Crash of a Beechcraft C90GTi King Air in Vila Rica

Date & Time: Sep 5, 2018 at 1120 LT
Type of aircraft:
Registration:
PR-GVJ
Flight Type:
Survivors:
Yes
Schedule:
Belo Horizonte – Confresa
MSN:
LJ-2145
YOM:
2017
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane departed Belo Horizonte-Pampulha-Carlos Drummond de Andrade Airport at 0820LT on a private flight to Confresa, carrying five passenger and one pilot. While descending to Confresa, the pilot decided to fly directly to the farm of the owner (Fazenda Angola) located in Vila Rica, about 80 km northeast of Confresa Airport. On final approach, the aircraft was too low when it struck the surface of a lake then its bank. On impact, the undercarriage were torn off and the aircraft crash landed and came to rest on its belly. There was no fire. All six occupants were injured, one seriously. The aircraft was damaged beyond repair.
Probable cause:
The pilot descended too low on approach to an umprepared terrain.
Contributing Factors:
- Attitude,
- Command application,
- Pilot judgment,
- Decision making process,
- Lack of adherence to regulations established by the authority of Brazilian civil aviation.
Final Report:

Crash of a Beechcraft 60 Duke in Destin: 4 killed

Date & Time: Aug 30, 2018 at 1030 LT
Type of aircraft:
Registration:
N1876L
Flight Type:
Survivors:
No
Schedule:
Toledo - Destin
MSN:
P-386
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2427
Captain / Total hours on type:
100.00
Aircraft flight hours:
4167
Circumstances:
The commercial pilot and three passengers departed on a cross-country flight in a twin-engine airplane. As the flight neared the destination airport, the pilot canceled his instrument flight rules (IFR) clearance. The approach controller transferred the flight to the tower controller, and the pilot reported to the tower controller that the airplane was about 2 miles from the airport. However, the approach controller contacted the tower controller to report that the airplane was 200 ft over a nearby joint military airport at the time. GPS data revealed that, when pilot reported that the airplane was 2 miles from the destination airport, the airplane's actual location was about 10 miles from the destination airport and 2 miles from the joint military airport. The airplane impacted a remote wooded area about 8 miles northwest of the destination airport. At the time of the accident, thunderstorm cells were in the area. A review of the weather information revealed that the pilot's view of the airport was likely obscured because the airplane was in an area of light precipitation, restricting the pilot's visibility. A review of airport information noted that the IFR approach course for the destination airport passes over the joint military airport. The Federal Aviation Administration chart supplement for the destination airport noted the airport's proximity to the other airport. However, it is likely that the pilot mistook the other airport for the destination airport due to reduced visibility because of weather. The accident circumstances were consistent with controlled flight into terrain. The ethanol detected in the pilot's blood specimens but not in his urine specimens was consistent with postmortem bacteria production. The carbon monoxide and cyanide detected in the pilot's blood specimens were consistent with inhalation after the postimpact fire.
Probable cause:
The pilot's controlled flight into terrain after misidentifying the destination airport during a period of restricted visibility due to weather.
Final Report:

Crash of a Cessna 414 Chancellor in Santa Ana: 5 killed

Date & Time: Aug 5, 2018 at 1229 LT
Type of aircraft:
Registration:
N727RP
Flight Type:
Survivors:
No
Site:
Schedule:
Concord – Santa Ana
MSN:
414-0385
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
980
Captain / Total hours on type:
120.00
Aircraft flight hours:
3963
Circumstances:
The pilot and four passengers were nearing the completion of a cross-county business flight. While maneuvering in the traffic pattern at the destination airport, the controller asked the pilot if he could accept a shorter runway. The pilot said he could not, so he was instructed to enter a holding pattern for sequencing; less than a minute later, the pilot said he could accept the shorter runway. He was instructed to conduct a left 270° turn to enter the traffic pattern. The pilot initiated a left bank turn and then several seconds later the bank increased, and the airplane subsequently entered a steep nose-down descent. The airplane impacted a shopping center parking lot about 1.6 miles from the destination airport. A review of the airplane's flight data revealed that, shortly after entering the left turn, and as the airplane’s bank increased, its airspeed decreased to about 59 knots, which was well below the manufacturer’s published stall speed in any configuration. Postaccident examination of the airframe and engines revealed no anomalies that would have precluded normal operation. It is likely that the pilot failed to maintain airspeed during the turn, which resulted in an exceedance of the aircraft's critical angle of attack and an aerodynamic stall.
Probable cause:
The pilot’s failure to maintain adequate airspeed while maneuvering in the traffic pattern which resulted in an aerodynamic stall and subsequent spin at a low altitude, which the pilot was unable to recover from.
Final Report:

Crash of an Extra EA-400 in Ponca City: 5 killed

Date & Time: Aug 4, 2018 at 1045 LT
Type of aircraft:
Operator:
Registration:
N13EP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ponca City - Independence
MSN:
10
YOM:
2000
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
4200
Captain / Total hours on type:
200.00
Aircraft flight hours:
1198
Circumstances:
The pilot was conducting a personal flight with four passengers. A witness observed the airplane take off and climb slowly from the airport. A pilot flying in the vicinity observed the airplane maneuver erratically before the airplane impacted terrain in a near-vertical attitude. The airplane was destroyed by impact forces and a postimpact fire. The wreckage was contained to a confined area in the field and the remains of the major airplane components were all accounted for. Extensive thermal damage to the airframe and engine limited the scope of the postaccident examination. The impact energy needed to drive the engine into the ground suggested that the engine was producing power at the time of the accident. A postaccident examination of the remaining airframe and engine components did not reveal any anomalies which would have precluded normal operation of the airplane. Depending on the amount of fuel, baggage and equipment on board, and the location of the adult passenger, the center of gravity (CG) could have been within or aft of the recommended CG. Since fuel load and location of the passengers could not be determined or may have shifted during flight, it is not known if loading contributed to the accident. The pilot was not operating with valid medical certification. His second-class medical certificate had expired several years prior to the accident and Federal Aviation Administration records did not indicate that he had obtained BasicMed medical certification. A pilot-rated passenger was seated in the rightfront seat. Investigators were unable to determine who was manipulating the flight controls of the airplane at the time of the accident. The circumstances of the accident are consistent with the pilot’s loss of control. However, the reason for the loss of control could not be determined with the available evidence.
Probable cause:
The pilot's loss of control for reasons that could not be determined with the available evidence.
Final Report:

Crash of a PZL-Mielec AN-2R near Tura

Date & Time: Jul 30, 2018 at 2030 LT
Type of aircraft:
Operator:
Registration:
RA-40649
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
1G213-56
YOM:
1985
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9689
Captain / Total hours on type:
9689.00
Copilot / Total flying hours:
260
Copilot / Total hours on type:
230
Aircraft flight hours:
4447
Circumstances:
The single engine aircraft departed a remote area located 250 km west of Tura, carrying five passengers and two pilots who were returning from a fishing camp. Shortly after takeoff, at a height of one meter, the engine started to vibrate and the crew noticed a 'pop' noise. The airplane descended and the crew positioned the flaps to 40°. The aircraft passed over the river then impacted the opposite bank and crashed. All seven occupants evacuated safely, except the pilot who was slightly injured. The aircraft was damaged beyond repair.
Probable cause:
Failure of the exhaust manifold tube due to fatigue cracks, which caused a loss of engine power after hot gases went through the carburetor that was open at 30%.
Final Report:

Crash of a Piper PA-60-602P Aerostar (Ted Smith 600) in Greenville: 3 killed

Date & Time: Jul 30, 2018 at 1044 LT
Operator:
Registration:
C-GRRS
Flight Type:
Survivors:
No
Schedule:
Pembroke – Charlottetown
MSN:
60-8265-026
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
590
Captain / Total hours on type:
136.00
Aircraft flight hours:
4856
Circumstances:
The private pilot of the multiengine airplane was in cruise flight at 23,000 ft mean sea level (msl) in day visual meteorological conditions when he reported to air traffic control that the airplane was losing altitude due to a loss of engine power. The controller provided vectors to a nearby airport; about 7 minutes later, the pilot reported the airport in sight and stated that he would enter a downwind leg for runway 14. By this time, the airplane had descended to about 3,200 ft above ground level. Radar data indicated that the airplane proceeded toward the runway but that it was about 400 ft above ground level on short final. The airplane flew directly over the airport at a low altitude before entering a left turn to a close downwind for runway 21. Witnesses stated that the airplane's propellers were turning, but they could not estimate engine power. When the airplane reached the approach end of runway 21, it entered a steep left turn and was flying slowly before the left wing suddenly "stalled" and the airplane pitched nose-down toward the ground. Postaccident examination of the airplane and engines revealed no mechanical deficiencies that would have precluded normal operation at the time of impact. Examination of both propeller systems indicated power symmetry at the time of impact, with damage to both assemblies consistent with low or idle engine power. The onboard engine monitor recorded battery voltage, engine exhaust gas temperature, and cylinder head temperature for both engines. A review of the recorded data revealed that about 14 minutes before the accident, there was a jump followed by a decrease in exhaust gas temperature (EGT) and cylinder head temperature (CHT) for both engines. The temperatures decreased for about 9 minutes, during which time the right engine EGT data spiked twice. Both engines' EGT and CHT values then returned to normal, consistent with both engines producing power, for the remaining 5 minutes of data. It is possible that a fuel interruption may have caused the momentary increase in both engines' EGT and CHT values and prompted the pilot to report the engine power loss; however, the engine monitor did not record fuel pressure or fuel flow, and examination of the airplane's fuel system and engines did not reveal any mechanical anomalies. Therefore, the reason for the reported loss of engine power could not be determined. It is likely that the pilot's initial approach for landing was too high, and he attempted to circle over the airport to lose altitude. While doing so, he exceeded the airplane's critical angle of attack while in a left turn and the airplane entered an aerodynamic stall at an altitude too low for recovery.
Probable cause:
The pilot's exceedance of the airplane's critical angle of attack while maneuvering to land, which resulted in an aerodynamic stall.
Final Report:

Crash of a Douglas C-47B in Burnet

Date & Time: Jul 21, 2018 at 0915 LT
Operator:
Registration:
N47HL
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Burnet – Sedalia – Oshkosh
MSN:
15758/27203
YOM:
1945
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12500
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
8000
Copilot / Total hours on type:
17
Circumstances:
According to the copilot, before takeoff, he and the pilot had briefed that the copilot would conduct the takeoff for the planned cross-country flight and be the pilot flying and that the pilot would be the pilot monitoring. The accident flight was the copilot's first takeoff in the accident airplane with it at or near its maximum gross weight. The pilot reported that he taxied the airplane onto the runway and locked the tailwheel in place and that the copilot then took over the controls. About 13 seconds after the start of the takeoff roll, the airplane veered slightly right, and the copilot counteracted with left rudder input. The airplane then swerved left, and shortly after the pilot took control of the airplane. The airplane briefly became airborne; the pilot stated that he knew the airplane was slow as he tried to ease it back over to the runway and set it back down. Subsequently, he felt the shudder “of a stall,” and the airplane rolled left and impacted the ground, the right main landing gear collapsed, and the left wing struck the ground. After the airplane came to a stop, a postimpact fire ensued. All the airplane occupants egressed through the aft left door. Postaccident examination of the airplane revealed no evidence of any mechanical malfunctions or failures with the flight controls or tailwheel. Both outboard portions of the of the aluminum shear pin within the tailwheel strut assembly were sheared off, consistent with side load forces on the tailwheel during the impact sequence. The copilot obtained his pilot-in-command type rating and his checkout for the accident airplane about 2 months and 2 weeks before the accident, respectively. The copilot had conducted two flights in the accident airplane with a unit instructor before the accident. The instructor reported that, during these flights, he noted that the copilot had directional control issues; made "lazy inputs, similar to those for small airplanes"; tended to go to the right first; and seemed to overcorrect to the left by leaving control inputs in for too long. He added that, after the checkout was completed, the copilot could take off and land without assistance; however, he had some concern about the his reaction time to a divergence of heading on the ground. Given the evidence, it is likely the copilot failed to maintain directional control during the initial takeoff roll. It is also likely that, if the pilot, who had more experience in the airplane, had monitored the copilot's takeoff more closely and taken remedial action sooner, he may have been able to correct the loss of directional control before the airplane became briefly airborne and subsequently experienced an aerodynamic stall.
Probable cause:
The copilot's failure to maintain directional control during the initial takeoff roll and the pilot's failure to adequately monitor the copilot during the takeoff and his delayed remedial action, which resulted in the airplane briefly becoming airborne and subsequently experiencing an aerodynamic stall.
Final Report:

Crash of a Convair CV-340 in Pretoria: 1 killed

Date & Time: Jul 10, 2018 at 1639 LT
Type of aircraft:
Operator:
Registration:
ZS-BRV
Flight Type:
Survivors:
Yes
Schedule:
Pretoria - Sun City
MSN:
215
YOM:
1954
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
18240
Captain / Total hours on type:
63.00
Copilot / Total flying hours:
19616
Aircraft flight hours:
18115
Circumstances:
On Tuesday 10 July 2018, at approximately 1439Z, two crew members and 17 passengers took off on a ZS-BRV aircraft for a scenic flight from Wonderboom Aerodrome (FAWB) destined for Pilanesberg Aerodrome (FAPN) when the accident occurred. During take-off, the left engine caught fire, however, the crew continued with the flight. They declared an emergency by broadcasting ‘MAYDAY’ and requesting to return to the departure aerodrome. The crew turned to the right with the intention of returning to the aerodrome. However, the left engine fire intensified, causing severe damage to the left wing rear spar and left aileron system, resulting in the aircraft losing height and the crew losing control of the aircraft and colliding with power lines, prior to crashing into a factory building. The footage taken by one of the passengers using their cellphone showed flames coming from the front top side of the left engine cowling and exhaust area after take-off. The air traffic control (ATC) on duty at the time of the accident confirmed that the left engine had caught fire during take-off and that the crew had requested clearance to return to the aerodrome. The ATC then activated the crash alarm and the aircraft was prioritized for landing. During the accident sequence that followed, one passenger (engineer) occupying the jump seat in the cockpit was fatally injured and 18 others sustained injuries. The investigation revealed that during take-off, the left engine had caught fire and the crew had continued with the flight without securing the left engine as prescribed in the aircraft flight manual (AFM). The crew had then declared an emergency and attempted to return to the aerodrome, however, they lost control of the aircraft and collided with power lines prior to crashing into a factory building. Owned by Rovos Air (part of the South African Rovos Rail Group), the aircraft was donated to the Dutch Museum Aviodrome based in Lelystad and has to be transferred to Europe with a delivery date on 23 July 2018. For this occasion, the aircraft was repaint with full Martin's Air Charter colorscheme. Part of the convoy program to Europe, the airplane was subject to several test flights, carrying engineers, technicians, pilots and also members of the Aviodrome Museum.
Probable cause:
During take-off, the left engine caught fire and the crew continued with the flight without securing the left engine as prescribed in the aircraft flight manual (AFM). The crew declared an emergency and attempted to return to the aerodrome, however, they lost control of the aircraft and collided with power lines prior to crashing into a factory building. The following contributing factors were reported:
- Pre-existing damage to the cylinder No 13 piston and ring pack deformation and, most probably, the cylinder No 7’s fractured exhaust valve head that were not detected during maintenance of the aircraft,
- Substandard maintenance for failing to conduct compression tests on all cylinders during the scheduled maintenance prior to the accident,
- Misdiagnosis of the left engine manifold pressure defect as it was reported twice prior to the accident,
- The crew not aborting take-off at 50 knots prior to reaching V1; manifold pressure fluctuation was observed by the crew at 50 knots and that should have resulted in an aborted take-off,
- Lack of crew resource management; this was evident as the crew ignored using the emergency checklist to respond to the in-flight left engine fire,
- Lack of recency training for both the PF and PM, as well as the LAME,
- Non-compliance to Civil Aviation Regulations by both the crew and the maintenance organisation.
Final Report:

Crash of a Cessna 414 Chancellor in Enstone

Date & Time: Jun 26, 2018 at 1320 LT
Type of aircraft:
Operator:
Registration:
N414FZ
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Enstone – Dunkeswell
MSN:
414-0175
YOM:
1971
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1194
Captain / Total hours on type:
9.00
Circumstances:
The aircraft departed Dunkeswell Airfield on the morning of the accident for a flight to Retford (Gamston) Airfield with three passengers on board, two of whom held flying licences. The passengers all reported that the flight was uneventful and after spending an hour on the ground the aircraft departed with two passengers for Enstone Airfield. This flight was also flown without incident.The pilot reported that before departing Enstone he visually checked the level in the aircraft fuel tanks and there was 390 ltr (103 US gal) on board, approximately half of which was in the wingtip fuel tanks. After spending approximately one hour on the ground the pilot was heard to carry out his power checks before taxiing to the threshold of Runway 08 for a flight back to Dunkeswell with one passenger onboard). During the takeoff run the left engine was heard to stop and the aircraft veered to the left as it came to a halt. The pilot later recalled that he had seen birds in the climbout area and this was a factor in the abandoned takeoff. The aircraft was then seen to taxi to an area outside the Oxfordshire Sport Flying Club, where the pilot attempted to start the left engine, during which time the right engine also stopped. The right engine was restarted, and several attempts appeared to have been made to start the left engine, which spluttered into life before stopping again. Eventually the left engine started, blowing out clouds of white and black smoke. After the left engine was running smoothly the pilot was seen to taxi to the threshold for Runway 08. The takeoff run sounded normal and the landing gear was seen to retract at a height of approximately 200 ft agl. The climbout was captured on a video recording taken by an individual standing next to the disused runway, approximately 400 m to the south of Runway 08. The aircraft was initially captured while it was making a climbing turn to the right and after 10 seconds the wings levelled, the aircraft descended and disappeared behind a tree line. After a further 5 seconds the aircraft came into view flying west over buildings to the east of the disused runway at a low height, in a slightly nose-high attitude. The right propeller appeared to be rotating slowly, there was some left rudder applied and the aircraft was yawed to the right. The left engine could be heard running at a high rpm and the landing gear was in the extended position. The aircraft appeared to be in a gentle right turn and was last observed flying in a north-west direction. The video then cut away from the aircraft for a further 25 seconds and when it returned there was a plume of smoke coming from buildings to the north of the runway. The pilot reported that the engine had lost power during a right climbing turn during the departure. He recovered the aircraft to level flight and selected the ‘right fuel booster’ pump (auxiliary pump) and the engine recovered power. He decided to return to Enstone and when he was abeam the threshold for Runway 08 the right engine stopped. He feathered the propeller on the right engine and noted that the single-engine performance was insufficient to climb or manoeuvre and, therefore, he selected a ploughed field to the north of Enstone for a forced landing. During the approach the pilot noticed that the left engine would only produce “approximately 57%” of maximum power, with the result that he could not make the field and crashed into some farm buildings. There was an immediate fire following the accident and the pilot and passenger both escaped from the wreckage through the rear cabin door. The pilot sustained minor burns. The passenger, who was taken to the John Radcliffe Hospital in Oxford, sustained burns to his body, a fractured vertebra, impact injuries to his chest and lacerations to his head.
Probable cause:
The pilot and the passengers reported that both engines operated satisfactory on the two flights prior to the accident flight. No problems were identified with the engines during the maintenance activity carried out 25 and 5 flying hours prior to the accident and the engine power checks carried out at the start of the flight were also satisfactory. It is therefore unlikely that there was a fault on both engines which would have caused the left engine to stop during the aborted takeoff and the right engine to stop during the initial climb. The aircraft was last refuelled at Dunkeswell Airfield and had successfully undertaken two flights prior to the accident flight. There had been no reports to indicate that the fuel at Dunkeswell had been contaminated; therefore, fuel contamination was unlikely to have been the cause. The pilot reported that there was sufficient fuel onboard the aircraft to complete the flight, which was evident by the intense fire in the poultry farm, most probably caused by the fuel from the ruptured aircraft fuel tanks. With sufficient fuel onboard for the aircraft to complete the flight, the most likely cause of the left engine stopping during the aborted takeoff, and the right engine stopping during the accident flight, was a disruption in the fuel supply between the fuel tanks and engine fuel control units. The reason for this disruption could not be established but it is noted that the fuel system in this design is more complex than in many light twin-engine aircraft. The AAIB calculated the single-engine climb performance during the accident flight using the performance curves3 for engines not equipped with the RAM modification. It was a hot day and the aircraft was operating at 280 lb below its maximum takeoff weight. Assuming the landing gear and flaps were retracted, the engine cowls on the right engine were closed and the aircraft was flown at 101 kt, then the single-engine climb performance would have been 250 ft/min. However, the circumstances of the loss of power at low altitude would have been challenging and, shortly before the accident, the aircraft was seen flying with the landing gear extended and the right engine still windmilling. These factors would have adversely affected the single-engine performance and might explain why the pilot was no longer able to maintain height.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Rock Sound: 3 killed

Date & Time: Jun 5, 2018 at 1545 LT
Registration:
N421MM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Rock Sound – Treasure Coast
MSN:
421B-0804
YOM:
1974
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
On 5th June, 2018 at approximately 3:45pm local, (Eastern Daylight Time) , a Cessna 421B aircraft crashed in dense bushes shortly after departure from Runway 27 at Rocksound Int’l Airport, Rock Sound, Eleuthera, Bahamas. The crash site was located approximately 2,503 feet / .41 nautical mile (nm) north of the threshold of Runway 09 and 8,588 feet / 1.42 nm from threshold of runway 27. The pilot and 2 passengers were killed and the aircraft was destroyed by impact forces and a post-crash fire. The aircraft made initial contact with trees before making contact with the ground and other trees in dense bushes. The aircraft descended right wing first, in an approximately 40 degree nose-down angle. A crater approximately 12 inches deep and 10 feet long by 5 feet wide was created when the aircraft hit the ground, subsequently crossing a dirt road, before coming to rest partially in an upward incline in trees. The nose of the aircraft came to rest on a heading of 355° degrees. The fuselage of the aircraft was located at Latitudes 24° 53’ 50”N and Longitude 076° 11’33”W. A fire ensued after the crash.
Probable cause:
The Air Accident Investigation Department has determined the probable cause of this accident to be the pilot failure to maintain control of the airplane. Circumstances contributing to the failure to maintain control undetermined. Evidence exist to demonstrate the aircraft was not producing full power at the time it loss control, the reasons for the reduced power unknown. It could not be determined why the fuel selector was position to the auxiliary tank and not the main tank as required by manufacturer’s recommendation. Critical evidence were destroyed in the post impact fire.
Final Report: