Crash of a Beechcraft F90 King Air in Midland

Date & Time: Dec 2, 2011 at 0810 LT
Type of aircraft:
Registration:
N90QL
Flight Type:
Survivors:
Yes
Site:
Schedule:
Wharton - Midland
MSN:
LA-2
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4600
Captain / Total hours on type:
25.00
Aircraft flight hours:
8253
Circumstances:
The aircraft collided with terrain while on an instrument approach to the Midland Airpark (MDD), near Midland, Texas. The commercial pilot, who was the sole occupant, sustained serious injuries. The airplane was registered to and operated by Quality Lease Air Services LLC., under the provisions of 14 Code of Federal Regulations Part 91 as a positioning flight. Instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan had been filed for the cross-country flight. The flight originated from the Wharton Regional Airport (ARM), Wharton, Texas, about 0626. The pilot obtained a weather briefing for the flight to MDD. The briefing forecasted light freezing drizzle for the proposed time and route of flight. While on approach to MDD, the airplane was experiencing an accumulation of moderate to severe icing and the pilot stated that he had all the deicing equipment on. According to the pilot, the autopilot was flying the airplane to a navigational fix called JIBEM. He switched the autopilot to heading mode and flew to the final approach fix called WAVOK. He deployed the deice boots twice before approaching WAVOK. An Airport Traffic Control Tower (ATCT) controller informed the pilot, that according to radar, he appeared to be flying to JIBEM. The pilot responded that he was correcting back and there was something wrong with the GPS. The controller canceled the airplane's approach clearance and the controller issued the pilot a turning and climbing clearance to fly for another approach. The pilot stated that his copilot's window iced up at that point. The pilot was vectored for and was cleared for another approach attempt. The pilot said that his window was "halfway iced up." About two minutes after being cleared for the second approach, the controller advised the pilot that the airplane appeared to be "about a half mile south of the course." The pilot responded, "Yep ya uh I got it." The pilot was given heading and climb instructions in case of a missed approach and was subsequently cleared to change to an advisory frequency. The pilot responded with, "Good day." The pilot had configured the aircraft with approach flaps and extended the landing gear prior to reaching the final approach fix. The pilot stated the aircraft remained in this configuration and he did not retract the gear and flaps. The pilot stated that he descended to 3,300 feet and was just under the cloud deck where he was looking for the runway. The pilot's accident report, in part, said: Everything was flying smooth until I accelerated throttles from about halfway to about three quarters. At this point I lost roll control and the airplane rolled approximately 90 degrees to the left. I disengaged autopilot and began to turn the yoke to the right and holding steady. It was slow to respond and when I thought that I had it leveled off the airplane continued to roll approximately 90 degrees to the right. At this time I was turning the yoke back to the left and pulling back to level it off, but it continued to roll to the left again. I was turning the yoke to the right again as I continued to pull back and the airplane rolled level, and the stall warning horn came on seconds before impact on the ground. The pilot stated he maintained a target airspeed speed of 120 knots on approach and 100 knots while on final approach. He stated he was close to 80 knots when the aircraft was in the 90° right bank. Witnesses in the area observed the airplane flying. A witness stated that the airplane's wings were "rocking." Other witnesses indicated that the airplane banked to the left and then nosed down. The airplane impacted a residential house, approximately 1 mile from the approach end of runway 25, and a post crash fire ensued. The pilot was able to exit the airplane and there were no reported ground injuries.
Probable cause:
The pilot's failure to maintain the recommended airspeed for icing conditions and his subsequent loss of airplane control while flying the airplane under autopilot control in severe
icing conditions, contrary to the airplane's handbook. Contributing to the accident was the pilot's failure to divert from an area of severe icing. Also contributing to the accident was the lack of an advisory for potential hazardous icing conditions over the destination area.
Final Report:

Crash of a Cessna 207 Skywagon in Chuathbaluk: 1 killed

Date & Time: Nov 29, 2011 at 1925 LT
Operator:
Registration:
N1673U
Flight Type:
Survivors:
No
Schedule:
Aniak - Chuathbaluk
MSN:
207-0273
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10000
Aircraft flight hours:
16889
Circumstances:
The pilot departed on a positioning flight during dark night, marginal visual meteorological conditions. A witness, who was waiting for the airplane at the destination airport, stated that shortly after the pilot-controlled airport lighting activated, a snow squall passed over the airport, greatly reducing the visibility. The accident airplane never arrived at its destination, and a search was initiated. The airplane’s fragmented wreckage was discovered early the next morning in a wooded area, about 2 miles from its destination. A review of archived automatic dependent surveillance-broadcast (ADS-B) data received from the accident airplane showed that the pilot departed, and the airplane climbed to about 700 feet above ground level. The airplane remained at about 700 feet for about 3 minutes, and then entered a shallow right-hand descending turn, until it impacted terrain. On-site examination of the airplane and engine revealed no preaccident mechanical anomalies that would have precluded normal operation. The cockpit area was extensively fragmented, thus the validity of any postaccident cockpit and instrument findings was unreliable. Likewise, structural damage to the airframe precluded the determination of flight control continuity. A postaccident examination of the engine and recovered components did not disclose any evidence of a mechanical malfunction. Given the witness account of worsening weather conditions at the airport just before the accident and the lack of mechanical anomalies with the airplane, it is likely that the accident pilot encountered heavy snow and instrument meteorological conditions while approaching the airport. It is also likely that the pilot became spatially disoriented during the unexpected weather encounter and subsequently collided with terrain.
Probable cause:
The pilot’s loss of situational awareness after an inadvertent encounter with instrument meteorological conditions, which resulted in an in-flight collision with tree-covered terrain.
Final Report:

Crash of a Dassault Falcon 10 in Toronto

Date & Time: Jun 17, 2011 at 1506 LT
Type of aircraft:
Operator:
Registration:
C-GRIS
Flight Type:
Survivors:
Yes
Schedule:
Toronto-Lester Bowles Pearson - Toronto-Buttonville
MSN:
02
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
7100
Copilot / Total hours on type:
475
Aircraft flight hours:
12697
Circumstances:
Aircraft was on a flight from Toronto-Lester B. Pearson International Airport to Toronto-Buttonville Municipal Airport, Ontario, with 2 pilots on board. Air traffic control cleared the aircraft for a contact approach to Runway 33. During the left turn on to final, the aircraft overshot the runway centerline. The pilot then compensated with a tight turn to the right to line up with the runway heading and touched down just beyond the threshold markings. Immediately after touchdown, the aircraft exited the runway to the right, and continued through the infield and the adjacent taxiway Bravo, striking a runway/taxiway identification sign, but avoiding aircraft that were parked on the apron. The aircraft came to a stop on the infield before Runway 21/03. The aircraft remained upright, and the landing gear did not collapse. The aircraft sustained substantial damage. There was no fire, and the flight crew was not injured. The Toronto-Buttonville tower controller observed the event as it progressed and immediately called for emergency vehicles from the nearby municipality. The accident occurred at 1506 Eastern Daylight Time.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The crew flew an unstabilized approach with excessive airspeed.
2. The lack of adherence to company standard operating procedures and crew resource management, as well as the non-completion of checklist items by the flight crew contributed to the occurrence.
3. The captain’s commitment to landing or lack of understanding of the degree of instability of the flight path likely influenced the decision not to follow the aural GPWS alerts and the missed approach call from the first officer.
4. The non-standard wording and the tone used by the first officer were insufficient to deter the captain from continuing the approach.
5. At touchdown, directional control was lost, and the aircraft veered off the runway with sufficient speed to prevent any attempts to regain control.
Finding as to Risk
1. Companies which do not have ground proximity warning system procedures in their standard operating procedures may place crews and passengers at risk in the event that a warning is received.
Final Report:

Mishap of a Beechcraft A100 King Air in Blountville

Date & Time: Jun 15, 2011 at 1405 LT
Type of aircraft:
Operator:
Registration:
N15L
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Bridgewater - Wichita
MSN:
B-212
YOM:
1974
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4837
Captain / Total hours on type:
87.00
Copilot / Total flying hours:
900
Copilot / Total hours on type:
2
Aircraft flight hours:
16170
Circumstances:
The airplane was flying in instrument meteorological conditions at flight level 200 (about 20,000 feet), and a large area of thunderstorm activity was located to the northwest. About 20 miles from the thunderstorm activity, the airplane began to encounter moderate turbulence and severe icing conditions. The pilot deviated to the south; however, the turbulence increased, and the airplane entered an uncommanded left roll and dive. The autopilot disengaged, and the pilot's attitude indicator dropped. The pilot leveled the airplane at an altitude of 8,000 feet and landed without further incident. Subsequent examination revealed that one-third of the outboard left elevator separated in flight and that the empennage was substantially damaged. Meteorological and radar data revealed the airplane entered an area of rapidly intensifying convective activity, which developed along the airplane's flight path, and likely encountered convectively-induced turbulence with a high probability of significant icing. The effect of icing conditions on the initiation of the upset could not be determined; however, airframe structural icing adversely affects an airplane's performance and can result in a loss of control.
Probable cause:
An encounter with convectively-induced turbulence and icing, which resulted in an in-flight upset and a loss of airplane control.
Final Report:

