Crash of a Cessna 421B Golden Eagle II in Clovis

Date & Time: Aug 9, 2015 at 0925 LT
Registration:
N726JB
Flight Type:
Survivors:
Yes
Schedule:
Melrose – Clovis
MSN:
421B-0020
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3700
Captain / Total hours on type:
300.00
Circumstances:
The private pilot reported that he was approaching the airport for landing in the multi-engine airplane when both engines began to surge. The pilot attempted to switch to the auxiliary fuel tanks, but inadvertently switched the left engine fuel selector to the off position. The left engine subsequently experienced a total loss of engine power. On final approach for landing, the airplane impacted terrain and was subsequently consumed by a postimpact fire; the fuel onboard the airplane at the time of the accident could not be determined. An examination of the airplane's engines and systems revealed no mechanical anomalies that would have precluded normal operation.
Probable cause:
The pilot's improper management of fuel to the left engine during approach for landing, which resulted in a total loss of left engine power due to fuel starvation, and his subsequent failure to maintain control during the final landing approach, which resulted in collision with terrain.
Final Report:

Crash of a Piper PA-46-500TP Malibu Meridian in Saranac Lake: 4 killed

Date & Time: Aug 7, 2015 at 1750 LT
Operator:
Registration:
N819TB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Saranac Lake – Rochester
MSN:
46-97117
YOM:
2001
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
4620
Captain / Total hours on type:
230.00
Circumstances:
The private pilot, who was experienced flying the accident airplane, was conducting a personal flight with three passengers on board the single-engine turboprop airplane. Earlier that day, the pilot flew uneventfully from his home airport to an airport about 1 hour away. During takeoff for the return flight, the airplane impacted wooded terrain about 0.5 mile northwest of the departure end of the runway. There were no witnesses to the accident, but the pilot's radio communications with flight service and on the common traffic advisory frequency were routine, and no distress calls were received. A postcrash fire consumed a majority of the wreckage, but no preimpact mechanical malfunctions were observed in the remaining wreckage. Examination of the propeller revealed that the propeller reversing lever guide pin had been installed backward. Without the guide pin installed correctly, the reversing lever and carbon block could dislodge from the beta ring and result in the propeller blades traveling to an uncommanded feathered position. However, examination of the propeller components indicated that the carbon block was in place and that the propeller was in the normal operating range at the time of impact. Additionally, the airplane had been operated for about 9 months and 100 flight hours since the most recent annual inspection had been completed, which was the last time the propeller was removed from and reinstalled on the engine. Therefore, the improper installation of the propeller reversing lever guide pin likely did not cause the accident. Review of the pilot's autopsy report revealed that he had severe coronary artery disease with 70 to 80 percent stenosis of the right coronary artery, 80 percent stenosis of the left anterior descending artery, and mitral annular calcification. The severe coronary artery disease combined with the mitral annular calcification placed the pilot at high risk for an acute cardiac event such as angina, a heart attack, or an arrhythmia. Such an event would have caused sudden symptoms such as chest pain, shortness of breath, palpitations, or fainting/loss of consciousness and would not have left any specific evidence to be found during the autopsy. It is likely that the pilot was acutely impaired or incapacitated at the time of the accident due to an acute cardiac event, which resulted in his loss of airplane control.
Probable cause:
The pilot's loss of airplane control during takeoff, which resulted from his impairment or incapacitation due to an acute cardiac event.
Final Report:

Crash of a Beechcraft C90B King Air in Georgetown

Date & Time: Aug 1, 2015 at 2100 LT
Type of aircraft:
Operator:
Registration:
N257CQ
Flight Type:
Survivors:
Yes
Schedule:
Dayton – Somerset
MSN:
LJ-1419
YOM:
1995
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3182
Captain / Total hours on type:
1122.00
Aircraft flight hours:
2324
Circumstances:
The airplane was fueled with 140 gallons of fuel before the second of three flight segments. The pilot reported that, while en route on the third segment, a fuel crossfeed light illuminated. He reset the indicator and decided to land the airplane to troubleshoot. He requested to divert to the nearest airport, which was directly beneath the airplane. Subsequently, the right engine lost power, and the autofeather system feathered the right engine propeller. He reduced power on the left engine, lowered the nose, and extended the landing gear while entering the traffic pattern. The pilot indicated that, after the landing gear was extended, the electrical system "failed," and shortly after, the left engine would not respond to power lever inputs. As the flight was on a base leg approach, the airplane was below the intended flightpath to reach the runway. The pilot stated that he pulled "gently on the control wheel"; however, the airplane impacted an embankment and came to rest on airport property, which resulted in substantial damage to both wings and the fuselage. Postaccident examination of the engines and airframe revealed no evidence of mechanical malfunctions or abnormalities that would have precluded normal operation. Signatures on the left propeller indicated that the engine was likely producing power at the time of impact; however, actual power settings could not be conclusively determined. Signatures on the right propeller indicated that little or no power was being produced. The quantity of fuel in the airplane's fuel system, as well as the configuration of the fuel system at the time of the accident, could not be determined based on the available evidence. Although the position of the master switch (which includes the battery, generator 1, and generator 2) was found in the OFF position, the airplane had been operating for about 30 minutes when the electrical power was lost; thus, it is likely that the airplane had been operating on battery power throughout the flight. This could have been the result of the pilot's failure to activate, or his inadvertent deactivation of, the generator 1 and 2 switch. If the flight were operating on battery power, it would explain what the pilot described as an electrical system failure after the landing gear extension due to the exhaustion of the airplane's battery. The postaccident examination of the left engine and propeller revealed that the engine was likely producing some power at the time of impact, and an explanation for why the engine reportedly did not respond to the pilot's throttle movements could not be determined. Additionally, given the available evidence, the reason for the loss of power to the right engine could not be determined.
Probable cause:
Undetermined based on the available evidence.
Final Report:

Crash of an Embraer EMB-505 Phenom 300 in Blackbushe: 4 killed

Date & Time: Jul 31, 2015 at 1508 LT
Type of aircraft:
Registration:
HZ-IBN
Flight Type:
Survivors:
No
Schedule:
Milan - Blackbushe
MSN:
505-00040
YOM:
2010
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
11000
Captain / Total hours on type:
1180.00
Aircraft flight hours:
2409
Aircraft flight cycles:
1377
Circumstances:
The aircraft had positioned to Milan earlier in the day, flown by the same pilot, and was returning to Blackbushe with the pilot and three passengers on board. After descending through the London Terminal Manoeuvring Area (TMA) it was handed over from London Control to Farnborough Approach. Its descent continued towards Blackbushe and, having reported that he had the airfield in sight, the pilot was instructed to descend at his own discretion. When the aircraft was approximately four miles south of its destination, he was instructed to contact Blackbushe Information. The weather at Blackbushe was fine with light and variable winds, visibility in excess of ten kilometres, and no low cloud. HZ-IBN entered the left-hand circuit for Runway 25 via the crosswind leg. Towards the end of the downwind leg, it overtook an Ikarus C42 microlight aircraft, climbing to pass ahead of and above that aircraft. As the climb began, at approximately 1,000 ft aal, the TCAS of HZ-IBN generated a ‘descend’ RA alert to resolve a conflict with the microlight. The TCAS RA changed to ‘maintain vertical speed’ and then ‘adjust vertical speed’, possibly to resolve a second conflict with a light aircraft which was above HZ-IBN and to the east of the aerodrome. Neither the microlight nor the light aircraft was equipped with TCAS. Following this climb, HZ-IBN then flew a curving base leg, descending at up to 3,000 feet per minute towards the threshold of Runway 25. The aircraft’s TCAS annunciated ‘clear of conflict’ when HZ-IBN was 1.1 nm from the runway threshold, at 1,200 ft aal, and at a speed of 146 KIAS, with the landing gear down and flap 3 selected. The aircraft continued its approach at approximately 150 KIAS. Between 1,200 and 500 ft aal the rate of descent averaged approximately 3,000 fpm, and at 500 ft aal the descent rate was 2,500 fpm. The aircraft’s TAWS generated six ‘pull up’ warnings on final approach. The aircraft crossed the Runway 25 threshold at approximately 50 ft aal at 151 KIAS. The aircraft manufacturer calculated that the appropriate target threshold speed for the aircraft’s mass and configuration was 108 KIAS. The AFISO initiated a full emergency as the aircraft touched down, because “it was clear at this time that the aircraft was not going to stop”. Tyre marks made by the aircraft at touchdown indicated that it landed 710 m beyond the Runway 25 threshold. The Runway 25 declared Landing Distance Available (LDA) was 1,059 m; therefore the aircraft touched down 349 m before the end of the declared LDA. The paved runway surface extended 89 m beyond the end of the LDA. The aircraft continued along the runway, decelerating, but departed the end of the paved surface at a groundspeed of 83 kt (84 KIAS airspeed) and struck an earth bank, which caused the aircraft to become airborne again. It then struck cars in a car park, part of a large commercial site adjacent to the aerodrome. The wing separated from the fuselage, and the fuselage rolled left through 350° before coming to rest on top of the detached wing, on a heading of 064°(M), 30° right side down and in an approximately level pitch attitude. A fire broke out in the underside of the aft fuselage and burned with increasing intensity. The aerodrome’s RFFS responded to the crash alarm but their path to the accident site was blocked by a locked gate between the aerodrome and commercial site. The first two RFFS vehicles arrived at the gate 1 minute and 34 seconds after the aircraft left the runway end. The third RFFS vehicle, which carried a key for the gate, arrived approximately one minute later, and the three RFFS vehicles proceeded through the gate 2 minutes and 46 seconds after the aircraft left the runway. As the aircraft was located in an area of the car park surrounded by a 2.4 m tall wire mesh fence, the RFFS vehicles had to drive approximately 400 m to gain access to the accident site. Despite applying all their available media, the RFFS was unable to bring the fire under control. The intensity of the fire meant that it was not possible to approach the aircraft to save life. All four occupants of the aircraft survived the impact and subsequently died from the effects of fire. Subsequently, local authority fire appliances arrived and the fire was extinguished.
Probable cause:
The pilot was appropriately licensed and experienced, and had operated into Blackbushe Aerodrome on 15 previous occasions. He was reported to be physically and mentally well. The aircraft was certified for single-pilot operations and the pilot was qualified to conduct them. The engineering investigation of the accident aircraft did not find evidence of any pre‑existing technical defect that caused or contributed to the accident. The meteorological conditions were suitable for the approach and landing and, at the actual landing weight and appropriate speed, a successful landing at Blackbushe was possible. HZ-IBN joined the circuit at a speed and height which would have been consistent with the pilot’s stated plan to extend downwind in order that the microlight could land first. The subsequent positioning of HZ-IBN and the microlight involved HZ-IBN manoeuvring across the microlight’s path, in the course of which the first of several TCAS warnings was generated. After manoeuvring to cross the microlight’s path, HZ-IBN arrived on the final approach significantly above the normal profile but appropriately configured for landing. In the ensuing steep descent, the pilot selected the speed brakes out but they remained stowed because they are inhibited when the flaps are deployed. The aircraft’s speed increased and it crossed the threshold at the appropriate height, but 43 KIAS above the applicable target threshold speed. The excessive speed contributed to a touchdown 710 m beyond the threshold, with only 438 m of paved surface remaining. From touchdown, at 134 KIAS, it was no longer possible for the aircraft to stop within the remaining runway length. The brakes were applied almost immediately after touchdown and the aircraft’s subsequent deceleration slightly exceeded the value used in the aircraft manufacturer’s landing performance model. The aircraft departed the paved surface at the end of Runway 25 at a groundspeed of 83 kt. The aircraft collided with an earth bank and cars in a car park beyond it, causing the wing to separate and a fire to start. Although the aircraft occupants survived these impacts, they died from the effects of fire. Towards the end of the flight, a number of factors came together to create a very high workload situation for the pilot, to the extent that his mental capacity could have become saturated. His ability to take on new and critical information, and adapt his situational awareness, would have been impeded. In conjunction with audio overload and the mental stressors this can invoke, this may have lead him to become fixated on continuing the approach towards a short runway.
Final Report:

Crash of a Socata TBM-700 in Milwaukee: 2 killed

Date & Time: Jul 29, 2015 at 1810 LT
Type of aircraft:
Registration:
N425KJ
Flight Type:
Survivors:
No
Schedule:
Beverly - Milwaukee
MSN:
518
YOM:
2009
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1875
Captain / Total hours on type:
721.00
Aircraft flight hours:
656
Circumstances:
The airline transport pilot was landing at the destination airport after a cross-country flight in visual meteorological conditions. The tower controller stated that the airplane's landing gear appeared to be extended during final approach and that the airplane landed within the runway's touchdown zone. The tower controller stated that, although the airplane made a normal landing, he heard a squealing noise that continued longer than what he believed was typical. The pilot subsequently transmitted "go-around." The tower controller acknowledged the go-around and cleared the pilot to enter a left traffic pattern. The tower controller stated that he heard the engine speed accelerate while the airplane maintained a level attitude over the runway until it passed midfield. He then saw the airplane pitch up and enter a climbing left turn. The tower controller stated that the airplane appeared to enter an aerodynamic stall before it descended into terrain in a left-wing-down attitude. Another witness reported that he saw the airplane, with its landing gear extended, in a steep left turn before it descended rapidly into terrain. A postaccident examination did not reveal any evidence of flight control, landing gear, or engine malfunction. An examination of the runway revealed numerous propeller slash marks that began about 215 ft past the runway's touchdown zone; however, there was no evidence that any portion of the airframe had impacted the runway during the landing. Additionally, measurement of the landing gear actuators confirmed that all three landing gear were fully extended at the accident site. Therefore, the pilot likely did not adequately control the airplane's pitch during the landing, which allowed the propeller to contact the runway. Due to the propeller strikes, the propeller was likely damaged and unable to provide adequate thrust during the go-around. Further, based on the witness accounts, the pilot likely did not maintain adequate airspeed during the climbing left turn, which resulted in the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall at a low altitude.
Probable cause:
The pilot's improper pitch control during the landing, which resulted in the propeller striking the runway, and his failure to maintain adequate airspeed during the subsequent go-around, which resulted in the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall at a low altitude.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Chofu: 3 killed

Date & Time: Jul 26, 2015 at 1058 LT
Operator:
Registration:
JA4060
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Chōfu - Amami
MSN:
46-22011
YOM:
1989
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1300
Captain / Total hours on type:
120.00
Aircraft flight hours:
2284
Circumstances:
On Sunday, July 26, 2015 at around 10:58 Japan Standard Time (JST: UTC + 9 hrs: unless otherwise stated, all times are indicated in JST using the 24-hour clock), a privately owned Piper PA-64-350P, registered JA4060, crashed into a private house at Fujimi Town in Chōfu City, right after its takeoff from Runway 17 of Chōfu Airport There were five people on board, consisting of the captain and four passengers. The captain and one passenger died and three passengers were seriously injured. In addition, one resident died and two residents had minor injuries. The aircraft was destroyed and a fire broke out. Furthermore, the house where the Aircraft crashed into were consumed in a fire, and neighboring houses sustained damage due to the fire and other factors.
Probable cause:
It is highly probable that this accident occurred as the speed of the Aircraft decreased during takeoff and climb, which led the Aircraft to stall and crashed into a residential area near Chōfu Airport. It is highly probable that decreased speed was caused by the weight of the Aircraft exceeding the maximum takeoff weight, takeoff at low speed, and continued excessive nose-up attitude. As for the fact that the Captain made the flight with the weight of the Aircraft exceeding the maximum takeoff weight, it is not possible to determine whether or not the Captain was aware of the weight of the Aircraft exceeded the maximum takeoff weight prior to the flight of the accident because the Captain is dead. However, it is somewhat likely that the Captain had insufficient understanding of the risks of making flights under such situation and safety awareness of observing relevant laws and regulations. It is somewhat likely that taking off at low speed occurred because the Captain decided to take a procedure to take off at such a speed; or because the Captain reacted and took off due to the approach of the Aircraft to the runway threshold. It is somewhat likely that excessive nose-up attitude was continued in the state that nose-up tended to occur because the position of the C.G. of the Aircraft was close to the aft limit, or the Captain maintained the nose-up attitude as he prioritized climbing over speed. Adding to these factors, exceeding maximum takeoff weight, takeoff at low speed and continued excessive nose-up attitude, as the result of analysis using mathematical models, it is somewhat likely that the decreased speed was caused by the decreased engine power of the Aircraft; however, as there was no evidence of showing the engine malfunction, it was not possible to determine this.
Final Report:

Crash of a Piper PA-46-310P Malibu in Oshkosh

Date & Time: Jul 22, 2015 at 0744 LT
Registration:
N4BP
Flight Type:
Survivors:
Yes
Schedule:
Benton Harbor – Oshkosh
MSN:
46-8408065
YOM:
1984
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
934
Captain / Total hours on type:
130.00
Aircraft flight hours:
5792
Circumstances:
The pilot was landing at a large fly-in/airshow and following the airshow arrival procedures that were in use. While descending on the downwind leg for runway 27, the pilot was cleared by a controller to turn right onto the base leg abeam the runway numbers and to land on the green dot (located about 2,500 ft from the runway's displaced threshold). About the time the pilot turned onto the base leg, he observed an airplane taxi onto the runway and start its takeoff roll. The controller instructed the pilot to continue the approach and land on the orange dot (located about 1,000 ft from the runway's displaced threshold) instead of the green dot. The pilot reported that he considered performing a go-around but decided to continue the approach. As the pilot reduced power, the airplane entered a stall and impacted the runway in a right-wing-low, nose-down attitude. Witnesses estimated that the bank angle before impact was greater than 60 degrees. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.
Analysis of a video recording of the accident showed that the airplane was about 180 ft above ground level (agl) when the turn onto the base leg began, and it descended to about 140 ft agl during the turn. The airplane's total inertial speed (the calculated vector sums of the airplane's ground speeds and vertical speeds) decreased from 98 knots (kts) to 80 kts during the turn. During the last 8 seconds of flight, the speed decreased below 70 kts, and the airplane descended from about 130 ft agl to ground impact. The wings-level stall speed of the airplane at maximum gross weight with landing gear and flaps down was 59 kts. In the same configuration at 60 degrees of bank, the stall speed was 86 kts and would have been higher at a bank angle greater than 60 degrees. Reduced runway separation standards for airplanes were in effect due to the airshow. When the accident airplane reached the runway threshold, the minimum distance required by the standards between the arriving accident airplane and the departing airplane was 1,500 ft. The video analysis indicated that it was likely that a minimum of 1,500 ft of separation was maintained during the accident sequence. Although the pilot was familiar with the procedures for flying into the airshow, the departing airplane
and the modified landing clearance during a period of typically high workload likely interfered with the pilot's ability to adequately monitor his airspeed and altitude. As a result, the airplane entered an accelerated stall when the pilot turned the airplane at a steep bank angle and a low airspeed in an attempt to make the landing spot, which resulted in the airplane exceeding its critical angle of attack. At such a low altitude, recovery from the stall was not possible. Although the airshow arrival procedures stated that pilots have the option to go around if necessary, and the pilot considered going around, he instead continued the unstable landing approach and lost control of the airplane.
Probable cause:
The pilot's failure to perform a go-around after receiving a modified landing clearance and his failure to maintain adequate airspeed while maneuvering to land, which resulted in the airplane exceeding its critical angle of attack in a steep bank and entering an accelerated stall at a low altitude.
Final Report:

Crash of a Cessna T303 Crusader in Serranía del Baudó: 1 killed

Date & Time: Jun 20, 2015 at 1305 LT
Type of aircraft:
Registration:
HK-4677-G
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Nuquí – Quibdo
MSN:
303-00189
YOM:
1982
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2322
Aircraft flight hours:
6491
Circumstances:
The twin engine airplane departed Nuquí Airport at 1256LT on a flight to Quibdó, carrying two passengers and one pilot. Two minutes after takeoff, the pilot informed ATC he was flying at an altitude of 1,500 feet and estimated his ETA at Quibdó-El Caraño Airport at 1315LT. Nine minutes into the flight, while cruising in IMC conditions, the aircraft contacted trees and crashed in a dense wooded area located near Serranía del Baudó, some 50 km north of Nuquí. SAR operations were initiated but the wreckage was found five days later only. Both passengers, a female aged 18 and her baby aged 8 months were evacuated with minor injuries while the pilot was killed. The aircraft was totally destroyed by impact forces.
Probable cause:
The accident was the consequence of a controlled flight into terrain following the decision of the pilot to continue under VFR mode in IMC conditions.
The following contributing factors were identified:
- Poor risk assessment when planning a flight in VFR conditions over a mountainous area, even though the weather conditions were unfavorable.
- Loss of situational awareness after entering the mountain area under VFR mode in IMC conditions, resulting in a CFIT.
Final Report:

Crash of a Beechcraft C90GTi King Air in Belo Horizonte: 3 killed

Date & Time: Jun 7, 2015 at 1525 LT
Type of aircraft:
Operator:
Registration:
PR-AVG
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Belo Horizonte – Setubinha
MSN:
LJ-1891
YOM:
2008
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine airplane departed Belo Horizonte-Pampulha-Carlos Drummond de Andrade Airport on a flight to Setubinha-Fazenda Sequóia Airfield, carrying one employee of the company and two pilots. Prior to takeoff, the captain informed the copilot he wanted to perform an 'American' takeoff with full engine power followed by a steep climb. After liftoff, the crew raised the landing gear then continued over the runway at low height until the end of the terrain to reach a maximum speed, then initiated a steep climb at 90°. The aircraft reached the altitude of 1,700 feet in 15 seconds then stalled and entered an uncontrolled descent. It dove into the ground and crashed in a vertical attitude into a houses located in a residential area some 800 metres from the airport. The aircraft was destroyed by impact forces and a post crash fire and all three occupants were killed. One people on the ground was slightly injured.
Probable cause:
Loss of control after the crew initiated aerobatic maneuvers at low altitude.
Final Report:

Crash of a Piper PA-31T Cheyenne II off Barcelona

Date & Time: May 30, 2015 at 1635 LT
Type of aircraft:
Registration:
YV2761
Flight Type:
Survivors:
Yes
Schedule:
Charallave – Barcelona
MSN:
31-8120055
YOM:
1981
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Charallave, the pilot initiated the descent to Barcelona-Jose Antonio Anzoátegui Airport in poor weather conditions. On final, in a flat attitude, the twin engine aircraft impacted the water surface and came to rest some 3,7 km short of runway 15. All four occupants evacuated the cabin and took place in a lifeboat. Slightly injured, they were rescued two hours later. The aircraft sank and was lost.