Crash of a Rockwell Sabreliner 65 in Las Vegas

Date & Time: Jul 5, 2013 at 1845 LT
Type of aircraft:
Operator:
Registration:
XB-RSC
Survivors:
Yes
Schedule:
Brownsville – Las Vegas
MSN:
465-55
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7400
Captain / Total hours on type:
2100.00
Copilot / Total flying hours:
1939
Copilot / Total hours on type:
788
Aircraft flight hours:
9940
Circumstances:
The pilots reported that, during the approach, the main hydraulic system lost pressure. They selected the auxiliary hydraulic system "on," continued the approach, and extended the landing gear using the emergency landing gear extension procedures. During the landing roll, about two-thirds down the runway, the pilots noticed that the brakes were not working normally and then turned onto a taxiway to clear the runway. The captain reported that, once on the taxiway, he was unable to stop or steer the airplane as it proceeded across a parallel runway and into an adjacent field where it subsequently struck a metal beam. A postaccident examination of the airplane revealed brake system continuity with the cockpit controls. The tires, brake assemblies, and brake pads were intact and undamaged. The hydraulic lines from the hydraulic pump to the wheel brakes were intact. No hydraulic fluid was observed leaking on the exterior or interior portions of the airplane. The hydraulic fluid reservoir was found about 1/4 full. Further, testing of the two hydraulic pumps revealed that they were both functional, and no mechanical failures or anomalies that would have precluded normal operation were noted. The airplane's hydraulic system failure emergency procedures state that, if hydraulic pressure is lost, the electrically driven hydraulic pump should be reset and that, if the hydraulic pressure was not restored, that the primary hydraulic system should be disengaged and the landing gear should be lowered using the emergency landing gear extension procedures. After the gear is extended, the auxiliary hydraulic system should be selected "on" for landing. However, the pilots stated that they did not attempt to reset the electric hydraulic pump and that they performed the emergency landing gear extension procedures with the auxiliary hydraulic pump engaged. It is likely that the pilots' failure to select the auxiliary hydraulic system "off" before extending the landing gear caused the hydraulic pressure in the auxiliary system to dissipate, which left only the emergency brake accumulator available for braking during the landing. The number of emergency brake applications that can be made by the pilots depends on the accumulator charge, which may be depleted in a very short time. The airplane's emergency braking procedures state that, as soon as the airplane is safely stopped, the pilots should request towing assistance. However, the pilots did not stop the airplane on the runway despite having about 3,900 ft of runway remaining; instead, they turned off the runway at an intersection, which resulted in a loss of directional control.
Probable cause:
The pilots' failure to follow the airplane manufacturer's emergency procedures for a hydraulic system failure and emergency braking, which resulted in the loss of braking action upon landing and the subsequent loss of directional control while turning off the runway. Contributing to the accident was the loss of hydraulic pressure for reasons that could not be determined because postaccident testing and examination of the hydraulic system revealed no mechanical failures or anomalies that would have precluded normal operation.
Final Report:

Crash of a Cessna 208 Caravan I in N'Gaoundéré: 1 killed

Date & Time: Jun 10, 2013 at 1000 LT
Type of aircraft:
Operator:
Registration:
TT-BAU
Survivors:
Yes
Schedule:
Moundou - Douala
MSN:
208-0045
YOM:
1985
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The single engine aircraft departed Moundou (Chad) on a flight to Douala, Cameroon, carrying three passengers and two pilots on behalf of CotonTchad, the Chadian National Coton Company (Société Cotonnière du Tchad). En route, the crew informed ATC about engine problems and elected to divert to N'Gaoundéré Airport. On final approach, the aircraft stalled and crashed in a marshy field located near the airport. All five occupants were injured, both crew seriously. Few hours later, the captain died from his injuries. The aircraft was destroyed.
Probable cause:
Engine trouble for unknown reasons.

Crash of a Raytheon 390 Premier I in South Bend: 2 killed

Date & Time: Mar 17, 2013 at 1623 LT
Type of aircraft:
Operator:
Registration:
N26DK
Survivors:
Yes
Site:
Schedule:
Tulsa - South Bend
MSN:
RB-226
YOM:
2008
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
613
Captain / Total hours on type:
171.00
Copilot / Total flying hours:
1877
Copilot / Total hours on type:
0
Aircraft flight hours:
457
Circumstances:
According to the cockpit voice recorder (CVR), during cruise flight, the unqualified pilot-rated passenger was manipulating the aircraft controls, including the engine controls, under the supervision and direction of the private pilot. After receiving a descent clearance to 3,000 feet mean sea level (msl), the pilot told the pilot-rated passenger to reduce engine power to maintain a target airspeed. The cockpit area microphone subsequently recorded the sound of both engines spooling down. The pilot recognized that the pilot-rated passenger had shutdown both engines after he retarded the engine throttles past the flight idle stops into the fuel cutoff position. Specifically, the pilot stated "you went back behind the stops and we lost power." According to air traffic control (ATC) radar track data, at the time of the dual engine shutdown, the airplane was located about 18 miles southwest of the destination airport and was descending through 6,700 feet msl. The pilot reported to the controller that the airplane had experienced a dual loss of engine power, declared an emergency, and requested radar vectors to the destination airport. As the flight approached the destination airport, the cockpit area microphone recorded a sound similar to an engine starter spooling up; however, engine power was not restored during the attempted restart. A review of the remaining CVR audio did not reveal any evidence of another attempt to restart an engine. The CVR stopped recording while the airplane was still airborne, with both engines still inoperative, while on an extended base leg to the runway. Subsequently, the controller told the pilot to go-around because the main landing gear was not extended. The accident airplane was then observed to climb and enter a right traffic pattern to make another landing approach. Witness accounts indicated that only the nose landing gear was extended during the second landing approach. The witnesses observed the airplane bounce several times on the runway before it ultimately entered a climbing right turn. The airplane was then observed to enter a nose low, rolling descent into a nearby residential community. The postaccident examinations and testing did not reveal any anomalies or failures that would have precluded normal operation of the airplane. Although the CVR did not record a successful engine restart, the pilot was able to initiate a go-around during the initial landing attempt, which implies that he was able to restart at least one engine during the initial approach. The investigation subsequently determined that only the left engine was operating at impact. Following an engine start, procedures require that the respective generator be reset to reestablish electrical power to the Essential Bus. If the Essential Bus had been restored, all aircraft systems would have operated normally. However, the battery toggle switch was observed in the Standby position at the accident site, which would have prevented the Essential Bus from receiving power regardless of whether the generator had been reset. As such, the airplane was likely operating on the Standby Bus, which would preclude the normal extension of the landing gear. However, the investigation determined that the landing gear alternate extension handle was partially extended. The observed position of the handle would have precluded the main landing gear from extending (only the nose landing gear would extend). The investigation determined that it is likely the pilot did not fully extend the handle to obtain a full landing gear deployment. Had he fully extended the landing gear, a successful single-engine landing could have been accomplished. In conclusion, the private pilot's decision to allow the unqualified pilot-rated passenger to manipulate the airplane controls directly resulted in the inadvertent dual engine shutdown during cruise descent. Additionally, the pilot's inadequate response to the emergency, including his failure to adhere to procedures, resulted in his inability to fully restore airplane systems and ultimately resulted in a loss of airplane control.
Probable cause:
The private pilot's inadequate response to the dual engine shutdown during cruise descent, including his failure to adhere to procedures, which ultimately resulted in his failure to
maintain airplane control during a single-engine go-around. An additional cause was the pilot's decision to allow the unqualified pilot-rated passenger to manipulate the airplane controls, which directly resulted in the inadvertent dual engine shutdown.
Final Report:

Crash of a Beechcraft A60 Duke in Abilene

Date & Time: Feb 24, 2013 at 1020 LT
Type of aircraft:
Registration:
N7466D
Survivors:
Yes
Schedule:
Fort Smith – Abilene
MSN:
P-139
YOM:
1970
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7500
Captain / Total hours on type:
800.00
Aircraft flight hours:
3725
Circumstances:
The pilot reported that he had added fuel at the previous fuel stop and that he was using a fuel totalizer to determine the quantity of fuel onboard. After climbing to a cruise altitude of 14,000 feet above ground level, he discovered that the fuel mixture control was frozen and that he was unable to lean the mixture to a lower fuel flow setting. The pilot reported that because of the increased fuel consumption, he briefly considered an en route stop for additional fuel but decided to continue. During descent, the airplane experienced a complete loss of power in both engines, and the pilot made an emergency off-field, gear-up landing about 7 miles from the destination. The airplane impacted terrain and thick scrub trees, which resulted in substantial damage to both wings, both engine mounts, and the fuselage. A postaccident examination found that only a trace of fuel remained. The pilot also reported that there was no mechanical malfunction or failure and that his inadequate fuel management was partly because he had become overconfident in his abilities after 50 years of flying.
Probable cause:
The pilot’s improper fuel management, which resulted in a loss of engine power due to fuel exhaustion.
Final Report:

Crash of a Raytheon 390 Premier I in Thomson: 5 killed

Date & Time: Feb 20, 2013 at 2006 LT
Type of aircraft:
Operator:
Registration:
N777VG
Flight Phase:
Survivors:
Yes
Schedule:
Nashville - Thomson
MSN:
RB-208
YOM:
2007
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
13319
Captain / Total hours on type:
198.00
Copilot / Total flying hours:
2932
Copilot / Total hours on type:
45
Aircraft flight hours:
635
Circumstances:
Aircraft was destroyed following a collision with a utility pole, trees, and terrain following a go-around at Thomson-McDuffie Regional Airport (HQU), Thomson, Georgia. The airline transport-rated pilot and copilot were seriously injured, and five passengers were fatally injured. The airplane was registered to the Pavilion Group LLC and was operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a business flight. Night visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight originated at John C. Tune Airport (JWN), Nashville, Tennessee, about 1828 central standard time (1928 eastern standard time). The purpose of the flight was to transport staff members of a vascular surgery practice from Nashville to Thomson, where the airplane was based. According to initial air traffic control information, the pilot checked in with Augusta approach control and reported HQU in sight. About 2003, the pilot cancelled visual flight rules flight-following services and continued toward HQU. The last recorded radar return was observed about 2005, when the airplane was at an indicated altitude of 700 feet above mean sea level and 1/2 mile from the airport. There were no distress calls received from the crew prior to the accident. Witnesses reported that the airplane appeared to be in position to land when the pilot discontinued the approach and commenced a go-around. The witnesses observed the airplane continue down the runway at a low altitude. The airplane struck a poured-concrete utility pole and braided wires about 59 feet above ground level. The pole was located about 1/4 mile east the departure end of runway 10. The utility pole was not lighted. During the initial impact with the utility pole, the outboard section of the left wing was severed. The airplane continued another 1/4 mile east before colliding with trees and terrain. A postcrash fire ensued and consumed a majority of the airframe. The engines separated from the fuselage during the impact sequence. On-scene examination of the wreckage revealed that all primary airframe structural components were accounted for at the accident site. The landing gear were found in the down (extended) position, and the flap handle was found in the 10-degree (go-around) position. An initial inspection of the airport revealed that the pilot-controlled runway lights were operational. An examination of conditions recorded on an airport security camera showed that the runway lights were on the low intensity setting at the time of the accident. The airport did not have a control tower. An inspection of the runway surface did not reveal any unusual tire marks or debris. Weather conditions at HQU near the time of the accident included calm wind and clear skies.
Probable cause:
The pilot's failure to follow airplane flight manual procedures for an antiskid failure in flight and his failure to immediately retract the lift dump after he elected to attempt a go-around on the runway. Contributing to the accident were the pilot's lack of systems knowledge and his fatigue due to acute sleep loss and his ineffective use of time between flights to obtain sleep.
Final Report:

Crash of a Beechcraft King Air C90A in Cândido Mota: 5 killed

Date & Time: Feb 3, 2013 at 2030 LT
Type of aircraft:
Registration:
PP-AJV
Flight Phase:
Survivors:
No
Schedule:
Maringá – São Paulo
MSN:
LJ-1647
YOM:
2001
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total hours on type:
441.00
Aircraft flight hours:
3137
Circumstances:
The twin engine aircraft departed Maringá Airport at 1837LT on a flight to São Paulo, carrying four passengers and one pilot. 35 minutes into the flight, about five minutes after he reached its assigned altitude of 21,000 feet, the aircraft stalled and entered an uncontrolled descent. The pilot was unable to regain control, the aircraft partially disintegrated in the air and eventually crashed in a flat attitude in a field. The aircraft was destroyed and all five occupants were killed.
Probable cause:
The following findings were identified:
- The lack of a prompt identification of the aircraft stall by the captain may have deprived him of handling the controls in accordance with the prescriptions of the aircraft emergency procedures, contributing to the aircraft entry in an abnormal attitude.
- The captain’s attention was focused on the passengers sitting in the rear seats, in detriment of the flight conditions under which the aircraft was flying. This had a direct influence on the maintenance of a poor situational awareness, which may have made it difficult for the captain to immediately identify that the aircraft was stalling.
- There was complacency when the copilot functions were assumed by a person lacking due professional formation and qualification for such. Even under an adverse condition, the prescribed procedure was not performed, namely, the use of the aircraft checklist.
- The fact that the aircraft was flying under icing conditions was confirmed by a statement of the female passenger in the cockpit (CVR). The FL210 (selected and maintained by the captain) gave rise to conditions favorable to severe icing on the aircraft structure. If the prevailing weather conditions are correlated with reduction of speed (attested by the radar rerun), the connection between loss of control in flight and degraded aircraft performance is duly established.
- The rotation of the aircraft after stalling may have contributed to the loss of references of the captain’s balance organs (vestibular system), making it impossible for him to associate the side of the turn made by the aircraft with the necessary corrective actions.
- The non-adherence to the aircraft checklists on the part of the captain, in addition to the deliberate adoption of non-prescribed procedures (disarmament of the starter and “seven killers”) raised doubts on the quality of the instruction delivered by the captain.
- The captain made an inappropriate flight level selection for his flight destined for São Paulo. Even after a higher flight level was offered to him, he decided to maintain FL 210. Also, after being informed about icing on the aircraft, he did not activate the Ice Protection System, as is expressly determined by the flight manual.
- The captain had the habit of making use of a checklist not prescribed for the aircraft, and this may have influenced his actions in response to the situation he was experiencing in flight.
- His recently earned technical qualification in the aircraft type; his inattention and distraction in flight; his attitude of non-compliance with operations and procedures prescribed in manuals; all of this contributed to the captain’s poor situational awareness.
- The flight plan was submitted via telephone. Therefore, it was not possible to determine the captain’s level of awareness of the real conditions along the route, since he did not report to the AIS office in SBMG. In any event, the selection of a freezing level for the flight, considering that the front was moving along the same proposed route, was indication of inappropriate planning.
- The investigation could neither determine the whole experience of the aircraft captain, nor whether his IFR flight experience was sufficient for conducting the proposed flight, since he made decisions which went against the best practices, such as, for example, selecting a flight level with known icing.
- With a compromised situational awareness, the pilot failed to correctly interpret the information available in the aircraft, as well as the information provided by the female passenger sitting in the cockpit, and he chose to maintain the flight level under inadequate weather conditions.
- The lack of monitoring/supervision of the activities performed by the captain allowed that behaviors and attitudes contrary to flight safety could be adopted in flight, as can be observed in this occurrence.
- Apparently, there was lack of an effective managerial supervision on the part of the aircraft operator, with regard to both the actions performed by the captain and the correction of the aircraft problems.
Final Report:

Crash of a Pilatus PC-12/45 in Burlington: 1 killed

Date & Time: Jan 16, 2013 at 0556 LT
Type of aircraft:
Operator:
Registration:
N68PK
Flight Phase:
Survivors:
No
Schedule:
Burlington - Morristown
MSN:
265
YOM:
1998
Flight number:
SKQ53
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6369
Captain / Total hours on type:
315.00
Aircraft flight hours:
4637
Circumstances:
The pilot departed in night instrument flight rules (IFR) conditions on a medical specimen transport flight. During the climb, an air traffic controller told the pilot that the transponder code he had selected (2501) was incorrect and instructed him to reset the transponder to a different code (2531). Shortly thereafter, the airplane reached a maximum altitude of about 3,300 ft and then entered a descending right turn. The airplane’s enhanced ground proximity warning system recorded a descent rate of 11,245 ft per minute, which triggered two “sink rate, pull up” warnings. The airplane subsequently climbed from an altitude of about 1,400 ft to about 2,000 ft before it entered another turning descent and impacted the ground about 5 miles northeast of the departure airport. The airplane was fragmented and strewn along a debris path that measured about 800-ft long and 300-ft wide. Postaccident examination of the airplane did not reveal any preimpact mechanical malfunctions that would have precluded the pilot from controlling the airplane. The engine did not display any evidence of preimpact anomalies that would have precluded normal operation. An open resistor was found in the flight computer that controlled the autopilot. It could not be determined if the open resistor condition existed during the flight or occurred during the impact. If the resistor was in an open condition at the time of autopilot engagement, the autopilot would appear to engage with a mode annunciation indicating engagement, but the pitch and roll servos would not engage. The before taxiing checklist included checks of the autopilot system to verify autopilot function before takeoff. It could not be determined if the pilot performed the autopilot check before the accident flight or if the autopilot was engaged at the time of the accident. The circumstances of the accident are consistent with the known effects of spatial disorientation. Dark night IFR conditions prevailed, and the track of the airplane suggests a loss of attitude awareness. Although the pilot was experienced in night instrument conditions, it is possible that an attempt to reset the transponder served as an operational distraction that contributed to a breakdown in his instrument scan. Similarly, if the autopilot’s resistor was in an open condition and the autopilot had been engaged, the pilot’s failure to detect an autopilot malfunction in a timely manner could have contributed to spatial disorientation and the resultant loss of control.
Probable cause:
The pilot's failure to maintain airplane control due to spatial disorientation during the initial climb after takeoff in night instrument flight rules conditions.
Final Report:

Crash of a Piper PA-46-500TP Malibu Meridian in Glory: 3 killed

Date & Time: Jan 12, 2013 at 0854 LT
Operator:
Registration:
N5339V
Flight Phase:
Survivors:
No
Schedule:
Paris – Austin
MSN:
46-97110
YOM:
2001
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2365
Captain / Total hours on type:
127.00
Aircraft flight hours:
1614
Circumstances:
The instrument-rated pilot obtained a weather briefing prior to departure that contained surface observations along the route of flight, as well as significant meteorological (SIGMET) and airman's meteorological (AIRMET) information. The briefing also included convective weather advisories, a convective outlook, the area forecast, pilot reports, radar summary, and winds aloft information. The area forecast included overcast ceilings at 1,500 feet mean sea level (msl) with cloud tops at 6,000 feet msl, visibility between 3 and 5 miles, light rain and mist, and isolated thunderstorms with cumulonimbus tops to 35,000 feet msl. After the pilot departed, he established contact with air traffic control; the airplane was initially observed on radar heading toward the destination airport. An analysis of radar from the day of the accident indicated that isolated thunderstorms existed and that, almost 4 minutes after departing, the airplane encountered an area of developing rain showers and vertical updrafts. The airplane began a descending right turn followed by a brief climb, then another descent; its ground speed slowed from 202 knots to 110 knots before the data ended. At that time, the airplane was at 4,500 feet msl. A witness said he heard the airplane but was unable to see it due to the low cloud layer. A few moments later, he saw the airplane exit the cloud layer in a spin before it impacted the ground. A postaccident examination revealed no mechanical deficiencies that would have precluded normal operation of the airplane and engine.
Probable cause:
The pilot's encounter with convective weather, which resulted in a loss of airplane control.
Final Report:

Crash of a Beechcraft B100 King Air in Libby: 2 killed

Date & Time: Dec 19, 2012 at 0002 LT
Type of aircraft:
Operator:
Registration:
N499SW
Survivors:
No
Schedule:
Coolidge - Libby
MSN:
BE-89
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
980
Circumstances:
When the flight was about 7 miles from the airport and approaching it from the south in dark night conditions, the noncertificated pilot canceled the instrument flight rules (IFR) flight plan. A police officer who was on patrol in the local area reported that he observed a twin-engine airplane come out of the clouds about 500 ft above ground level and then bank left over the town, which was north of the airport. The airplane then turned left and re-entered the clouds. The officer went to the airport to investigate, but he did not see the airplane. He reported that it was dark, but clear, at the airport and that he could see stars; there was snow on the ground. He also observed that the rotating beacon was illuminated but that the pilot-controlled runway lighting was not. The Federal Aviation Administration issued an alert notice, and the wreckage was located about 7 hours later 2 miles north of the airport. The airplane had collided with several trees on downsloping terrain; the debris path was about 290 ft long. Postaccident examination of the airframe and engine revealed no mechanical malfunctions or failures that would have precluded normal operation. The town and airport were located within a sparsely populated area that had limited lighting conditions, which, along with the clouds and 35 percent moon illumination, would have restricted the pilot’s visual references. These conditions likely led to his being geographically disoriented (lost) and his subsequent failure to maintain sufficient altitude to clear terrain. Although the pilot did not possess a valid pilot’s certificate, a review of his logbooks indicated that he had considerable experience flying the airplane, usually while accompanied by another pilot, and that he had flown in both visual and IFR conditions. A previous student pilot medical certificate indicated that the pilot was color blind and listed limitations for flying at night and for using color signals. The pilot had applied for another student pilot certificate 2 months before the accident, but this certificate was deferred pending a medical review.
Probable cause:
The noncertificated pilot’s failure to maintain clearance from terrain while maneuvering to land in dark night conditions likely due to his geographic disorientation (lost). Contributing to the accident was the pilot’s improper decision to fly at night with a known visual limitation.
Final Report:

Crash of a Learjet 25 near Iturbide: 7 killed

Date & Time: Dec 9, 2012 at 0333 LT
Type of aircraft:
Registration:
N345MC
Flight Phase:
Survivors:
No
Site:
Schedule:
Monterrey - Toluca
MSN:
25-046
YOM:
1969
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
22610
Copilot / Total hours on type:
67
Circumstances:
The aircraft departed Monterrey-General Mariano Escobido Airport at 0315LT on a flight to Toluca, carrying five passengers and two pilots. Few minutes later, while cruising at 28,700 feet via radial 163, the aircraft went out of control, dove into the ground and crashed in a mountainous area located near Iturbide, in the south part of the Parque Natural Sierra de Arteaga, some 100 km south of Monterrey. Debris were found scattered on an area of approximately 300 metres and all seven occupants were killed, among them the American-Mexican singer Dolores Jenney Rivera, aged 43. She was accompanied with her impresario and members of her team. They left Monterrey after she gave a concert and they should fly to Toluca to take part to a TV show.
Probable cause:
The exact cause of the loss of control could not be determined. However, it was reported that the pilot aged 78 was not allowed to conduct commercial flight due to his age. Also, the young copilot aged 21 did not have a type rating for such aircraft.
Final Report: