Private

The single engine airplane departed Us-Khatyn on a flight to Suordakh, carrying five passengers, two pilots and a load consisting of 600 kilos of various goods. While cruising at an altitude of about 1,450 metres, the crew encountered moderate atmospheric turbulences and was unable to maintain the altitude. The aircraft lost height and crashed on the rocky slope of amountain located 15 km southeast from the Lake Siljan-Kuel, some 250 km from the destination. Two passengers were killed while five others occupants were injured. The aircraft was destroyed.

After flying one flight leg earlier in the day, the pilot flew to an intermediate stop on the way to his home base to purchase fuel. A surveillance video recording from the fueling airport showed the airplane land and taxi to the self-serve fuel pump where the engines were shut down for about 10 minutes while the airplane was fueled. The pilot then had difficulty starting both engines over several minutes. After the engines were running, the airplane taxied to the runway and did not appear to stop for an engine run-up. The pilot performed a rolling takeoff, and the airplane lifted off after a roll of about 2,100 ft, slightly more than half the available runway length. A passenger reported that after liftoff, at an altitude of about 50 to 100 ft above ground level (agl), both engines lost partial power and began “stuttering,” which continued for the remainder of the flight. He further reported that the engines did not stop, but they were “not producing full RPM.” The airplane drifted left of centerline, which a witness described as a left yawing motion. The pilot corrected the drift and flew the runway heading over the grass on the left side of the runway; however, the airplane would not climb. After crossing the end of the runway, the pilot pitched the airplane up to avoid obstacles. Automatic dependent surveillance-broadcast data indicated that the airplane climbed from about 20 to 120 ft agl in a gradual left turn. During this time the groundspeed decreased from about 80 knots to about 69 knots. The altitude then decreased to about 50 ft agl, the groundspeed decreased to about 66 knots, and the left turn decreased in radius until the recorded data ended about 100 ft west of the accident site. The airplane descended and
impacted a house. Witness descriptions of the airplane yawing to the left while over the runway and again during its final left turn suggest that the loss of engine power may not have been symmetric (that is, one engine may have suffered more of a loss than the other).

The pilots were conducting a visual flight rules cross-country flight with three passengers onboard. The preflight, departure, and cruise portions of the flight were uneventful. During the initial approach to the airport, the flight crew discussed having some difficulty visually acquiring the airport. They also discussed traffic in the area and were maneuvering around clouds, which may have increased the pilots' workload. As the approach continued, the airplane crossed a ridgeline at 710 ft above ground level (agl), which triggered a terrain awareness and warning system (TAWS) alert. Further, the flight crew made several comments about the airplane flying too fast and allowed the airspeed to increase well above the reference speed (Vref) for the approach. At 1535:57 (about 1 minute 52 seconds before landing), the pilot pulled back the throttles to idle, where they stayed for the remainder of the approach. In an attempt to slow the airplane for landing, the pilot partially extended the speedbrakes when the airplane was below 500 ft agl, which is prohibited in the airplane flight manual (AFM). Five seconds before touchdown, the airplane's descent rate was 1,500 ft per minute (fpm), which exceeded the maximum allowed for landing per the AFM of 600 fpm. When the airplane first touched down, it was traveling about 18 knots above Vref. The pilot did not extend the speedbrakes upon touchdown, which the landing checklist required, but instead attempted to deploy the thrust reversers immediately after touchdown, which was a later item on the landing checklist. However, the thrust reversers did not unlock because the airplane bounced and was airborne again before the command could be executed, which was consistent with system design and logic: the thrust reversers will not unlock until all three landing gear are on the ground. The airplane touched down four times total; on the third touchdown (after the second bounce), when all three landing gear contacted the runway, the thrust reversers unlocked as previously commanded during the first touchdown. Although the pilot subsequently advanced the throttles to idle, which would normally stow the thrust reversers, the airplane had bounced a third time and had already become airborne again before the thrust reversers could stow. When the airplane became airborne, the system logic cut hydraulic power to the thrust reverser actuators; thus the reversers would not stow. The thrust reversers were subsequently pulled open due to the aerodynamic forces. The pilot attempted to go around by advancing the throttles when the airplane was airborne. However, the electronic engine controls prevented the increase in engine power because the thrust reversers were not stowed. When the airplane touched down the fourth and final time, the pilot attempted to land straight ahead on the runway; the airplane touched down hard and the right main landing gear then collapsed under the wing. The airplane departed the paved surface and came to rest about 600 ft beyond the runway threshold. The passengers and crew eventually evacuated the airplane through the main cabin door, and the airplane was destroyed in a postaccident fire. A postaccident examination of the airplane systems, structure, powerplants, and landing gear revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation. The airplane's approach was unstabilized: its airspeed during the approach and landing well exceeded Vref and its descent rate exceeded the maximum allowed for landing just seconds before touchdown. Both the pilot and copilot commented on the airplane's high speed several times during the approach. During short final, the pilot asked the copilot if he should go around, and the copilot responded, "no." Although the copilot was the director of operations for the flight department and the direct supervisor of the pilot, the pilot stated that the copilot's position did not influence his decisions as pilot-in-command nor did it diminish his command authority. Neither the pilot nor copilot called for a go-around before landing despite awareness that the approach was unstabilized. As the airplane touched down, the pilot failed to follow the AFM guidance and used the thrust reversers before the speedbrakes. According to the airplane manufacturer's calculations, the airplane could have stopped within the length of runway available if the airplane had not bounced and the speedbrakes and wheel brakes were used at the point of the first touchdown. After the third touchdown, when the airplane became airborne again, the pilot attempted a go-around; the AFM prohibits touch-and-go landings after the thrust reversers are deployed. It is critical for pilots to know the point at which they should not attempt a go-around; a committed-to-stop (CTS) point is the point at which a go-around or rejected landing procedure will not be initiated and the only option will be bringing the aircraft to a stop. Establishing a CTS point eliminates the ambiguity for pilots making decisions during time-critical events. The FAA issued Information for Operators 17009, "Committed-toStop Point on Landings," to inform operators and pilots about the importance of establishing a CTS point; however, the director of operations was not aware of the concept of a CTS point during landing.

On final approach to Los Ángeles-María Dolores Airport, the airplane crashed in a wooded area located about 412 metres short of runway 18, bursting into flames. The aircraft was destroyed by impact forces and a post crash fire and the pilot, sole on board, was killed. The accident occurred 19 minutes after sunset.

En route from Vancouver to Pender Harbour, the pilot encountered engine problems and elected to ditch the aircraft about three miles off Sechelt. All three occupants were able to evacuate the cabin before the aircraft sank and was lost. All three occupants were rescued.

The pilot was in cruise flight at an altitude of 19,000 feet mean sea level (msl) for about 1 hour and 10 minutes on an easterly heading when he requested a diversion from his filed destination to an airport along his route of flight to utilize a restroom. Two miles west of his amended destination at 12,000 ft msl, the pilot advised the controller that he had a “fuel emergency light" and wanted to expedite the approach. The controller acknowledged the low fuel warning and cleared the airplane to descend from its assigned altitude. Instead of conducting the descent over the airport, the airplane continued its easterly heading past the airport for nearly 8 miles before reversing course. After reversing course, instead of assuming a direct heading back to the airport, the pilot assumed a parallel reciprocal track and didn’t turn for the airport until the airplane intercepted the extended centerline of the landing runway. The pilot informed the controller that he was unable to make it to the airport and performed a forced landing less than 1 mile from the landing runway. Both fuel tanks were breached during the accident sequence, and detailed postaccident inspections of the airplane’s fuel system revealed no leaks in either the supply or return sides of the system. A computer tomography scan and flow-testing of the engine-driven fuel pump revealed no leaks or evidence of fuel leakage. The engine ran successfully in a test cell. Data recovered from an engine and fuel monitoring system revealed that, during the two flights before the accident flight, the reduction in fuel quantity was consistent with the fuel consumption rates depicted at the respective power settings (climb, cruise, etc). During the accident flight, the reduction in fuel quantity was consistent with the indicated fuel flow throughout the climb; however, the fuel quantity continued to reduce at a rate consistent with a climb power setting even after engine power was reduced, and the fuel flow indicated a rate consistent with a cruise engine power setting. The data also showed that the indicated fuel quantity in the left and right tanks reached 0 gallons within about 10 minutes of each other, and shortly before the accident. Given this information, it is likely that the engine lost power due to an exhaustion of the available fuel supply; however, based on available data and findings of the fuel system and component examinations, the disparate rates of indicated fuel flow and fuel quantity reduction could not be explained.

While approaching class B airspace, the airline transport pilot was in communication with a controller who later stated that the pilot's speech was slurred, and the controller repeatedly asked if the oxygen system on the airplane was working properly. As the airplane approached a nearby airport, about 85 miles from his destination airport, the pilot stated he had the airport in sight and repeatedly requested a visual approach. The controller instructed the pilot to continue his flight to his destination, in a southwest direction. As the controller attempted to maintain communications, the pilot dropped off radar shortly after passing the nearby airport and subsequently landed at the nearby airport, which was not his destination airport. According to a surveillance video and impact marks on the runway, the airplane landed hard about halfway down the runway and slid to a stop on the left side of the runway. The airplane fuselage and wings were mostly consumed by postimpact fire. After authorities arrived onsite, the pilot was arrested for operating an aircraft under the influence of alcohol. The pilot was found to have a blood alcohol level of .288, which likely contributed to the pilot landing at the incorrect airport and his subsequent loss of airplane control during landing.

At approximately 1000LT on 12 July 2019, a private de Havilland DHC-2 Mk. 1 Beaver floatplane (registration C‑GRHF, serial number 1123) took off from the St-Mathias Water Aerodrome (CSV9), Quebec, with only the pilot on board, for a series of visual flight rules (VFR) flights. The aircraft landed at approximately 1130 on Désert Lake in La Minerve, Quebec, and came alongside a private dock where 3 individuals were waiting to board and fly to a fishing lodge. Once the baggage was stowed on the aircraft, the pilot provided a safety briefing to the passengers, who were all wearing a personal flotation device. The aircraft took off from Désert Lake at approximately 1215, bound for the Barrage Gouin Water Aerodrome (CTP3), Quebec, where the aircraft was scheduled to be refuelled. The aircraft landed at approximately 1430. Once the refuelling was complete, the aircraft took off once again around 1528, headed northwest to Weakwaten Lake, Quebec, where the fishing lodge was located. After approximately 48 minutes of flight, at around 1616, the aircraft collided with trees and struck the ground. There was no post-impact fire. The emergency locator transmitter was activated by the force of impact, and began transmitting a signal on frequency 121.5 MHz. This signal was detected by the flight crew of a commercial airliner at 1705 and reported to air traffic services. At 1850, the Joint Rescue Coordination Centre in Trenton dispatched a CC130 Hercules aircraft to try to locate the distress signal. The occurrence aircraft was found in a densely wooded area at 2032. Two search and rescue technicians were parachuted to rescue the aircraft occupants. Three of the 4 occupants received fatal injuries. The survivor was evacuated and transported to the hospital in Chibougamau, Quebec.

The pilot, co-pilot, and eight passengers departed on a cross-country flight in the twin-engine airplane. One witness located on the ramp at the airport reported that the airplane sounded underpowered immediately after takeoff “like it was at a reduced power setting.” Another witness stated that the airplane sounded like it did not have sufficient power to takeoff. A third witness described the rotation as “steep,” and other witnesses reported thinking that the airplane was performing aerobatics. Digital video from multiple cameras both on and off the airport showed the airplane roll to its left before reaching a maximum altitude of 100 ft above ground level; it then descended and impacted an airport hangar in an inverted attitude about 17 seconds after takeoff and an explosion immediately followed. After breaching a closed roll-up garage door, the airplane came to rest on its right side outside of the hangar and was immediately involved in a postimpact fire. Sound spectrum analysis of data from the airplane’s cockpit voice recorder (CVR) estimated that the propeller speeds were at takeoff power (1,714 to 1,728 rpm) at liftoff. About 7 seconds later, the propeller speeds diverged, with the left propeller speed decreasing to about 1,688 rpm and the right propeller speed decreasing to 1,707 rpm. Based on the airplane’s estimated calibrated airspeed of about 110 knots and the propeller rpm when the speeds diverged, the estimated thrust in the left engine decreased to near 0 while the right engine continued operating at slightly less than maximum takeoff power. Analysis of available data estimated that, 2 seconds after the propeller speed deviation, the airplane’s sideslip angle was nearly 20°. During the first 5 seconds after the propeller speed deviation, the airplane’s roll rate was about 5° per second to the left; its roll rate then rapidly increased to more than 60° per second before the airplane rolled inverted. Witness marks on the left engine and propeller, the reduction in propeller speed, and the airplane’s roll to the left suggest that the airplane most likely experienced a loss of thrust in the left engine shortly after takeoff. The airplane manufacturer’s engine-out procedure during takeoff instructed that the landing gear should be retracted once a positive rate of climb is established, and the propeller of the inoperative engine should be feathered. Right rudder should also be applied to balance the yawing moment imparted by a thrust reduction in the left engine. Examination of the wreckage found both main landing gear in a position consistent with being extended and the left propeller was unfeathered. The condition of the wreckage precluded determining whether the autofeather system was armed or activated during the accident flight. Thus, the pilot failed to properly configure the airplane once the left engine thrust was reduced. Calculations based on the airplane’s sideslip angle shortly after the propeller speed deviation determined that the thrust asymmetry alone was insufficient to produce the sideslip angle. Based on an evaluation of thrust estimates provided by the propeller manufacturer and performance data provided by the airplane manufacturer, it is likely that the pilot applied left rudder, the opposite input needed to maintain lateral control, before applying right rudder seconds later. However, by then, the airplane’s roll rate was increasing too rapidly, and its altitude was too low to recover. The data support that it would have been possible to maintain directional and lateral control of the airplane after the thrust reduction in the left engine if the pilot had commanded right rudder initially rather than left rudder. The pilot’s confused reaction to the airplane’s performance shortly after takeoff supports the possibility that he was startled by the stall warning that followed the propeller speed divergence, which may have prompted his initial, improper rudder input. In addition, the NTSB’s investigation estimated that rotation occurred before the airplane had attained Vr (rotation speed), which decreased the margin to the minimum controllable airspeed and likely lessened the amount of time available for the pilot to properly react to the reduction in thrust and maintain airplane control. Although the airplane was slightly over its maximum takeoff weight at departure, its rate of climb was near what would be expected at maximum weight in the weather conditions on the day of the accident (even with the extended landing gear adding drag); therefore, the weight exceedance likely was not a factor in the accident. Engine and propeller examinations and functional evaluations of the engine and propeller controls found no condition that would have prevented normal operation; evidence of operation in both engines at impact was found. Absent evidence of an engine malfunction, the investigation considered whether the left engine’s thrust reduction was caused by other means, such as uncommanded throttle movement due to an insufficient friction setting of the airplane’s power lever friction locks. Given the lack of callouts for checklists on the CVR and the pilot’s consistently reported history of not using checklists, it is possible that he did not check or adjust the setting of the power lever friction locks before the accident flight, which led to uncommanded movement of the throttle. Although the co-pilot reportedly had flown with the pilot many times previously and was familiar with the B-300, he was not type rated in the airplane and was not allowed by the pilot to operate the flight controls when passengers were on board. Therefore, the co-pilot may not have checked or adjusted the friction setting before the flight’s departure. Although the investigation considered inadequate friction setting the most likely cause of the thrust reduction in the left engine, other circumstances, such as a malfunction within the throttle control system, could also result in loss of engine thrust. However, heavy fire and impact damage to the throttle control system components, including the power quadrant and cockpit control lever friction components, precluded determining the position of the throttle levers at the time of the loss of thrust or the friction setting during the accident flight. Thus, the reason for the reduction in thrust could not be determined definitively. In addition to a lack of callouts for checklists on the CVR, the pilots did not discuss any emergency procedures. As a result, they did not have a shared understanding of how to respond to the emergency of losing thrust in an engine during takeoff. Although the co-pilot verbally identified the loss of the left engine in response to the pilot’s confused reaction to the airplane’s performance shortly after takeoff, it is likely the co-pilot did not initiate any corrective flight control inputs, possibly due to the pilot’s established practice of being the sole operator of flight controls when passengers were on board. The investigation considered whether fatigue from inadequately treated obstructive sleep apnea contributed to the pilot’s response to the emergency; however, the extent of any fatigue could not be determined from the available evidence. In addition, no evidence indicates that the pilot’s medical conditions or their treatment were factors in the accident. In summary, the available evidence indicates that the pilot improperly responded to the loss of thrust in the left engine by initially commanding a left rudder input and did not retract the landing gear or feather the left propeller, which was not consistent with the airplane manufacturer’s engine out procedure during takeoff. It would have been possible to maintain directional and lateral control of the airplane after the thrust reduction in the left engine if right rudder had been commanded initially rather than left rudder. It is possible that the pilot’s reported habit of not using checklists resulted in his not checking or adjusting the power lever friction locks as specified in the airplane manufacturer’s checklists. However, fire and impact damage precluded determining the position of the power levers or friction setting during the flight.

During a cross-country flight, the pilot initiated a descent to his intended destination. During the descent, the pilot informed air traffic control (ATC) that he could not retard power on the right engine. Later in the descent, the pilot decided to shut down the right engine. The pilot communicated his desire to land at the nearest airport to ATC, and ATC provided the pilot with the clearance to divert. Radar data showed the airplane in a steady descent toward the airport. When the airplane was at an altitude of about 2,500 ft mean sea level, the pilot contacted ATC and stated that he was trying to get the airplane under control; radar data showed the airplane in a 360° right turn at the time. The pilot contacted ATC again and stated that he was going to land on a highway. No further transmissions were received from the pilot. After the right turn, the airplane continued in a descent through 1,300 ft mean sea level, at which point radar contact was lost. A witness saw the airplane and stated that the airplane was low and slow but appeared to be in stable flight with both propellers spinning. She did not see any smoke coming from the airplane. She saw the airplane flying northeast to southwest when it suddenly descended nose first into the ground. The airplane impacted a gravel road adjacent to a 100-fttall grain silo about 1 mile from the highway and about 3.3 miles from the airport.