Crash of a Cessna 421C Golden Eagle III in Wells: 1 killed

Date & Time: Nov 26, 2012 at 2124 LT
Operator:
Registration:
N67SR
Flight Phase:
Survivors:
No
Schedule:
West Houston - Tulsa
MSN:
421C-0257
YOM:
1977
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2500
Aircraft flight hours:
6736
Circumstances:
The airplane was substantially damaged during an in-flight encounter with weather, in-flight separation of airframe components, and subsequent impact with the ground near Wells, Texas. The private pilot, who was the sole occupant, was fatally injured. The airplane sustained impact and fire damage to all major airframe components. The aircraft was registered to H-S Air LP and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a business flight. Instrument meteorological conditions prevailed for the flight, which operated on an instrument flight rules (IFR) flight plan. The flight originated from the West Houston Airport (IWS), Houston, Texas, about 2040 and was bound for the Richard Lloyd Jones Jr. Airport (RVS), Tulsa, Oklahoma. Witnesses near the accident site reported hearing an explosion and then seeing a fireball descending through the clouds to the ground. Radar track data for the last portion of the flight depicted the airplane on a 7720 transponder code. The track showed the airplane initially on a heading of about 20 degrees at 23,000 feet. The track continued in this direction until 2120:03.73 when the airplane began a right turn. The right turn continued for about 30 seconds during which time the altitude remained constant and the heading changed to about 90 degrees. After 2120:45.86, the track showed an erratic steep descent that continued to the end of the data. The final data location was received at 2122:15.53 at an altitude of 2,800 feet. The accident location was 0.86 miles and 94 degrees from the last recorded radar position.
Probable cause:
The pilot’s decision to continue the flight into an area of extreme weather, which led to the in-flight encounter with a thunderstorm and structural failure of the wings and tail.
Final Report:

Crash of a Beechcraft Beechjet 400A in Macon

Date & Time: Sep 18, 2012 at 1003 LT
Type of aircraft:
Operator:
Registration:
N428JD
Survivors:
Yes
Schedule:
Charleston - Macon
MSN:
RJ-13
YOM:
1986
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7000
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
2500
Copilot / Total hours on type:
450
Aircraft flight hours:
5416
Circumstances:
The aircraft was substantially damaged when it overran runway 28 during landing at Macon Downtown Airport (MAC), Macon, Georgia. The airplane departed from Charleston Air Force Base/International Airport (CHS), Charleston, South Carolina, about 0930. Visual meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed. Both Airline Transport Pilots (ATP) and one passenger sustained minor injuries. The airplane was owned by Dewberry, LLC and operated by The Aviation Department. The corporate flight was conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. According to an interview with the pilots, they arrived at DeKalb-Peachtree Airport (PDK), Atlanta, Georgia, which was their home base airport, about 0400, and then drove about 4 1/2 hours to CHS for the 0930 flight. The flight departed on time, the airspeed index bug was set on the co-pilot's airspeed for a decision takeoff speed (V1) of about 102 knots and a single engine climb speed (V2) on the pilot's side of 115 knots. The flight climbed to 16,000 feet prior to beginning the descent into MAC. When the flight was about 11 miles from the airport the flight crew visually acquired the airport and cancelled their IFR clearance with the Macon Radar Approach controller and proceeded to the airport visually. The second-in-command activated the runway lights utilizing the common traffic advisory frequency for the airport. Both crew members reported that about 3 seconds following activation of the lights and the precision approach path indicator (PAPI) lights, the PAPI lights turned off and would not reactivate. During the approach, the calculated reference speed (Vref) was 108 knots and was set on both pilots' airspeed indicator utilizing the index bug that moved around the outside face of the airspeed instrument. The landing was within the first 1,000 feet of the runway and during the landing roll out the airplane began to "hydroplane" since there was visible standing water on the runway and the water was "funneling into the middle." Maximum reverse thrust, braking, and ground spoilers were deployed; however, both pilots reported a "pulsation" in the brake system. The airplane departed the end of the runway into the grass, went down an embankment, across a road, and into trees. They further added that the airplane "hit hard" at the bottom of the embankment. They also reported that there were no mechanical malfunctions with the airplane prior to the landing. According to an eyewitness statement, a few minutes prior to the airplane landing, the airport experienced a rain shower with a "heavy downpour." The witness reported observing the airplane on approach, heard the engine thrust reverse, and then observed the airplane "engulfed in a large ball of water vapor." However, he did not observe the airplane as it departed the end of the runway. Another witness was located in a hangar on the west side of the airport and heard the airplane, looked outside and then saw the airplane with the reverse thrusters deployed. He watched it depart the end of the runway and travel into the nearby woods.
Probable cause:
The pilot’s failure to maintain proper airspeed, which resulted in the airplane touching down too fast on the wet runway with inadequate runway remaining to stop and a subsequent runway overrun. Contributing to the landing overrun were the flight crew members’ failure to correctly use the appropriate performance chart to calculate the runway required to stop on a contaminated runway and their general lack of proper crew resource management.
Final Report:

Crash of a Pilatus PC-12/47 in Solemont: 4 killed

Date & Time: Aug 24, 2012 at 1800 LT
Type of aircraft:
Operator:
Registration:
HB-FPZ
Flight Phase:
Survivors:
No
Schedule:
Antwerp - Saanen (Gstaad)
MSN:
702
YOM:
2006
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
5971
Captain / Total hours on type:
1785.00
Circumstances:
The pilot took off from Anvers (Belgium) at around 14 h 40 bound for Saanen (Switzerland) where he was supposed to drop off his three passengers. The flight was performed in IFR then VFR, at a cruise altitude of 26,000 ft. After about 1 h 15 min of flight, still under IFR, the Geneva controller cleared the pilot to descend towards FL 210 and to fly towards Saanen with a view to an approach. A short time later, the radar data showed that the aeroplane deviated from the planned trajectory. Following a question from the controller, the pilot said he had an autopilot problem. The controller then asked the pilot to follow heading 165°, which the pilot read back, then asked him ‘‘are you okay, okay for the safety, it’s good for you? ‘‘. The pilot answered that he had a ‘‘big problem’’. The radar data show tight turns on descent. During these manœuvres, in reply to a request from the controller, the pilot said that he was in ‘‘total IMC’’. During this communication, the aeroplane‘s overspeed warning could be heard. The aeroplane was then descending at 15,500 ft/min. About ten seconds later, it was climbing at 15,500 ft/min. The right wing broke off about twenty seconds later. The indicated airspeed was then 274 kt and the altitude was 12,750 ft. The wreckage was found in woods in the commune of Solemont (25). A piece of the right wing was found about 2.5 km from the main wreckage. Some debris, all from the right wing, was found on a south-west/north-east axis. The aeroplane part that was furthest away was found 10 km from the main site. The aircraft disintegrated on impact and all four occupants were killed.
Probable cause:
The in-flight failure of the right wing was due to exceeding the aeroplane’s structural limits (ultimate loads) during loss of control by the pilot. In the absence of any flight recorders, the investigation was not able to determine the causes of this loss of control. It is possible that it may have been induced by a loss of situational awareness by the pilot at the controls of an aeroplane affected by an icing phenomenon. This phenomenon may have affected the aeroplane’s wings or an area around the roll control.
Final Report:

Crash of a Beechcraft B200 Super King Air in Juiz de Fora: 8 killed

Date & Time: Jul 28, 2012 at 0745 LT
Operator:
Registration:
PR-DOC
Survivors:
No
Schedule:
Belo Horizonte - Juiz de Fora
MSN:
BY-51
YOM:
2009
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
14170
Captain / Total hours on type:
2170.00
Copilot / Total flying hours:
730
Copilot / Total hours on type:
415
Aircraft flight hours:
385
Aircraft flight cycles:
305
Circumstances:
The twin engine aircraft departed Belo Horizonte-Pampulha Airport at 0700LT on a flight to Juiz de Fora, carrying six passengers and two pilots. In contact with Juiz de Fora Radio, the crew learned that the weather conditions at the aerodrome were below the IFR minima due to mist, and decided to maintain the route towards the destination and perform a non-precision RNAV (GNSS) IFR approach for landing on runway 03. During the final approach, the aircraft collided first with obstacles and then with the ground, at a distance of 245 meters from the runway 03 threshold, and exploded on impact. The aircraft was totally destroyed and all 8 occupants were killed, among them both President and Vice-President of the Vilmas Alimentos Group.
Probable cause:
The following factors were identified:
- The pilot may have displayed a complacent attitude, both in relation to the operation of the aircraft in general and to the need to accommodate his employers’ demands for arriving in SBJF. It is also possible to infer a posture of excessive self-confidence and confidence in the aircraft, in spite of the elements which signaled the risks inherent to the situation.
- It is possible that the different levels of experience of the two pilots, as well as the copilot’s personal features (besides being timid, he showed an excessive respect for the captain), may have resulted in a failure of communication between the crewmembers.
- It is possible that the captain’s leadership style and the copilot’s personal features resulted in lack of assertive attitudes on the part of the crew, hindering the exchange of adequate information, generating a faulty perception in relation to all the important elements of the environment, even with the aircraft alerts functioning in a perfect manner.
- The meteorological conditions in SBJF were below the minima for IFR operations on account of mist, with a ceiling at 100ft.
- The crew did not inform Juiz de Fora Radio about their passage of the MDA and, even without visual contact with the runway, deliberately continued in their descent, not complying with the prescriptions of the items 10.4 and 15.4 of the ICA 100-12 (Rules of the Air and Air Traffic Services).
- The crew judged that it would be possible to continue descending after the MDA, even without having the runway in sight.
Final Report:

Crash of a Beechcraft Beechjet 400A in Atlanta

Date & Time: Jun 18, 2012 at 1006 LT
Type of aircraft:
Operator:
Registration:
N826JH
Survivors:
Yes
Schedule:
Gadsden - Atlanta
MSN:
RK-70
YOM:
1993
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10800
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
3500
Copilot / Total hours on type:
150
Aircraft flight hours:
4674
Circumstances:
The second-in-command (SIC) was the pilot flying for most of the flight (takeoff, climb, cruise, and descent) and was in the left seat, while the pilot-in-command (PIC) was the pilot monitoring for most of the flight and was in the right seat. Before takeoff, the PIC calculated reference speed (Vref) for the estimated landing weight and flaps 30-degree extension was 120 knots, with a calculated landing distance of 3,440 ft. Further, before takeoff, there were no known mechanical difficulties with the brakes, flaps, antiskid, or traffic alert and collision avoidance (TCAS) systems. After takeoff and for most of the flight, the PIC coached/instructed the SIC, including instructions on how to set the airspeed command cursor, a request to perform the after-takeoff checklist, and a comment to reduce thrust to silence an overspeed warning aural annunciation. When the flight was northwest of Dekalb Peachtree Airport (PDK), Atlanta, Georgia, on a right base leg for a visual approach to runway 20L with negligible wind, air traffic controllers repeatedly announced the location and distance of a Cessna airplane (which was ahead of the Beech 400A on a straight-in visual approach to runway 20R). Because the Beech 400A flight crew did not see the other airplane, the controllers appropriately instructed them to maintain their altitude (which was 2,300 ft mean sea level [msl]) for separation until they had the traffic in sight; radar data indicated the Beech 400A briefly descended to 2,200 ft msl then climbed back to 2,300 ft msl. According to the cockpit voice recorder (CVR) transcript, at 1004:42, which was about 12 seconds after the controller instructed the Beech 400A flight crew to maintain altitude, the on board TCAS alerted "traffic traffic." While the Beech 400A did climb back to 2,300 ft msl, this was likely a response to the air traffic control (ATC) instruction to maintain altitude and not a response to the TCAS "traffic traffic" warning. At 1004:47, the CVR recorded the SIC state, "first degree of," likely referring to flap extension, but the comment was not completed. The CVR recorded an immediate increase in background noise, which was likely due to the landing gear extension. The PIC then advised the local controller that the flight was turning onto final approach. The CVR did not record any approach briefing or discussion of runway length or Vref speed. After landing on runway 20L at Atlanta-DeKalb Peachtree Airport, aircraft did not stop as expected. It overrun the runway, went through a fence and came to rest near a road, broken in two. All four occupants were injured, both pilots seriously.
Probable cause:
The flight crew's failure to obtain the proper airspeed for landing, which resulted in the airplane touching down too fast with inadequate runway remaining to stop and a subsequent
runway overrun. Contributing to the accident were the failure of either pilot to call for a go-around and the flight crew's poor crew resource management and lack of professionalism.
Final Report:

Crash of a Cessna 441 Conquest II in Battle Creek

Date & Time: Mar 27, 2012 at 0730 LT
Type of aircraft:
Operator:
Registration:
N1212C
Survivors:
Yes
Schedule:
Muskegon - Aurora
MSN:
441-0346
YOM:
1984
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
20154
Captain / Total hours on type:
13000.00
Aircraft flight hours:
12499
Circumstances:
After the pilot finished the preflight inspection in the hangar, the maintenance technician pulled the airplane out of the hangar and connected the auxiliary power cart to the airplane. Shortly thereafter, the pilot boarded the airplane and proceeded with the normal checklist. The pilot signaled to the maintenance technician to disconnect the power cart. The maintenance technician subsequently signaled that the pilot was clear to start the engines. After departure, the pilot noted a problem with the landing gear, and, after establishing that the tow bar was, most likely, still attached to the nosewheel, he diverted to a nearby airport for a precautionary landing. During the landing, the nose landing gear collapsed and the primary structure in the nose of the airplane was substantially damaged.
Probable cause:
The maintenance technician did not remove the tow bar prior to the flight.
Final Report:

Crash of a Cessna 750 Citation X in Egelsbach: 5 killed

Date & Time: Mar 1, 2012 at 1856 LT
Type of aircraft:
Operator:
Registration:
N288CX
Survivors:
No
Schedule:
Linz – Egelsbach - Bratislava
MSN:
750-0219
YOM:
2003
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
4580
Copilot / Total flying hours:
3000
Aircraft flight hours:
3377
Aircraft flight cycles:
2223
Circumstances:
The airplane was on a business trip in Austria from Innsbruck via Salzburg to Linz. At 1816 hrs the airplane took off in Linz with two pilots and three passengers aboard; destination airport was to be Bratislava, Czech Republic. On the way to Bratislava a stopover in Egelsbach, Germany (EDFE) was planned; an additional passenger would board there. For the flight from Linz to Egelsbach a Y-flight plan was filed; it scheduled a flight according to Instrument Flight Rules (IFR) including an approach according to Visual Flight Rules (VFR). At 1824 hrs the airplane reached German airspace. The radio communication recorded by the air traffic service provider showed that the Cessna Citation 750 crew made the initial call to Langen Radar at 1836:54 hrs on frequency 120.575 MHz. At 1839:10 hrs the air traffic controller cleared a descent to Flight Level (FL) 140 after the identification of the airplane. Initially, the crew did not understand the instruction to fly a left turn toward SPESSART NDB and then later toward CHARLIE VOR. The Pilot in Command (PIC) apologized and let the controller know that he did not come here very often. At 1843:58 hrs a descent to 5,000 ft was instructed and the barometric air pressure QNH of 1,025 hPa passed. After "high speed approved" given by the controller the Citation 750 was passed on to Frankfurt Approach Control (136.125 MHz). At 1845:00 hrs the PIC made the initial call to Frankfurt Approach Control. He said he was in descent to 5,000 ft and did have the weather for Frankfurt. The controller issued a clearance for a visual approach at night (VFR Night) to Frankfurt-Egelsbach Airfield and asked him to report "Egelsbach in sight". The co-pilot acknowledged the clearance and that he would report "field in sight". The controller asked for a confirmation by the crew that it was indeed a VFR Night flight. About one minute later the controller asked the pilot if the IFR part had already been cancelled. The copilot answered "negative". The controller apologized and said it was his fault and he should continue his flight to CHARLIE. The controller added: “Disregard the VFR Night“. The crew made contact with the destination airport with VHF 2. The Aviation Supervision Office at Frankfurt-Egelsbach told the PIC that he could choose his landing direction. The crew received the information that runway 27 was easier to approach and that YANKEE ZWO was a good approach point. Afterwards the co-pilot said: “ … we’re proceeding direct to Egelsbach and we have just been talking to them we will take runway two seven for four miles final.” The controller advised of the “YANKEE inbound routing”; the pilot acknowledged with the reference that they were not yet flying VFR. The controller's information “ja however you may proceed YANKEE ONE“ was read back by the pilot with “YANKEE ONE“. The read-out of the Cockpit Voice Reorder (CFR) indicates that the crew had entered reporting point ECHO into the Flight Management System (FMS). The crew asked for a descent clearance to 4,000 ft which was granted at 1850:59 hrs. At 1851:36 hrs a descent for 3,000 ft was cleared. The pilot acknowledged the clearance with “…descend three thousand“; the controller answered: “….direct YANKEE ZWO für die zwo sieben“ (direct YANKEE ZWO for the two seven). After a further descent clearance to 2,500 ft, the controller asked at 1853:58 hrs if the pilot could cancel the IFR part. The co-pilot answered "affirmative". The controller confirmed the change from IFR to VFR with the time indication of 17:54 UTC. He added that the pilot should continue his descent to 1,500 ft or lower for the VFR Night flight and report airfield in sight. The pilot acknowledged that he would report back once he had the airfield in sight. Afterwards the PIC ordered “Flaps five“ which the co-pilot acknowledged with "Speed check. Flaps five selected“. According to the radar recording the airplane passed reporting point ECHO at 1854:42 hrs. The airplane passed YANKEE ONE to the south with a distance of 1.2 Nautical Miles (NM). The read-out of the Flight Data Recorder (FDR) data showed the airplane was in 2,800 ft AMSL at that time. The ground speed was about 285 kt with a rate of descent of 600 ft/min. Ten seconds after the PIC said “Okay. Let’s slow it down“ the flaps were set to 15° and the landing gear was extended. At that time the airplane was in about 1,770 ft AMSL with a brief rate of descent of 2,500 ft/min. At 1855:05 hrs the controller reported “…, field now eleven clock position, range six miles.“ The co-pilot answered that he had the airfield in sight after he had gotten the PIC's assurance. The airplane turned left to a heading of about 265°. At that time the rate of descent was about 600 ft/min and speed decreased further with 1 kt/s. At 18 55:16 hrs the last radio communication with Frankfurt Approach Control was “…. approved to leave any time …" which the co-pilot acknowledged. The co-pilot established radio contact with the Flugleiter of Egelsbach Airfield where he was asked to report airfield in sight. According to the recorded communication be-tween crew and Frankfurt-Egelsbach Info the runway lighting including the strobe lights were activated. The FDR recorded that at 1855:32 hrs the altitude select of the auto flight system was changed from 1,500 ft to 1,160 ft AMSL. The radar data showed that the on-request reporting point YANKEE TWO was passed at 1855:37 hrs in 1,530 ft AMSL with an airspeed of 175 kt. Based on the determined data the airplane was in about 820 ft AGL. At 1855:56 hrs the preselected altitude was reduced to 580 ft. The co-pilot's comment “….thousand feet above“ answered the PIC with “… and three miles to go only“. At 1856:06 hrs the radio altimeter reported “Five hundred“. The rate of descent was now 1,200 ft/min and increased in the following ten seconds up to 2,500 ft/min. The flaps drove from 15° to 35°. Two seconds after the radio altimeter the Enhanced Ground Proximity Warning System (EGPWS) generated the announcement "Sink rate, pull up, pull up, pull up, ...". Seven seconds after the beginning of the EGPWS warning the co-pilot said: “That’s five ….three hundred feet“. At 1856:08 hrs the EGPWS announced "...sink rate, too low, terrain, sink rate, terrain." The PIC asked "Terrain?" which the co-pilot answered with "Terrain!!!". At that moment an elevator deflection of up to 17° nose up occurred. The pitch increased from -4° to +20° within two seconds. At 1856:22 hrs the airplane collided with trees one second before the airplane reached the maximum pitch. At the time the autopilot was engaged. The engine parameter N1 (engine thrust) remained at 34% for both engines until the end of the recording. In the further course of the accident individual parts of the airplane were torn off by contact with trees. About 430 m after the initial tree contact the airplane impacted the ground. Prior to the impact the airplane had inverted itself. About 25 m prior to the ground impact both wings were torn-off by trees. The accident site was about 3.6 km (1.96 NM) from the threshold of runway 27 of Frankfurt-Egelsbach Airfield. The airplane was destroyed by impact forces and ensuing fire. Both pilots and the three passengers sustained fatal injuries.
Final Report:

Crash of a Beechcraft F90 King Air off Belém

Date & Time: Feb 8, 2012 at 2244 LT
Type of aircraft:
Operator:
Registration:
PT-OFD
Survivors:
Yes
Schedule:
São Paulo – Belém
MSN:
LA-118
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5500
Captain / Total hours on type:
70.00
Copilot / Total flying hours:
6750
Copilot / Total hours on type:
7
Circumstances:
The aircraft departed São Paulo-Congonhas Airport at 1630LT on a flight to Belém, carrying two passengers and two pilots. During the approach to Belém-Val de Cans-Júlio Cezar Ribeiro Airport runway 06 by night, one of the engine flamed out. Few seconds later, the second engine failed as well. The crew ditched the aircraft in the Bay of Guajará, about 1,2 km short of runway 06 threshold. All four occupants were rescued by servicemen of the Naval Base who were on duty at the time of the accident. A pilot was slightly injured while three other occupants escaped uninjured. The aircraft sank and the wreckage was recovered 12 days later.
Probable cause:
The following findings were identified:
a) The pilots had valid aeronautical medical certificates;
b) The pilots had valid technical qualification certificates;
c) The aircraft captain had qualification and enough experience for the flight in question;
d) The copilot was under training;
e) The aircraft had a valid airworthiness certificate;
f) The planning of the flight from SBSP to SBBE was done by the pilot in command, who took in consideration an aircraft with a full load of fuel;
g) The flight plan read that the fuel endurance was 7 hours and 30 minutes of flight, for an estimated elapse time of 5 hours and 40 minutes at FL230;
h) When the aircraft was passing over the city of Palmas, State of Tocantins, the pilots decided, in conjunction, to proceed non-stop to the destination, discarding the need to make an intermediate landing for refueling;
i) The aircraft was registered in the passenger transport category (TPP) and was engaged in the transport of a sick person;
j) The fuel quantity indicators and the fuel flow indicators of the aircraft were not showing dependable information;
k) The flight plan for the leg betwren SBSP and SBBE contained information of sick person transportation, but there was no sick person on board;
l) The aircraft made a ditching near the banks of Guajará Bay, at a distance of approximately 1,200 meters from the threshold of runway 06 of SBBE;
m) The passengers and crew were rescued by Brazilian Navy servicemen on duty on the Naval Base of Val de Cans;
n) One of the pilots and both passengers got out uninjured, while the other pilot suffered minor injuries; and
o) The aircraft sustained substantial damage.
Contributing factors:
Concerning the operation of the aircraft
a) Attitude – a contributor
The captain failed to comply with norms and procedures by accepting to fly an aircraft on his day of rest, even knowing that he was to start his on-call duty hours as soon as he landed in SBBE.
He also showed to be overconfident when he decided to fly directly from SBSP to SBBE, trusting the 7-hour fuel endurance of his aircraft and the fuel consumption information displayed by the instruments, even after identifying their malfunction. The pilot under training, in turn, was complacent by accepting and agreeing with the pilot-in-command’s decision, without questioning his calculations or motivations for flying direct to the destination.
b) Motivation – a contributor
The captain was eager to return to SBBE on that same day, because he was supposed to start his on-call duty hours in the air taxi company for which he worked.
c) Decision-making process – a contributor
The captain failed to comply with important aspects concerning the route conditions and aircraft instruments by making a decision to fly directly from SBSP to SBBE.
Psychosocial information
a) Communication – a contributor
There was lack of assertiveness on the part of the copilot since he did not question the captain’s calculations and/or motivations to fly non-stop, when he (the copilot) considered that making a stop for refueling would be safer.
b) External influence – a contributor
The involvement of the captain with activities of another company on that same day, in addition to events belonging to his private life, had influence on his decisions in the initial planning of the flight and during the flight en route.
Organizational information
a) Work organization – a contributor
The company delegated responsibility for the entire planning of the flight to the pilots. Therefore, there was not any interference on the part of the company in the crew’s work day and in the legs defined for the flight.
b) Organizational culture – a contributor
The fact that the company performed an operation for which it was not certified reflected the fragility of an organizational culture which allowed it to perform activities unfavorable to operational safety.
Operational Factor
Concerning the operation of the aircraft
a) Flight indiscipline – a contributor
On several occasions during the flight, the pilots failed to comply with the norms and regulations in force, such as the sections 91.167 and 91.205 of the RBHA 91, the Pilot Operating Handbook and FAA Approved Airplane Flight Manual, and the Lei do Aeronauta (Law of the Aeronaut, Law nº 7.183 of 5 April 1984).
b) Training – undetermined
Before the ditching, the pilot unlocked the rear door of the aircraft and, then, failed to instruct the passengers as to the opening of the emergency exit. This fact shows a probable deviation in the process of training previously received by the captain, since the procedure prescribed for the situation was to abandon the aircraft through the emergency exit, which had to be unlocked after the ditching.
c) Piloting judgment – a contributor
At the moment of their decision to proceed non-stop to the destination, there was an inappropriate evaluation on the part of the crew, because they did not consider the hourly consumption until that point, and the malfunction of the fuel capacity indicator did not allow them to know the exact amount of fuel remaining in the tanks.
d) Flight planning – a contributor
There was a mistake on the part of the captain relative to the planning of the flight, since, in addition to a total flight time of 5 hours and 40 minutes, he did not consider the fuel necessary to fly to an alternate airport plus 45 minutes of flight. The captain and the pilot under training made an inappropriate evaluation of the effects brought by the operational conditions along the flight route.
Final Report:

Crash of a Piper PA-31T Cheyenne II in Puerto Montt

Date & Time: Jan 19, 2012 at 2100 LT
Type of aircraft:
Operator:
Registration:
CC-PLL
Survivors:
Yes
Schedule:
Santiago – Puerto Montt
MSN:
31-7920005
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
30353
Captain / Total hours on type:
972.00
Aircraft flight hours:
6989
Circumstances:
The twin engine aircraft departed Santiago-Eulogio Sánchez Errázuriz-Tobalaba Airport at 1815LT on a flight to Puerto Montt, carrying seven passengers and one pilot. On approach to Puerto Montt-Marcel Marchant Airport runway 19, his attention was focused on the GPS and he forgot to lower the landing gear. The aircraft belly landed and slid for few dozen metres before coming to rest on the main runway. All eight occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Belly landing on runway 19 after the pilot forgot to lower the landing gear while approaching the airport.
The following contributing factors were identified:
- Probable distraction of the pilot by keeping his attention mainly on the GPS equipment to maintain the flight path and avoid unnecessary engine power adjustments,
- The pilot failed to follow the approach and landing checklist,
- The pilot failed to check the three gear lights on the cockpit panel,
- The pilot performed an unstabilized approach without completing the pre-landing checklist and eventually stabilized the airplane at a height of 500 feet.
Final Report:

Crash of a Cessna S550 Citation S/II in Warroad

Date & Time: Nov 11, 2011 at 2130 LT
Type of aircraft:
Registration:
N600KM
Survivors:
Yes
MSN:
S550-0008
YOM:
1984
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After a night landing on runway 13 at Warroad Airport, the aircraft collided with a White-tailed deer. The crew was able to stop the aircraft that suffered structural damages to the left wing. There were no injuries but the aircraft was damaged beyond repair.
Probable cause:
No investigation was conducted by NTSB.