Crash of a Douglas DC-6BF in Cold Bay

Date & Time: Jun 12, 2011 at 1455 LT
Type of aircraft:
Operator:
Registration:
N600UA
Flight Type:
Survivors:
Yes
Schedule:
Togiak - Cold Bay
MSN:
44894/651
YOM:
1956
Location:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10000
Captain / Total hours on type:
4000.00
Aircraft flight hours:
37334
Circumstances:
According to the captain, while on approach to land, he distracted the crew by pointing out a boat dock. He said that after touchdown, he realized that the landing gear was not extended, and the airplane slid on its belly, sustaining substantial damage to the underside of the fuselage. He said that the crew did not hear the landing gear retracted warning horn, and the accident could have been prevented if he had not distracted the crew. The captain reported that there were no mechanical malfunctions with the airplane that would have precluded normal operation.
Probable cause:
The flight crew's failure to extend the landing gear, which resulted in an inadvertent wheels up landing. Contributing to the accident was the flight crew's diverted attention.
Final Report:

Crash of a BAe 125-700A off Loreto

Date & Time: May 5, 2011 at 1155 LT
Type of aircraft:
Operator:
Registration:
N829SE
Flight Type:
Survivors:
Yes
MSN:
257095
YOM:
1980
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Loreto Airport, the crew encountered technical problems and elected to return. On final approach over the Gulf of California, in a gear up configuration, the aircraft struck the water surface and came to rest into the sea close to the shore, few dozen metres short of runway 34 threshold. Both pilots escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Raytheon 390 Premier IA in Samedan: 2 killed

Date & Time: Dec 19, 2010 at 1502 LT
Type of aircraft:
Operator:
Registration:
D-IAYL
Flight Type:
Survivors:
No
Schedule:
Zagreb - Samedan
MSN:
RB-249
YOM:
2008
Flight number:
GQA631V
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4306
Captain / Total hours on type:
244.00
Copilot / Total flying hours:
1071
Copilot / Total hours on type:
567
Aircraft flight hours:
1047
Aircraft flight cycles:
820
Circumstances:
After an uneventful flight, the IFR flight plan was cancelled at 13:53:09 UTC and the flight continued under visual flight rules. When the crew were requested at 13:54:01 UTC by the Zurich sector south air traffic controller (ATCO) to switch to the Samedan Information frequency, they wanted to remain on the frequency for a further two minutes. The aircraft was on a south-westerly heading, approx. 5 km south of Zernez, when the crew informed the ATCO at 13:57:12 UTC that they would now change frequency. After first contact with Samedan Information, when the crew reported that they were ten miles before the threshold of runway 21, the aircraft was in fact approximately eight miles north-east of the threshold of runway 21. When at 13:58:40 UTC the crew of a Piaggio 180 asked the flight information service officer (FISO) of Samedan Information about the weather as follows: "(…) and the condition for inbound still ok?", the crew of D-IAYL responded at 13:58:46 UTC, before the FISO was able to answer: "Yes, for the moment good condition (…)". D-IAYL was slightly north-east of Zuoz when the crew asked the FISO about the weather over the aerodrome. D-IAYL was over Madulein when at 13:59:46 UTC the FISO informed the crew that they could land at their own discretion. Immediately afterwards, the crew increased their rate of descent to over 2200 ft/min and maintained this until a final recorded radio altitude (RA) of just under 250 ft, which they reached over the threshold of runway 21. The crew then initiated a climb to an RA of approximately 600 ft, turned a little to the left and then flew parallel to the runway centre line. The landing gear was extended and the flaps were set to 20 degrees with a high probability. At the end of runway 21 the crew initiated a right turn onto the downwind leg, during which they reached a bank angle of 55 degrees; in the process their speed increased from 110 to 130 knots. Abeam the threshold of runway 21, the crew turned onto the final approach on runway 21. The bank angle in this turn reached up to 62 degrees, without the speed being noticeably increased. The aircraft then turned upside down and crashed almost vertically. Both pilots suffered fatal injuries on impact. A power line was severed, causing a power failure in the Upper Engadine valley. An explosion-type fire broke out. The aircraft was destroyed.
Probable cause:
The accident is attributable to the fact that the aircraft collided with the ground, because control of the aircraft was lost due to a stall.
- The following causal factors have been identified for the accident:
- The crew continued the approach under weather conditions that no longer permitted safe control of the aircraft
- The crew performed a risky manoeuvre close to ground instead of a consistent missed approach procedure
- The fact that the flight information service did not consistently communicate to the crew relevant weather information from another aircraft was a contributing factor to the genesis of the accident
As a systemic factor that contributed to the genesis of the accident, the following point was identified:
- The visibility and cloud bases determined on Samedan airport were not representative for an approach from Zernez, because they did not correspond to the actual conditions in the approach sector.
Final Report:

Crash of a Learjet 25B in Portland

Date & Time: Nov 17, 2010 at 1553 LT
Type of aircraft:
Operator:
Registration:
N25PJ
Flight Type:
Survivors:
Yes
Schedule:
Boise - Portland
MSN:
25-111
YOM:
1973
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6000
Copilot / Total flying hours:
652
Copilot / Total hours on type:
10
Aircraft flight hours:
8453
Circumstances:
The airplane was flying a VOR/DME-C approach that was on an oblique course about 40 degrees to the runway 30 centerline; the wind conditions produced an 8-knot tailwind for landing on runway 30. Despite the tailwind, the captain elected to land on the 6,600-foot-long runway instead of circling to land with a headwind. Moderate to heavy rain had been falling for the past hour, and the runway was wet. The crew said that the airplane was flown at the prescribed airspeed (Vref) for its weight with the wing flaps fully extended on final approach, and that they touched down just beyond the touchdown zone. The captain said that he extended the wings' spoilers immediately after touchdown. He tested the brakes and noted normal brake pedal pressure. However, during rollout, he noted a lack of deceleration and applied more brake pressure, with no discernible deceleration. The airplane's optional thrust reversers had been previously rendered non-operational by company maintenance personnel and were therefore not functional. The captain stated that he thought about performing a go-around but believed that insufficient runway remained to ensure a safe takeoff. While trying to stop, he did not activate the emergency brakes (which would have bypassed the anti-skid system) because he thought that there was insufficient time, and he was preoccupied with maintaining control of the airplane. He asked the first officer to apply braking with him, and together the crew continued applying brake pedal pressure; however, when the airplane was about 2,000 feet from the runway's end, it was still traveling about 100 knots. As the airplane rolled off the departure end on runway 30, which was wet, both pilots estimated that the airplane was still travelling between 85 and 90 knots. The airplane traveled 618 feet through a rain-soaked grassy runway safety area before encountering a drainage swale that collapsed the nose gear. As the airplane was traversing the soft, wet field, its wheels partially sank into the ground. While decelerating, soil impacted the landing gear wheels and struts where wiring to the antiskid brake system was located. The crew said that there were no indications on any cockpit annunciator light of a system failure or malfunction; however, after the airplane came to a stop they observed that the annunciator light associated with the antiskid system for the No. 2 wheel was illuminated (indicating a system failure). The other three annunciator lights (one for each wheel) were not illuminated. During the approach, the first officer had completed the landing data card by using a company-developed quick reference card. The quick reference card’s chart, which contained some data consistent with the landing charts in the Airplane Flight Manual (AFM), did not have correction factors for tailwind conditions, whereas the charts in the AFM do contain corrective factors for tailwind conditions. The landing data prepared by the first officer indicated that 3,240 feet was required to stop the airplane on a dry runway in zero wind conditions, with a wet correction factor increasing stopping distance to 4,538 feet. The Vref speed was listed as 127 knots for their landing weight of 11,000 pounds, and the first officer’s verbal and written statements noted that they crossed the runway threshold at 125 knots. During the investigation, Bombardier Lear calculated the wet stopping distances with an 8-knot tailwind as 5,110 feet. The touchdown zone for runway 30 is 1,000 feet from the approach end. The crew’s estimate of their touchdown location on the runway is about 1,200 feet from the approach end, yielding a remaining runway of 5,400 feet. On-duty controllers in the tower watched the landing and said that the airplane touched down in front of the tower at a taxiway intersection that is 1,881 feet from the approach end, which would leave about 4,520 feet of runway to stop the airplane. The controllers observed water spraying off the airplane’s main landing gear just after touchdown. Post accident testing indicated that the brake system, including the brake wear, was within limits, with no anomalies found. No evidence of tire failure was noted. The antiskid system was removed from the airplane for functional tests. The control box and the left and right control valves tested within specifications. The four wheel speed sensors met the electrical resistance specification. For units 1, 2 and 3, the output voltages exceeded the minimum specified voltages for each of the listed frequencies. Unit 4 was frozen and could not be rotated and thus could not be tested. Sensors 1 and 2 exceeded the specified 15% maximum to minimum voltage variation limit. Sensor 3 was within the limit and 4 could not be tested. Based on all the evidence, it is likely that the airplane touched down on the water-contaminated runway beyond the touchdown zone, at a point with about 600 feet less remaining runway than the performance charts indicated that the airplane required for the wet conditions. Since a reverted rubber hydroplaning condition typically follows an encounter with dynamic hydroplaning, the reverted rubber signatures on the No. 2 tire indicate that the airplane encountered dynamic hydroplaning shortly after touchdown, and the left main gear wheel speed sensor anomalies allowed the left tires to progress to reverted rubber hydroplaning. This, along with postaccident testing, indicates that the anti-skid system was not performing optimally and, in concert with the hydroplaning conditions, significantly contributed to the lack of deceleration during the braking attempts.
Probable cause:
The failure of the flight crew to stop the airplane on the runway due to the flying pilot’s failure to attain the proper touchdown point. Contributing to the accident was an anti-skid system that was not performing optimally, which allowed the airplane to encounter reverted rubber hydroplaning, and the company-developed quick reference landing distance chart that did not provide correction factors related to tailwind conditions.
Final Report:

Crash of a Learjet 55C Longhorn in Rio de Janeiro

Date & Time: Aug 12, 2010 at 0926 LT
Type of aircraft:
Operator:
Registration:
PT-LXO
Flight Type:
Survivors:
Yes
Schedule:
Rio de Janeiro - Rio de Janeiro
MSN:
55C-135
YOM:
1988
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17000
Captain / Total hours on type:
500.00
Copilot / Total flying hours:
2800
Copilot / Total hours on type:
49
Circumstances:
The aircraft departed Rio de Janeiro-Santos Dumont Airport on a positioning flight to Rio de Janeiro-Galeão-Antonio Carlos Jobim Airport with three crew members on board. Two minutes after takeoff, while in initial climb, the electrical system of the aircraft suffered a voltage power loss. Several instruments lost their functionality such as TCAS, altimeters and airspeed indicator. In good weather conditions, the captain decided to return to Santos Dumont Airport but did not declare any emergency. After being cleared to descend to 3,000 feet, the crew lost all radio communications. On final approach to runway 02R, most of the instruments failed but the crew continued the approach. The aircraft passed over the runway threshold with an excessive speed of 25 knots and after touchdown, the crew started the braking procedure but the spoilers and the reversers could not be activated. Unable to stop within the remaining distance, the aircraft overran and came to rest in the Guanabara Bay. All three crew members escaped uninjured while the aircraft was damaged repair.
Probable cause:
An error in the assembly was detected in the left generator, which interfered with the D+ terminal signal sent to the voltage regulator. Due to a voltage drop, some of the instruments lost their functionality. The following contributing factors were identified:
- The crew did not follow the emergency procedures;
- The crew decided to return to land at Santos Dumont Airport without considering that the runway length was less than the length required for an emergency landing;
- The speed of the aircraft while passing over the runway threshold was 25 knots above the reference speed;
- The pilots were unable to engage the spoilers or the thrust reversers;
- Wrong attitude from the captain;
- Overconfidence of the crew;
- Emotional load due to an emergency situation;
- Poor assessment of the situation due to high stress associated with decreased situational awareness;
- Poor crew coordination;
- Lack of crew resource management;
- Poor judgment;
- Lack of procedures on the part of the operator.
Final Report:

Ground accident of a Boeing 747-306M in Cairo

Date & Time: Jul 17, 2010 at 0730 LT
Type of aircraft:
Operator:
Registration:
HS-VAC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cairo - Jeddah
MSN:
23056/587
YOM:
1983
Flight number:
SV9302
Country:
Region:
Crew on board:
22
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a positioning flight from Cairo to Jeddah. During the takeoff roll, the engine n°4 experienced an uncontained failure. The takeoff procedure was rejected and the aircraft came to a halt and later transferred to a hangar. All 22 crew members escaped uninjured while the aircraft was considered as damaged beyond repair.
Probable cause:
Failure of the n°4 engine during takeoff following the failure of the high pressure compressor.