Crash of a De Havilland DHC-6 Twin Otter 300 on Mt Elizabeth: 3 killed

Date & Time: Jan 23, 2013 at 0827 LT
Operator:
Registration:
C-GKBC
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Amundsen-Scott Station - Terra Nova-Zucchelli Station
MSN:
650
YOM:
1979
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
22300
Captain / Total hours on type:
7770.00
Copilot / Total flying hours:
790
Copilot / Total hours on type:
450
Aircraft flight hours:
28200
Circumstances:
The aircraft departed South Pole Station, Antarctica, at 0523 Coordinated Universal Time on 23 January 2013 for a visual flight rules repositioning flight to Terra Nova Bay, Antarctica, with a crew of 3 on board. The aircraft failed to make its last radio check-in scheduled at 0827, and the flight was considered overdue. An emergency locator transmitter signal was detected in the vicinity of Mount Elizabeth, Antarctica, and a search and rescue effort was initiated. Extreme weather conditions hampered the search and rescue operation, preventing the search and rescue team from accessing the site for 2 days. Once on site, it was determined that the aircraft had impacted terrain and crew members of C-GKBC had not survived. Adverse weather, high altitude and the condition of the aircraft prevented the recovery of the crew and comprehensive examination of the aircraft. There were no indications of fire on the limited portions of the aircraft that were visible. The accident occurred during daylight hours.
Probable cause:
The accident was caused by a controlled flight into terrain (CFIT).
Findings:
The crew of C-GKBC made a turn prior to reaching the open region of the Ross Shelf. The aircraft might have entered an area covered by cloud that ultimately led to the aircraft contacting the rising terrain of Mount Elizabeth.
Other findings:
The cockpit voice recorder (CVR) was not serviceable at the time of the occurrence.
The company did not have a practice in place to verify the functionality of the CVR prior to flight.
The rate of climb recorded in the SkyTrac ISAT-100 tracking equipment prior to contacting terrain was consistent with the performance figures in the DHC-6 Twin Otter Series 300 Operating Data Manual 1-63-1, Revision 7.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Grand Central

Date & Time: Nov 25, 2012 at 1027 LT
Registration:
ZS-JHN
Flight Type:
Survivors:
Yes
Schedule:
Grand Central – Tzaneen
MSN:
31-7405496
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1699
Captain / Total hours on type:
1.00
Aircraft flight hours:
8029
Circumstances:
On the morning of 25 November 2012 at 0902Z the pilot, sole occupant on board the aircraft, took off from FAGC to FATZ. He filed an IFR flight plan to cruise at F110 in controlled airspace. The take-off roll and initial climb from RWY 17 was uneventful and passing FL075 FAGC Tower Controller transferred the aircraft to Johannesburg Approach Control (Approach) on 124.5 MHz. On contact with Approach the pilot was cleared to climb to FL110. On the climb approaching FL090 the aircraft lost power on the left engine, oil pressure dropped and the cylinder head temperature increased. He then advised Approach of the problem and requested to level out at FL090 to attempt to identify the problem. He requested radar vectors from Approach to route direct to FAGC and proceeded to shut down the left engine. The pilot continued routing FAGC using the right engine but was unable to maintain height. He noticed the oil pressure and manifold pressure on the right engine dropping. The pilot also reported seeing fire through the cooling vents of the right engine cowling. The pilot requested distance to FAGC from Approach and was told it is 2.5nm (nautical miles) and the aircraft continued loosing height. An update from Approach seconds later indicated that the aircraft was 1nm from FAGC. The pilot decided to do a wheels up forced landing on an open field when he realized that the aircraft was too low. He landed wheels up in a wings level attitude. The aircraft impacted and skidded across an uneven field and came to a stop 5m from Donovan Street. The pilot disembarked the aircraft and attempted to put out the fire which had started inflight on the right engine but without success. Eventually the right wing and the fuselage were engulfed by fire. Minutes later the FAGC fire department using two vehicles extinguished the fire. The pilot escaped with no injuries and the aircraft was destroyed by the ensuing fire.
Probable cause:
An inspection the left wings outboard tank was full and the main tank was empty. Both fuel selectors were also found on main tanks (left and right) position. Unsuccessful forced landing due to fuel starvation and the cause of the fire was undetermined. The left engine failed because of fuel exhaustion and the cause of fire could not be determined.
Final Report:

Crash of a Cessna 560 Citation V in Edmonton

Date & Time: Oct 30, 2012 at 0633 LT
Type of aircraft:
Operator:
Registration:
C-FBCW
Flight Type:
Survivors:
Yes
Schedule:
Edmonton - Edmonton
MSN:
560-0191
YOM:
1992
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Edmonton-City Centre Airport in the early morning on a positioning flight to Edmonton-Intl, carrying two pilots. En route, the crew encountered IMC conditions with moderate icing and the deicing systems were activated. For unknown reasons, the aircraft landed hard on runway 02, causing the right main gear to collapse. The aircraft veered off runway to the right and came to rest in a grassy area. Both pilots escaped with minor injuries and the aircraft was damaged beyond repair.

Crash of a Gulfstream GIV in Le Castellet: 3 killed

Date & Time: Jul 13, 2012 at 1518 LT
Type of aircraft:
Operator:
Registration:
N823GA
Flight Type:
Survivors:
No
Schedule:
Nice - Le Castellet
MSN:
1005
YOM:
1987
Flight number:
UJT823
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
22129
Captain / Total hours on type:
690.00
Copilot / Total flying hours:
1350
Copilot / Total hours on type:
556
Aircraft flight hours:
12210
Aircraft flight cycles:
5393
Circumstances:
The crew, consisting of a Captain and a co-pilot, took off at around 6 h 00 for a flight between Athens and Istanbul Sabiha Gokcen (Turkey). A cabin aid was also on board the aeroplane. The crew then made the journey between Istanbul and Nice (06) with three passengers. After dropping them off in Nice, the aeroplane took off at 12 h 56 for a flight to Le Castellet aerodrome in order to park the airplane for several days, the parking area at Nice being full. The Captain, in the left seat, was Pilot Monitoring (PM). The copilot, in the right seat, was Pilot Flying (PF). Flights were operated according to US regulation 14 CFR Part 135 (special rules applicable for the operation of flights on demand). The flight leg was short and the cruise, carried out at FL160, lasted about 5 minutes. At the destination, the crew was cleared to perform a visual approach to runway 13. The autopilot and the auto-throttle were disengaged, the gear was down and the flaps in the landing position. The GND SPOILER UNARM message, indicating nonarming of the ground spoilers, was displayed on the EICAS and the associated single chime aural warning was triggered. This message remained displayed on the EICAS until the end of the flight since the crew forgot to arm the ground spoilers during the approach. At a height of 25 ft, while the aircraft was flying over the runway threshold slightly below the theoretical descent path, a SINK RATE warning was triggered. The PF corrected the flight path and the touchdown of the main landing gear took place 15 metres after the touchdown zone - that’s to say 365 metres from the threshold - and slightly left of the centre line of runway 13(3). The ground spoilers, not armed, did not automatically deploy. The crew braked and actuated the deployment of the thrust reversers, which did not deploy completely(4). The hydraulic pressure available at brake level slightly increased. The deceleration of the aeroplane was slow. Four seconds after touchdown, a MASTER WARNING was triggered. A second MASTER WARNING(5) was generated five seconds later. The nose landing gear touched down for the first time 785 metres beyond the threshold before the aeroplane’s pitch attitude increased again, causing a loss of contact of the nose gear with the ground. The aircraft crossed the runway centre line to the right, the crew correcting this by a slight input on the rudder pedals to the left. They applied a strong nose-down input and the nose gear touched down on the runway a second time, 1,050 metres beyond the threshold. The speed brakes were then manually actuated by the crew with an input on the speed brake control, which then deployed the panels. Maximum thrust from the thrust reversers was reached one second later(6). The aircraft at this time was 655 metres from the runway end and its path began to curve to the left. In response to this deviation, the crew made a sharp input on the right rudder pedal, to the stop, and an input on the right brake, but failed to correct the trajectory. The aeroplane, skidding to the right(7), ran off the runway to the left 385 metres from the runway end at a ground speed of approximately 95 knots. It struck a runway edge light, the PAPI of runway 31, a metal fence then trees and caught fire instantly. An aerodrome firefighter responded quickly onsite but did not succeed in bringing the fire under control. The occupants were unable to evacuate the aircraft.
Probable cause:
Forgetting to arm the ground spoilers delayed the deployment of the thrust reversers despite their selection. Several MASTER WARNING alarms were triggered and the deceleration was low. The crew then responded by applying a strong nose-down input in order to make sure that the aeroplane stayed in contact with the ground, resulting in unusually high load for a brief moment on the nose gear. After that, the nose gear wheels deviated to the left as a result of a left input on the tiller or a failure in the steering system. It was not possible to establish a formal link between the high load on the nose gear and this possible failure. The crew was then unable to avoid the runway excursion at high speed and the collision with trees. The aerodrome fire-fighter, alone at the time of the intervention, was unable to bring the fire under control after the impact. Although located outside of the runway safety
area on either side of the runway centre line, as provided for by the regulations, the presence of rocks and trees near the runway contributed to the consequences of the accident.
The accident was caused by the combination of the following factors:
- The ground spoilers were not armed during the approach,
- A lack of a complete check of the items with the ‘‘before landing’’ checklist, and more generally the UJT crews’ failure to systematically perform the checklists as a challenge and response to ensure the safety of the flight,
- Procedures and ergonomics of the aeroplane that were not conducive to monitoring the extension of the ground spoilers during the landing,
- A possible left input on the tiller or a failure of the nose gear steering system having caused its orientation to the left to values greater than those that can be commanded using the rudder pedals, without generating any warning,
- A lack of crew training in the ‘‘Uncommanded Nose Wheel Steering’’ procedure, provided to face uncommanded orientations of the nose gear,
- An introduction of this new procedure that was not subject to a clear assessment by Gulfstream or the FAA,
- Failures in updating the documentation of the manufacturer and the operator,
- Monitoring by the FAA that failed to detect both the absence of any updates of this documentation and the operating procedure for carrying out checklists by the operator.
Final Report:

Crash of a Beechcraft E90 King Air in Karnack: 1 killed

Date & Time: Jul 7, 2012 at 0404 LT
Type of aircraft:
Operator:
Registration:
N987GM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
DeKalb - Brownsville
MSN:
LW-65
YOM:
1973
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5300
Aircraft flight hours:
15082
Circumstances:
Before the flight, the pilot did not obtain a weather briefing and departed without approval from company personnel. The airplane departed the airport about 0230 and climbed to 14,500 feet mean sea level. The pilot obtained visual flight rules (VFR) flight following services from air traffic control (ATC) personnel during the flight. While the airplane was en route, ATC personnel advised the pilot that an area of moderate precipitation was located about 15 miles ahead along the airplane’s flight path. The pilot acknowledged the transmission and was then directed to contact another controller. About 3 minutes later, the new controller advised the pilot of an area of moderate to extreme precipitation about 2 miles ahead of the airplane. The pilot responded that he could see the weather and asked the controller for a recommendation for a reroute. The controller indicated he didn’t have a recommendation, but finished by saying a turn to the west (a right turn) away from the weather would probably be better. The pilot responded that he would make a right turn. There was no further radio contact with the pilot. Flight track data indicated the airplane was in a right turn when radar contact was lost. A review of the radar data, available weather information, and airplane wreckage indicated the airplane flew through a heavy to extreme weather radar echo containing a thunderstorm and subsequently broke up in flight. Postaccident examination revealed no mechanical malfunctions or anomalies with the airframe and engines that would have precluded normal operation. During the VFR flight, the pilot was responsible for remaining in VFR conditions and staying clear of clouds. However, Federal Aviation Administration directives instruct ATC personnel to issue pertinent weather information to pilots, provide guidance to pilots to avoid weather (when requested), and plan ahead and be prepared to suggest alternate routes or altitudes when there are areas of significant weather. The weather advisories and warnings issued to the pilot by ATC were not in compliance with these directives. The delay in providing information to the pilot about the heavy and extreme weather made avoiding the thunderstorm more difficult and contributed to the accident.
Probable cause:
The pilot's inadvertent flight into thunderstorm activity, which resulted in the loss of airplane control and the subsequent exceedance of the airplane’s design limits and in-flight breakup. Contributing to the accident was the failure of air traffic control personnel to use available radar information to provide the pilot with a timely warning that he was about to encounter extreme precipitation and weather along his route of flight or to provide alternative routing to the pilot.
Final Report:

Crash of an Airbus A300B4-605R in Jeddah

Date & Time: May 1, 2012 at 1449 LT
Type of aircraft:
Operator:
Registration:
TC-OAG
Flight Type:
Survivors:
Yes
Schedule:
Madinah - Jeddah
MSN:
747
YOM:
1994
Flight number:
SV2865
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9200
Copilot / Total flying hours:
15957
Aircraft flight hours:
54832
Aircraft flight cycles:
18308
Circumstances:
On 1 May 2012, aircraft TC-OAG, an Airbus A300-605R was performing a commercial flight for Saudi Arabian Airlines (SVA) as SVA2865. SVA 2865 departed from Prince Mohammed Bin Abdulaziz International Airport (PMAI) Madinah at 08h50 en-route to the King Abdulaziz International Airport (KAIA) Jeddah, Kingdom of Saudi Arabia. SVA 2865 was on a positioning flight with 10 crew members and no passengers. No discrepancies were noted on this aircraft prior to departure from Madinah. The visibility at Jeddah was good with a few clouds present. During the initial ILS approach to runway 16 Right (16R), while at 8 nautical miles (nm) and 2600 feet (ft), the landing gear handle was lowered. Both main landing gear extended and locked down and, the nose gear doors opened but the nose landing gear did not lower. The Captain who was then the Pilot Monitoring (PM) took over the controls and carried out a missed approach. The First Officer (FO) became the Pilot Monitoring (PM). SVA 2865 was then given an area to the northeast of Jeddah to carry out attempts at lowering the nose gear. The flight crew attempted to manually free fall the nose landing gear at least ten (10) times. The nose landing gear would not lower into the locked position, but the nose gear doors remained open during all those attempts. As a precautionary measure, SVA 2865 performed a fly-by of runway 16R at 500 ft. The air traffic controller confirmed that the nose landing gear (NLG) was not down. SVA 2865 was vectored over the Red Sea to lower the fuel load, thus reducing the landing weight. During this period, the Fire & Rescue Services (FRS) at Jeddah foamed a portion of runway 16 Left (16L) between taxiway Kilo 5 (K5) and K2. The majority of the FRS vehicles were standing by at the junction of taxiways K4 and K3. SVA 2865 was vectored for an instrument approach for Runway 16L. The Auto Pilot and the Auto Throttle Systems were OFF. The surface winds were from 220° at 12 knots (kt), gusting to 19 kt and the temperature was + 37 Celsius (°C). The flight crew used the "Landing with Nose Landing Gear Abnormal" checklist ensuring the aircraft was properly prepared and configured for the approach, the before landing, the flare and the touchdown sequences, including when the aircraft stopped and the necessary procedures to secure the aircraft before evacuation. The aircraft landed on its main landing gear 4000 ft past the threshold of runway 16L. The nose of the aircraft was slowly lowered to the runway with the nose landing gear doors touching the runway within the foamed area 4500 ft from the end of runway 16L. The front of the fuselage then touched the runway within the last portion of foam, 3500 ft from the end of runway 16L. The nose area of the aircraft slid on the runway, where sparks were present until the aircraft came to a full stop 1500 ft prior to the end of runway 16L. As soon as the aircraft passed by the position of the FRS vehicles, the FRS vehicles gave chase to the aircraft and reached it within 30 seconds after it came to a full stop. Although there was no post-crash fire, the FRS personnel applied water and foam to the nose area of the aircraft. All of the crew members were evacuated from the aircraft by ladder provided by the FRS. The crew was taken to the airport clinic as a precautionary measure. All were released the same day. The accident occurred at 14h49 on runway 16L at the KAIA - Jeddah, Kingdom of Saudi Arabia.
Probable cause:
Cause related findings:
- The NLG up-lock contained a spring, Part Number GA71102 that was broken as a result of fatigue initiated at the third coil of the spring.
- The spring had been broken for a prolonged period of time, as noted by the spring linear wear marks on the outside area of the spring coils.
- Damage observed on the NLG up-lock resulted from hard contact with the broken spring during normal NLG operation.
- The fracture process of the spring was initiated at the third coil level. At least 6000 cycles of fatigue (number of striations) have been estimated by fatigue striation measurements. The crack on the spring started on the internal surface of the spring which was not shot peened.
- The normal and free fall extensions of the NLG failed due to a mechanical blockage created by the broken spring jammed against the cam.
Final Report:

Crash of a Cessna 208B Grand Caravan in Manaus: 1 killed

Date & Time: Feb 28, 2012 at 0715 LT
Type of aircraft:
Operator:
Registration:
PT-PTB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Manaus - Manaus
MSN:
208B-0766
YOM:
1999
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12000
Captain / Total hours on type:
158.00
Circumstances:
The pilot was performing a positioning flight from Manaus-Aeroclube de Flores Airport to the international Airport of Manaus-Eduardo Gomes. Shortly after takeoff from runway 11 which is 860 metres long, the single engine aircraft failed to gain sufficient altitude. It collided with an electric pole, stalled and crashed in a wooded area. The pilot, sole occupant, was killed.
Probable cause:
It was determined that the loss of control results from the fact that the flight controls were locked. Investigations show that the pilot failed to prepare the flight properly, that he did not follow the pre takeoff checklist and that he rushed the departure. It was reported that the operator was using since two years a control lock that had not been approved by the Civil Aviation Authority, and that no procedure had been put in place place concerning this lock system.
Final Report:

Crash of a Learjet 55 Longhorn in Brooksville

Date & Time: Feb 13, 2012 at 2200 LT
Type of aircraft:
Operator:
Registration:
N75LJ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Brooksville - Houston
MSN:
55-065
YOM:
1982
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from runway 27 at Brooksville-Hernando County Airport, control was lost. The aircraft veered off runway and came to rest. All three crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
NTSB did not proceed to any investigation regarding this incident.

Crash of a Rockwell Aero Commander 500B in Bartlesville

Date & Time: Jan 13, 2012 at 1930 LT
Operator:
Registration:
N524HW
Flight Type:
Survivors:
Yes
Schedule:
Kansas City - Cushing
MSN:
500-1533-191
YOM:
1965
Flight number:
CTL327
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8487
Captain / Total hours on type:
3477.00
Circumstances:
The pilot was en route on a positioning flight when the airplane’s right engine surged and experienced a partial loss of power. He adjusted the power and fuel mixture controls; however, a few seconds later, the engine surged again. The pilot noted that the fuel flow gauge was below 90 pounds, so he turned the right fuel pump on. The pilot then felt a surge on the left engine, so he performed the same actions he as did for the right engine. He believed that he had some sort of fuel starvation problem. The pilot then turned to an alternate airport, at which time both engines lost total power. The airplane impacted trees and terrain about 1.5 miles from the airport. The left side fuel tank was breached during the accident; however, there was no indication of a fuel leak, and about a gallon of fuel was recovered from the airplane during the wreckage retrieval. The company’s route coordinator reported that prior to the accident flight, the pilot checked the fuel gauge and said the airplane had 120 gallons of fuel. A review of the airplane’s flight history revealed that, following the flight immediately before the accident flight, the airplane was left with approximately 50 gallons of fuel on board; there was no record of the airplane having been refueled after that flight. Another company pilot reported the airplane fuel gauge had a unique trait in that, after the airplane’s electrical power has been turned off, the gauge will rise 40 to 60 gallons before returning to zero. When the master switch was turned to the battery position during an examination of another airplane belonging to the operator, the fuel gauge indicated approximately 100 gallons of fuel; however, when the master switch was turned to the off position, the fuel quantity on the gauge rose to 120 gallons, before dropping off scale, past empty. Additionally, the fuel cap was removed and fuel could be seen in the tank, but there was no way to visually verify the quantity of fuel in the tank.
Probable cause:
The total loss of engine power due to fuel exhaustion and the pilot’s inadequate preflight inspection, which did not correctly identify the airplane’s fuel quantity before departure.
Final Report:

Crash of a Rockwell Aero Commander 560F in Venice: 1 killed

Date & Time: Dec 26, 2011 at 1406 LT
Operator:
Registration:
N560WM
Flight Type:
Survivors:
No
Schedule:
Venice - LaFayette
MSN:
560-1305-58
YOM:
1964
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6000
Captain / Total hours on type:
1500.00
Aircraft flight hours:
5826
Circumstances:
The airplane departed and was climbing to an assigned altitude when the pilot informed an air traffic controller of a loss of engine power on the left engine. The pilot received radar vectors back to the departure airport and reported the airport in sight. There was no further communication with the controller. Review of radar data revealed that the airplane was about 825 feet from and 200 feet above the landing runway threshold. Seventeen seconds later, the airplane was at 100 feet above ground level and left of the intended landing runway. The last radar return was 5 seconds later, and the airplane was at 200 feet above ground level. A witness observed the airplane in the vicinity of landing runway. The airplane pitched straight up, stalled, spun to the left three times before it collided with the ground and caught fire. Postcrash examination of the airframe and flight controls revealed no anomalies. The left engine was disassembled and all connecting rods were intact except for the No.2 connecting rod. Metallugical examination of the connecting rod revealed that the bearing failed, most likely due to a progressive delamination of the bearing. Review of the airplane flight manual revealed a minimum of 300 feet of altitude is required to recover from power-off stalls with 7500 pounds at both forward and aft center of gravity. The stall speed with the landing gear and flaps up with 0 degree angle of bank is 83 miles per hour or 72 knots. The stall speed with the landing gear extended and the flaps down is 73 miles per hours or 63 knots.
Probable cause:
The pilot’s failure to maintain adequate airspeed during a single-engine approach, which resulted in an aerodynamic stall. Contributing to the accident was the total loss of power in the left engine due to a failed No. 2 connecting rod bearing.
Final Report: