the cockpit that allows the pilot to supply fuel to the engine from either the right tank or the left tank, but not from both tanks simultaneously. The pilot reported that he conducted the flight with the fuel selector switched to the left tank. He also reported that he did not move the selector during the flight and only moved it to the right tank as part of his trouble checks when the engine failed. The pilot reported that he did not complete flight or fuel plans for the flight, but operated on previous knowledge from other flights. A post occurrence analysis of the weather indicated that the winds at 7000 feet were as forecast. Post flight analysis of the flight revealed that the aircraft would have required 57 litres of fuel to complete the flight, which included allowances for taxi and climb. The engine was sent by the owner to an engine overhaul facility for testing. The ATSB did not attend the testing of the engine. The engine was fitted to the test cell in the condition as removed from the aircraft. The engine was started and test run in accordance with the engine manufacturer's overhaul manual. The engine ran normally and all temperature and pressure limits were within normal ranges. The investigation was unable to determine why the engine failed to operate normally in the latter stages of the flight.
Final Report:

Crash of a Cessna 207 Skywagon in Marshall

Date & Time: Oct 28, 2002 at 2000 LT
Operator:
Registration:
N91090
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Marshall - Bethel
MSN:
207-0069
YOM:
1969
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1745
Captain / Total hours on type:
115.00
Aircraft flight hours:
14551
Circumstances:
The commercial pilot was positioning the airplane from the departure airport to another airport. The flight took place on a dark night with overcast skies, and no discernible horizon. The pilot departed and climbed to a cruise altitude between 1,200 and 1,400 feet msl. About 4 miles south of the departure airport, the airplane collided with an east-west ridge at 1,200 feet msl. The ridgeline is perpendicular to the direct route of flight between the departure and destination airports, and rises from west to east with a summit elevation of 1,714 feet msl. The departure airport was a newly commissioned airport 3 miles east-northeast of the old airport. The accident flight was the pilot's second trip to the new airport, and his first night departure from either the old or new airport. Direct flight from the new airport to the destination airport requires a higher altitude to clear the ridgeline than does a direct flight from the old airport. A direct flight from the old airport crosses the same ridgeline farther to the west, where the elevation of the ridge is less than 500 feet msl.
Probable cause:
The pilot's failure to maintain clearance from terrain, which resulted in an in-flight collision with a ridgeline. Factors contributing to the accident were the high terrain, the pilot's inadequate preflight planning, and the dark night light conditions.
Final Report: