Crash of a De Havilland DHC-6 Twin Otter 310 near Punia

Date & Time: Aug 31, 2007 at 1300 LT
Operator:
Registration:
ZS-NJK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Punia - Goma
MSN:
598
YOM:
1978
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew departed Punia on a ferry flight to Goma. About 10 minutes into the flight, while cruising at a relative low altitude, the aircraft collided with power lines. The crew attempted an emergency landing when the aircraft crashed in the Lowa River located about 30 km northeast of Punia, coming to rest upside down. Both pilots escaped with minor injuries while the aircraft was damaged beyond repair.

Crash of a PAC Cresco 08-600 near Tully: 1 killed

Date & Time: Aug 16, 2007 at 1513 LT
Type of aircraft:
Registration:
VH-XMN
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Ingham - Tully
MSN:
036
YOM:
2002
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Total fatalities:
1
Captain / Total flying hours:
397
Captain / Total hours on type:
138.00
Circumstances:
The pilot was ferrying the aircraft under the visual flight rules (VFR) from the operator’s base at Tully, Qld to Ingham and return. The flights, conducted in the private category without passengers, were to allow aircraft maintenance to be conducted at Ingham. The flight from Tully to Ingham was conducted in the morning, with no reported difficulties. At 1454 Eastern Standard Time, the pilot departed Ingham on the return flight to Tully. The aircraft did not arrive at Tully. It was not until the next day that the pilot and aircraft were reported missing. Australian Search and Rescue (AusSAR) was notified and a search, based on the last air traffic control radar observed position of an unidentified aircraft from a replay of recorded radar data together with witness reports from the area, was initiated. Searchers located the aircraft wreckage on the morning of 18 August. The aircraft had impacted mountainous terrain in a state forest 24 km south of Tully. The pilot was fatally injured and the aircraft was destroyed.
Probable cause:
Contributing safety factors:
• The aircraft probably entered an area of weather that deteriorated below visual meteorological conditions and for which the pilot was not experienced or qualified.
• The pilot probably became unsure of his position in poor visibility, leading to controlled flight into terrain, fatally injuring the pilot and destroying the aircraft.
Other safety factors:
• The aircraft had not been configured for poor visibility operations, possibly increasing the pilot’s difficulty in navigating.
• The pilot did not submit any form of flight notification such as a SARTIME or Flight Note, as required for a flight in a designated remote area, resulting in a delay to the search and rescue response.
• The operator did not have procedures to provide assurance that a search and rescue would be initiated in a timely way if one of their aircraft did not arrive at the planned destination. [Safety issue]
• As a result of damage to the emergency locator beacon antenna, the beacon did not alert search and rescue organisations to the aircraft accident.
Final Report:

Crash of an Ilyushin II-76TD in Mogadishu: 11 killed

Date & Time: Mar 23, 2007 at 1400 LT
Type of aircraft:
Operator:
Registration:
EW-78849
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mogadishu - Djibouti City - Minsk
MSN:
10134 05192
YOM:
1991
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The aircraft was departing Mogadishu on a ferry flight to Minsk with an intermediate stop in Djibouti City, carrying 4 technicians of the operator and 7 crew members who were returning to Belarus after they recovered materials and instruments from another II-76 (EW-78826) that was damaged beyond repair at Mogadishu Airport last March 9. Shortly after takeoff, while in initial climb, the aircraft was hit by a missile that struck the left wing between both engines n°1 and 2. An explosion occurred and the aircraft caught fire. The crew initiated a turn when the left wing detached and crashed in the sea. Out of control, the aircraft crashed on a beach near the airport, killing all 11 occupants.
Probable cause:
Shot down by rebels located on a boat.

Crash of a Swearingen SA227AC Metro III in Grain Valley

Date & Time: Aug 17, 2006 at 1551 LT
Type of aircraft:
Operator:
Registration:
N620PA
Flight Type:
Survivors:
Yes
Schedule:
Tuscaloosa - Grain Valley
MSN:
AC-533
YOM:
1982
Flight number:
PKW321
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1379
Captain / Total hours on type:
188.00
Copilot / Total flying hours:
1127
Copilot / Total hours on type:
165
Aircraft flight hours:
22504
Circumstances:
The airplane impacted a fence and terrain on short final during a visual approach to runway 27. The airplane was operated as a cargo airplane with two flight crewmembers by a commercial operator certificated under 14 CFR Part 135. The flightcrew worked approximately 18.75 hours within a 24-hour period leading up to the accident performing flights listed by the operator as either 14 CFR Part 91 or 14 CFR Part 135, all of which were in the conduct of company business. Of this total, 5.9 hours involved flying conducted under 14 CFR Part 135. The flight to the accident airport was for the purposes of picking up repair parts for another company airplane that received minor damage in which the flight crew was previously piloting in the 24- hour period. They were then going to fly back to the operator's home base on the same day, which would have had an estimated flying time of 2:45 hours. The captain said he was tired and that he and the first officer had not slept at any of the stops made during the period. The captain said that the company likes for the airplanes to return to their home base. The captain said that the company prefers an option for pilots to stay overnight if tired and he has stayed overnight on previous trips but only due to maintenance related reasons. The Aeronautical Information Manual states that acute fatigue affects timing and perceptional field performance.
Probable cause:
The pilot not maintaining clearance from the fence. Contributing factors were the pilot's fatigue and the fence.
Final Report:

Crash of an Embraer EMB-110P1 Bandeirante in Pownal: 1 killed

Date & Time: Aug 4, 2006 at 0918 LT
Operator:
Registration:
N59BA
Flight Type:
Survivors:
No
Site:
Schedule:
Binghamton - Bennington
MSN:
110-396
YOM:
1982
Flight number:
BEN059
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2877
Captain / Total hours on type:
47.00
Aircraft flight hours:
40043
Circumstances:
The airport's instrument approach procedures included a very high frequency, omnidirectional range (VOR) approach, and a global positioning system (GPS) approach that was not an overlay. The VOR approach procedure included an inbound course to the VOR, and after passage, a descent along the same course to a missed approach point. The missed approach point was defined as 6 nautical miles beyond the VOR, as well as by timing. The pilot twice attempted the VOR approach in instrument meteorological conditions. He flew the first approach to the missed approach point, initiated a missed approach, contacted the controller, and requested a second VOR approach. He then received vectors to rejoin the approach course inbound to the VOR. The airplane subsequently passed over the VOR, on course, about 100 feet above the minimum altitude. However, instead of descending as described in the procedure, the airplane maintained that altitude until reaching the airport, then began a descent. The airplane continued to travel outbound along the same approach course until it impacted rising terrain about 6.5 miles beyond the airport. There was no dedicated distance measuring equipment (DME) onboard the airplane. Instead, distance was determined by the use of an instrument flight rules (IFR)-approved GPS unit. Due to the non-storage capability of the unit, historical waypoint selection could not be determined. The pilot could have selected the airport as a "direct to" waypoint, or, if he had entered flight plan waypoints, the unit would have sequenced from the VOR to the airport during the first approach. In either case, unless the pilot reprogrammed the unit, the last waypoint entered would have remained at the airport, rather than the VOR. The pilot then most likely mistook the airport position for the VOR position, and displaced the beginning of the descent by 6 nautical miles. Also noted, was that once the airplane passed over the VOR en route to the airport, the HSI would have indicated a change of "to" to "from". There were no medical anomalies noted with the pilot and no mechanical anomalies noted with the airplane.
Probable cause:
The pilot's misinterpretation of the airplane's position relative to the final approach fix, which resulted in the displacement of the descent profile by 6 nautical miles and the subsequent controlled flight into rising terrain. Contributing to the accident were the low clouds.
Final Report:

Crash of a Mitsubishi MU-2B-60 Marquise in Fort Pierce: 1 killed

Date & Time: Jun 25, 2006 at 1224 LT
Type of aircraft:
Operator:
Registration:
N316PR
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Fort Pierce - Murfreesboro
MSN:
761
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
11000
Captain / Total hours on type:
2000.00
Aircraft flight hours:
4073
Circumstances:
Witnesses stated that they observed the twin-engine airplane roll into a steep right bank and enter a spin at a low altitude (less than 700 feet) during the initial climb. The airplane then descended and impacted terrain about 1.5 miles from the end of the departure runway. Some witnesses reported hearing an unusual engine noise just before the airplane began to roll and spin. Day visual meteorological conditions prevailed. Examination of the right engine revealed that the ring gear support of the engine/propeller gearbox had fractured in flight due to high cycle fatigue originating from the corner radii of the high-speed pinion cutout. The reason for the fatigue could not be determined. The ring gear support disengaged from the ring gear due to this failure, resulting in a disconnection in power being transferred from the engine power section to the propeller. In addition to the ability for a pilot to manually feather the propellers, and an automatic feathering feature, the engine (Honeywell TPE-331) design also includes a “Negative Torque Sensing” (NTS) system that would automatically respond to a typical failed engine condition involving a propeller that is driving the coupled engine. Feathering the propeller reduces drag and asymmetric yawing due to the failed engine. All Federal Aviation Administration (FAA) certification evaluations for one-engine inoperative handling qualities for the airplane type were conducted with the NTS system operational. According to the airplane manufacturer, the NTS system was designed to automatically reduce the drag on the affected engine to provide a margin of safety until the pilot is able to shut down the engine with the condition lever. However, if a drive train disconnect occurs at the ring gear support, the NTS system is inoperable, and the propeller can come out of feather on its own, if the disconnect is followed by a pilot action to retard the power lever on the affected engine. In this scenario, once the fuel flow setting is reduced below the point required to run the power section at 100% (takeoff) rpm, the propeller governor would sense an “underspeed” condition and would attempt to increase engine rpm by unloading the propeller, subsequently driving the propeller out of feather toward the low pitch stop. This flat pitch condition would cause an increase in aerodynamic drag on one side of the airplane, and unanticipated airplane control difficulty could result due to the asymmetry.
Probable cause:
The pilot’s loss of aircraft control during the initial climb which was precipitated by the sudden loss of thrust and increase in drag from the right engine, and the pilot’s failure to adhere to the published emergency procedures regarding the position of the failed engine power lever. Contributing to the accident was the fatigue failure of the right engine’s ring gear support for undetermined reasons, which rendered the propeller’s automatic drag reducing system inoperative.
Final Report:

Crash of a Beechcraft 350 Super King Air in Freiburg im Brisgau: 2 killed

Date & Time: Jan 12, 2006 at 1826 LT
Operator:
Registration:
D-CUNO
Flight Type:
Survivors:
No
Schedule:
Karlsruhe – Freiburg im Breisgau
MSN:
FL-311
YOM:
2001
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
1500
Circumstances:
After the crew dropped off passengers at Karlsruhe-Baden-Baden Airport, he was returning to his base in Freiburg im Breisgau. On final approach to runway 16 in marginal weather conditions (poor visibility due to night and fog), the crew descended too low when the aircraft collided with trees and crashed in a wooded area located 450 metres short of runway, bursting into flames. The aircraft was destroyed by a post crash fire and both pilots were killed.
Probable cause:
The aircraft impacted ground during a controlled descent after the crew took the decision to continue the approach under VFR mode in poor visibility due to the night and foggy conditions.

Crash of a PZL-Mielec AN-28 in Zalingei: 2 killed

Date & Time: Dec 24, 2005
Type of aircraft:
Operator:
Registration:
ER-AJE
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Zalingei - Al Fashir
MSN:
1AJ006-12
YOM:
1989
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Zalingei Airport, en route to Al Fashir on behalf of the African Union, the twin engine aircraft crashed in unknown circonstances. Both pilots, Ukrainian and Moldavian citizens, were killed.

Crash of a Fletcher FU-24-950 in Whangarei: 2 killed

Date & Time: Nov 22, 2005 at 1142 LT
Type of aircraft:
Operator:
Registration:
ZK-DZG
Flight Type:
Survivors:
No
MSN:
207
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
16000
Captain / Total hours on type:
2382.00
Aircraft flight hours:
10597
Circumstances:
On 21 November 2005, the day before the accident, the pilot had completed a day of aerial topdressing in ZK-DZG, a New Zealand Aerospace Industries Fletcher FU24-950, then flown the aircraft with his loader-driver as a passenger to Whangarei Aerodrome. That evening the pilot contacted his operator’s (the company’s) chief engineer in Hamilton and said that the airspeed indicator in ZK-DZG was stuck on 80 knots. The chief engineer told him the pitot-static line for the indicator was probably blocked and to have a local aircraft engineer blow out the line. Early the next morning, the day of the accident, the pilot flew ZK-DZG with his loader-driver on board to an airstrip 50 km north-west of Whangarei to spread fertiliser on a farm property. As the morning progressed, the weather conditions became unsuitable for aerial topdressing. At about 1020, the pilot used his mobile telephone to talk to another company pilot at Kerikeri, and told him that the wind was too strong for further work. The conversation included general work-related issues and ended about 1045, with the pilot saying that he was shortly going to return to Whangarei and go to his motel. Before leaving for Whangarei, the pilot spoke with a truck driver who had delivered fertiliser to the airstrip about 1100. The driver commented later that the pilot said the wind had picked up enough to preclude further topdressing. After they had covered the fertiliser, the pilot told the driver that he and the loader-driver would fly to Whangarei. The driver did not recall anything untoward, except that the pilot had casually mentioned there was some electrical fault causing an amber light in the cockpit to flicker and that it would only be a problem if a second light came on. He said the pilot did not appear to be concerned about the light. The driver then left and did not see the aircraft depart. The pilot used his mobile telephone to tell an aircraft engineer at Whangarei Aerodrome about the airspeed indicator problem and asked him if he could have a look at it and blow out the pitot-static system. The engineer believed the call was made from the ground at about 1130, but he could not be certain of the time. The engineer agreed to rectify the problem and the pilot said he would arrive at the Aerodrome about noon. The engineer said he did not know that the pilot had spent the previous night in Whangarei or that the aircraft had been parked at the Aerodrome overnight. ZK-DZG was equipped with a global positioning system (GPS) and its navigation data was downloaded for analysis. From the data it was established that the aircraft departed from the airstrip at 1131 and flew for about 39 km on a track slightly right of the direct track to Whangarei Aerodrome, before altering heading direct to the aerodrome and Pukenui Forest located 5 km west of Whangarei city. A witness who had some aeroplane pilot flying experience, and was on a property close to the track of ZK-DZG, said he saw the aircraft fly past shortly after about 1130 at an estimated height of 500 feet. He watched it fly in the direction of Pukenui Forest for about 40 seconds before turning his head away. A short time later he turned again to look at the aircraft, which by then was just above the horizon about 2 ridges away. He said there was a strong, constant wind blowing from the right (south) of the aircraft, which appeared to be drifting sideways and rocking its wings. He then saw the aircraft enter a steep descending turn that seemed to tighten before it disappeared from view. He estimated it to have turned about 270 degrees. Another witness near the aircraft track and accident site reported seeing the aircraft at about 1140 flying just above the tree line and thought it might have been “dusting” the forest. The aircraft then turned and disappeared behind some trees. Other witnesses who heard or saw the aircraft described the weather as squally throughout the morning with strong winds from the south, and said that near the time of the accident there was no rain. The witnesses noticed nothing untoward with the aircraft itself, and at the time none was concerned that the aircraft may have been involved in an accident. The local aircraft engineer said he was not concerned when ZK-DZG did not arrive at Whangarei, because from his experience it was not unusual for agricultural pilots to change their plans at the last minute and to not inform the engineers. He described his conversation with the pilot as being casual and said the pilot did not mention that he was finishing topdressing for the day because of the weather. He thought the pilot was just trying to fit in the maintenance work and that his plans had changed. The pilot had not asked him to provide any search and rescue watch, nor did the engineer expect him to because he could not recall any pilot having asked him to do so. There was no evidence that the pilot made any radio calls during the flight. The frequency to which the radio was selected and its serviceability could not be determined because of the accident damage. At about 2200 a member of the pilot’s family contacted the emergency services when she became concerned that there had been no contact from the pilot. An extensive aerial search began at first light the next morning, and at about 1120 the wreckage of ZK-DZG was located about 50 metres (m) below a ridge in a heavily wooded area of Pukenui Forest, at an elevation of 920 feet above sea level. Both occupants were fatally injured.
Probable cause:
Findings are listed in order of development and not in order of priority.
- The pilot was correctly licensed, experienced and authorised for the flight.
- The pilot was operating the aircraft in an unserviceable condition because of a stuck airspeed indicator, which prevented him accurately assessing the aircraft airspeed. Consequently the
aircraft could have exceeded its airspeed limitations by some degree in the turbulent conditions.
- The structural integrity of the vertical fin had been reduced to such an extent by a cluster of unnoticed pre-existing fatigue cracks in its leading edge that eventual failure was inevitable. When the fin failed, it brought about an unrecoverable loss of control and the accident.
- Although the early design of the vertical fin met recognised requirements, it did not provide for any structural redundancy and the leading edge of the fin (a structural component) was not
damage-tolerant.
- The cracks in the fin leading edge went unnoticed until the failure, most likely because an approved black rubber anti-abrasion strip along that surface had prevented any detailed examination of it.
- The approved maintenance programmes did not reflect the inspection-dependent nature of the vertical fin for its ongoing airworthiness, with the inspection periods having been extended over
the years without full consideration given to the importance of frequent inspections for timely detection of fatigue damage.
- There was no evidence that the fitment of a more powerful STC-approved turbine engine, in place of a piston engine, had initiated the fatigue cracks in the fin leading edge. However, once
started, the extra engine power might have contributed to the rate of propagation of the cracks.
- The vertical fin defects and failures in the Fletcher aircraft over the years were not confined to turbine-powered aircraft.
- The CAA’s STC approval process for the turbine engine installation was generally robust and had followed recognised procedures, but the process should have been enhanced by an in-depth
evaluation of the fatigue effects on the empennage.
- Given the generally harsh operating environment and frequency of operations for the turbine powered Fletcher, the continued airworthiness requirements of the fin were not scrutinised as
robustly as they should have been during the STC approval process. Consequently the maintenance programmes had not been improved to ensure the ongoing structural integrity of the fin.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Elross Lake: 1 killed

Date & Time: Sep 1, 2005 at 1630 LT
Type of aircraft:
Operator:
Registration:
C-FODG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Pons Camp - Squaw Lake
MSN:
205
YOM:
1952
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2550
Captain / Total hours on type:
1700.00
Aircraft flight hours:
20900
Circumstances:
The float-equipped de Havilland DHC-2 Beaver (registration C-FODG, serial number 205) departed the outfitter base camp at Squaw Lake, Quebec, at 0925 eastern daylight time, with a passenger and a few supplies on board, for a round-trip visual flight rules (VFR) flight to two wilderness camps, Camp 2 and Camp Pons. The weather in Squaw Lake was suitable for visual flight at the time of take-off but was forecast to deteriorate later in the day. The pilot completed the flights to the two camps and on the way back to Squaw Lake, the weather forced the pilot to make a precautionary landing on Elross Lake, 15 nautical miles (nm) northwest of Squaw Lake. At 1630, he reported to the company via high frequency (HF) radio that he intended to take off from Elross Lake, as there seemed to be a break in the weather. Rescue efforts were initiated in the evening when the aircraft did not arrive at the base camp. The aircraft was located at 1230 the following day, 4 nm from Elross Lake. The aircraft was destroyed by a post-impact fire. The pilot sustained fatal injuries.
Probable cause:
Finding as to Causes and Contributing Factors:
1. The pilot attempted to cross the mountain ridge in adverse weather, and the aircraft stalled at an altitude from which recovery was not possible. Loss of visual references, strong updrafts, moderate to severe turbulence and possible wind shear likely contributed to the onset of the aerodynamic stall.
Other Finding:
1. Had this been a survivable accident, rescue efforts may have been compromised by a lack of communication. A satellite phone provides a more effective means of communication when in remote areas.
Final Report: