Crash of a PZL-Mielec AN-2R in Sanamer

Date & Time: May 18, 2015 at 0912 LT
Type of aircraft:
Operator:
Registration:
RA-56528
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Kevsala – Gribnoye
MSN:
1G183-28
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
20000
Captain / Total hours on type:
17500.00
Circumstances:
The single engine aircraft was completing a flight from Kevsala (Ipatovo district of the Stavropol region) to Gribnoye, in the Novopavlovsk district, carrying one pilot and four oil drums. En route, while approaching Sanamer at low altitude, the pilot encountered engine problems and attempted an emergency landing. After touchdown, the aircraft hit a fence, crushed some trees and came to rest against the wall of a church. The pilot was seriously injured and the aircraft was damaged beyond repair.
Probable cause:
The need of the emergency landing was due to the engine flameout in the air most probably caused by the oil tank swelling and pressing its wall on the fuel shutoff valve lever. Oil tank pressure and its swelling most probably caused carbon deposit in vent pipeline connecting oil tank with atmosphere.
The following factors most probably contributed to the accident:
- No water washing of the oil tank and vent pipeline of oil tank with atmosphere specified by scheduled maintenance after 400±30 flight hours or 12±1 month of operation;
- Aircraft maintenance by people not having the aircraft maintenance license;
- Flight operation over locality at the altitude insufficient to perform landing within its limits in case of aircraft nonoperation;
- Flight operation by PIC in moderate alcohol intoxication.
Final Report:

Crash of a Pilatus PC-12/45 in Ciudad Acuña

Date & Time: Apr 24, 2015 at 1245 LT
Type of aircraft:
Registration:
XA-BLU
Flight Type:
Survivors:
Yes
MSN:
481
YOM:
2003
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
3508
Circumstances:
Following an uneventful flight, the pilot initiated a VFR approach to Ciudad Acuña-El Bonito Airport runway 28 in good weather conditions with 9 km visibility and an OAT of +30° C. On short final, the pilot failed to realize his altitude was too low when the aircraft impacted ground five metres short of runway. The aircraft bounced, rolled for few dozen metres then veered off runway to the left and came to rest in a wooded area. All six occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The accident occurred after the pilot suffered a loss of situational awareness while completing a visual approach below the glide, causing the aircraft to struck the ground five metres short of runway 28 threshold.
The following contributing factors were identified:
- Overconfidence on part of the pilot,
- Unstabilized approach,
- Lack of visual aids.
Final Report:

Crash of a Piper PA-31T Cheyenne I in Fort Lauderdale: 4 killed

Date & Time: Apr 12, 2015 at 1625 LT
Type of aircraft:
Operator:
Registration:
N119RL
Flight Type:
Survivors:
No
Schedule:
Orlando - Fort Lauderdale
MSN:
31T-7904002
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1221
Aircraft flight hours:
3267
Circumstances:
Following an uneventful personal flight, the pilot contacted the air traffic control tower controller and was immediately cleared to land. About 36 seconds later, the pilot reported "smoke in the cockpit." When asked to repeat, the pilot repeated "smoke in the cockpit." The tower controller cleared the pilot to land on any runway. About 47 seconds after the initial call of smoke, the pilot reported "mayday mayday mayday mayday mayday (unintelligible)." The airplane then crashed about ¼ mile short of the airport in a wooded area and burned. Security video showed the airplane pitch nose-down suddenly just before impact. The video revealed no visible smoke or fire trailing the airplane before ground impact. The pilot reported about 1,221 hours of total flight time on his Federal Aviation Administration first class medical certificate, issued about two months prior to the accident. He completed an initial training course for the airplane make and model 1 week before the accident. The airplane had recently undergone an annual inspection and extensive upgrades to its avionics. Both the left and right engines displayed contact signatures to their internal components characteristic of engines developing significant power at the time of impact, likely in the mid-to-high power range. The engines displayed no indications of any pre-impact anomalies or distress that would have precluded normal engine operation. Both propeller assemblies broke free from the engine during the crash sequence and the blades on both engines revealed signatures consistent with the development of power at impact. The center fuselage and cockpit areas were completely consumed in the postcrash fire. An examination of all remaining wires, wire bundles, switches, terminals, circuit breakers, electrical components, instruments, and avionics did not reveal evidence of precrash thermal distress. However, a small fire just before impact likely would not have had time to create thermal damage that would be discernable after an extensive postcrash fire.
Probable cause:
A rapid onset of smoke and/or fire inflight for reasons that could not be determined due to the postimpact fire and the condition of the wreckage.
Final Report:

Crash of a Cessna 414A Chancellor in Bloomington: 7 killed

Date & Time: Apr 7, 2015 at 0006 LT
Type of aircraft:
Registration:
N789UP
Flight Type:
Survivors:
No
Schedule:
Indianapolis - Bloomington
MSN:
414A-0495
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
12100
Captain / Total hours on type:
1150.00
Aircraft flight hours:
8390
Circumstances:
The twin-engine airplane, flown by an airline transport pilot, was approaching the destination airport after a cross-country flight in night instrument meteorological conditions. The destination airport weather conditions about 1 minute before the accident included an overcast ceiling at 200 ft and 1/2-mile visibility with light rain and fog. According to air traffic control (ATC) data, the flight received radar vectors to the final approach course for an instrument landing system (ILS) approach to runway 20. As shown by a post accident simulation study based on radar data and data recovered from the airplane's electronic horizontal situation indicator (EHSI), the airplane's flight path did not properly intercept and track either the localizer or the glideslope during the instrument approach. The airplane crossed the final approach fix about 360 ft below the glideslope and then maintained a descent profile below the glideslope until it leveled briefly near the minimum descent altitude, likely for a localizer-only instrument approach. However, the lateral flight path from the final approach fix inbound was one or more dots to the right of the localizer centerline until the airplane was about 1 nautical mile from the runway 20 threshold when it turned 90° left to an east course. The turn was initiated before the airplane had reached the missed approach point; additionally, the left turn was not in accordance with the published missed approach instructions, which specified a climb on runway heading before making a right turn to a 270° magnetic heading. The airplane made a series of pitch excursions as it flew away from the localizer. The simulation study determined that dual engine power was required to match the recorded flight trajectory and ground speeds, which indicated that both engines were operating throughout the approach. The simulation results also indicated that, based on calculated angle of attack and lift coefficient data, the airplane likely encountered an aerodynamic stall during its course deviation to the east. The airplane impacted the ground about 2.2 miles east-northeast of the runway 20 threshold and about 1.75 miles east of the localizer centerline. According to FAA documentation, at the time of the accident, all components of the airport's ILS were functional, with no recorded errors, and the localizer was radiating a front-course to the correct runway. Additionally, a post accident flight check found no anomalies with the instrument approach.An onsite examination established that the airplane impacted the ground upright and in a nose-low attitude, and the lack of an appreciable debris path was consistent with an aerodynamic stall/spin. Wreckage examinations did not reveal any anomalies with the airplane's flight control systems, engines, or propellers. The glideslope antenna was found disconnected from its associated cable circuit. Laboratory examination and testing determined that the glideslope antenna cable was likely inadequately connected/secured during the flight, which resulted in an unusable glideslope signal to the cockpit avionics. There was no history of recent maintenance on the glideslope antenna, and the reason for the inadequate connection could not be determined. Data downloaded from the airplane's EHSI established that the device was in the ILS mode during the instrument approach phase and that it had achieved a valid localizer state on both navigation channels; however, the device never achieved a valid glideslope state on either channel during the flight. Further, a replay of the recorded EHSI data confirmed that, during the approach, the device displayed a large "X" through the glideslope scale and did not display a deviation pointer, both of which were indications of an invalid glideslope state. There was no evidence of cumulative sleep loss, acute sleep loss, or medical conditions that indicated poor sleep quality for the pilot. However, the accident occurred more than 2 hours after the pilot routinely went to sleep, which suggests that the pilot's circadian system would not have been promoting alertness during the flight. Further, at the time of the accident, the pilot likely had been awake for 18 hours. Thus, the time at which the accident occurred and the extended hours of continuous wakefulness likely led to the development of fatigue. The presence of low cloud ceilings and the lack of glideslope guidance would have been stresses to the pilot during a critical phase of flight. This would have increased the pilot's workload and situational stress as he flew the localizer approach, a procedure that he likely did not anticipate or plan to conduct. In addition, weight and balance calculations indicated that the airplane's center of gravity (CG) was aft of the allowable limit, and the series of pitch excursions that began shortly after the airplane turned left and flew away from the localizer suggests that the pilot had difficulty controlling airplane pitch. This difficulty was likely due to the adverse handling characteristics associated with the aft CG. These adverse handling characteristics would have further increased the pilot's workload and provided another distraction from maintaining control of the airplane. Therefore, it is likely that the higher workload caused by the pilot's attempt to fly an unanticipated localizer approach at night in low ceilings and his difficulty maintaining pitch control of the airplane with an aft CG contributed to his degraded task performance in the minutes preceding the accident.
Probable cause:
The pilot's failure to maintain control of the airplane during the instrument approach in night instrument meteorological conditions, which resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall/spin. Contributing to the accident were pilot fatigue, the pilot's increased workload during the instrument approach resulting from the lack of glide slope guidance due to an inadequately connected/secured glide slope antenna cable, and the airplane being loaded aft of its balance limit.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Spokane: 1 killed

Date & Time: Feb 22, 2015 at 1405 LT
Registration:
C-GVZW
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Villeneuve – Spokane – Stockton
MSN:
46-36281
YOM:
2000
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
667
Captain / Total hours on type:
63.00
Aircraft flight hours:
2388
Circumstances:
The pilot was conducting a cross-country flight from Canada to California and had landed to clear customs into the United States and to refuel his airplane. The pilot then departed to continue the flight. During the initial climb after takeoff, the engine experienced a total loss of power, and the pilot attempted to make an off-airport forced landing. The right wing struck railroad tracks at the top of a hill, and the airplane continued down an embankment, where it came to rest adjacent to the bottom of a railroad bridge. Postaccident interviews revealed that, when requesting fuel from the fixed-base operator (FBO), the pilot did not specify a grade of fuel to be used to service the airplane. The refueler mistakenly identified the airplane as requiring Jet A fuel, even though the fuel filler ports were placarded "AVGAS (aviation gasoline) ONLY." The fueler subsequently fueled the airplane with Jet A instead of aviation gasoline. Additionally, the fueling nozzle installed on the fuel truck at the time of the refueling was not the proper type of nozzle. Jet A and AvGas fueling nozzles are different designs in order to prevent fueling an airplane with the wrong type of fuel. Following the fueling, the pilot returned to the FBO and signed a receipt, which indicated that the airplane had been serviced with Jet A. There were no witnesses to the pilot's preflight activities, and it is unknown if the pilot visually inspected or obtained a fuel sample before takeoff; however, had the pilot done this, it would have been apparent that the airplane had been improperly fueled.
Probable cause:
A total loss of engine power due to the refueler's incorrect refueling of the airplane. Contributing to the accident was the fixed-base operator's improper fueling nozzle, which facilitated the use of an incorrect fuel, and the pilot's inadequate preflight inspection.
Final Report:

Crash of a Piper PA-46-500TP Malibu Meridian in Västerås

Date & Time: Feb 13, 2015 at 1203 LT
Registration:
N164ST
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Västerås – Prague
MSN:
46-97064
YOM:
2001
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
674
Captain / Total hours on type:
184.00
Aircraft flight hours:
2767
Circumstances:
The aircraft, a Piper PA46-500TP Malibu Meridian, should carry out a private flight from Västeras airport to Prague. On board were a pilot and two passengers. Shortly after take-off an engine failure occurred and the pilot decided to make an emergency landing on Björnö Island, situated slightly to the right in the flight direction. The aircraft hit the ground with the left wing first and then rolled a number of times before it came to a final stop. During the accident both wings and parts of the tail separated from the aircraft. The fuselage remained relatively undamaged during the crash course. All three occupants escaped with minor injuries. A special study of the sequence of events shows that the impact, with the left wing first, caused the airplane's wings to act as shock absorbers, which greatly contributed to that the occupants only received minor injuries. During the accident - which occurred next to a secondary protection zone for water supply to the city of Västerås – a significant amount of fuel leaked out from the wreckage. The accident site was decontaminated after the accident. Examination undertaken in the area after the accident has not showed any trace of residual contamination in the soil.
Probable cause:
The engine failure was caused by damage to the engine's power turbine section. Most likely, the damage has been initiated in a labyrinth seal to the power turbine. The cause of the initial damage of the seal has not been established. The technical failure can not be assessed to be in a risk category where the risk of repeated failures of the same type is high. The accident was caused by damage to the power turbine which occurred over time, and that could not be identified by the engine's maintenance program.
Final Report:

Crash of a Cessna 404 Titan II on Roseau

Date & Time: Feb 8, 2015
Type of aircraft:
Operator:
Registration:
YV1139
Flight Type:
Survivors:
Yes
MSN:
404-628
YOM:
1980
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Roseau-Canefield, the pilot encountered difficulties to stop the aircraft that overran. It collided with a fence and came to rest against various obstacles. All seven occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of a Cessna 441 Conquest II in Denton: 1 killed

Date & Time: Feb 4, 2015 at 2109 LT
Type of aircraft:
Registration:
N441TG
Flight Type:
Survivors:
No
Schedule:
Willmar - Denton
MSN:
441-200
YOM:
1981
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4935
Aircraft flight hours:
3830
Circumstances:
The instrument-rated commercial pilot was approaching the destination airport after a cross country flight in night instrument meteorological conditions. According to radar track data and air traffic control communications, while receiving radar vectors to the final approach course, the pilot did not always immediately comply with assigned headings and, on several occasions, allowed the airplane to descend below assigned altitudes. According to airplane performance calculations based on radar track and GPS data, the pilot made an engine power reduction about 2.5 minutes before the accident as he maneuvered toward the final approach fix. Following the engine power reduction, the airplane's airspeed decreased from 162 to 75 knots calibrated airspeed, and the angle of attack increased from 2.7° to 14°. About 4 miles from the final approach fix, the airplane descended below the specified minimum altitude for that segment of the instrument approach. The tower controller subsequently alerted the pilot of the airplane's low altitude, and the pilot replied that he would climb. At the time of the altitude alert, the airplane was 500 ft below the specified minimum altitude of 2,000 ft mean sea level. According to airplane performance calculations, 5 seconds after the tower controller told the pilot to check his altitude, the pilot made an abrupt elevator-up input that further decreased airspeed, and the airplane entered an aerodynamic stall. A witness saw the airplane abruptly transition from a straight-and-level flight attitude to a nose-down, steep left bank, vertical descent toward the ground, consistent with the stall. Additionally, a review of security camera footage established that the airplane had transitioned from a wings-level descent to a near vertical spiraling descent. A post accident examination of the airplane did not reveal any anomalies that would have precluded normal operation during the accident flight. Although the pilot had monocular vision following a childhood injury that resulted in very limited vision in his left eye, he had passed a medical flight test and received a Statement of Demonstrated Ability. The pilot had flown for several decades with monocular vision and, as such, his lack of binocular depth perception likely did not impede his ability to monitor the cockpit instrumentation during the accident flight. The pilot had recently purchased the airplane, and records indicated that he had obtained make and model specific training about 1 month before the accident and had flown the airplane about 10 hours before the accident flight. The pilot's instrument proficiency and night currency could not be determined from the available records; therefore, it could not be determined whether a lack of recent instrument or night experience contributed to the pilot's difficulty in maintaining control of the airplane.
Probable cause:
The pilot's failure to maintain adequate airspeed during the instrument approach in night instrument meteorological conditions, which resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall/spin at a low altitude.
Final Report:

Crash of a Piper PA-46-500TP Malibu Meridian in Lubbock: 1 killed

Date & Time: Feb 4, 2015 at 1930 LT
Operator:
Registration:
N301D
Flight Type:
Survivors:
No
Schedule:
Carlsbad – Lubbock
MSN:
46-97043
YOM:
2001
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1073
Aircraft flight hours:
1378
Circumstances:
The instrument-rated private pilot was conducting a personal cross-country flight in the airplane. A review of the air traffic control transcripts and radar data revealed that the pilot was executing the RNAV GPS Y instrument approach to the runway. The air traffic controller then canceled the pilot's approach clearance and issued a heading change off of the approach course to provide spacing between a preceding aircraft. The pilot acknowledged the heading assignment. Radar data indicated that, after the controller cancelled the approach, the airplane began a left climbing turn from 5,600 to 5,800 ft, continued the left turn through the assigned 270 heading, and then descended rapidly. At that point, the airplane was no longer visible on the controller's radar display, and contact with the pilot was lost. The final recorded radar return showed the airplane at 5,100 ft. The airplane impacted a television tower guy wire, several power lines, and terrain, and then came to rest in an open field about 800 ft from the tower. A postaccident examination of the airplane and engine revealed no anomalies that would have precluded normal operation. A postaccident examination of the engine revealed rotational signatures on the first stage compressor blades and light rotational signatures in the compressor and power turbines, and debris was found in the engine's gas path, all of which are consistent with engine rotation at impact. A witness in the parking lot next to the television tower stated that he heard the accident airplane overhead, saw a large flash of light that filled his field of view, and then observed the television tower collapse on top of itself. Surveillance videos located 1.5 miles north-northeast and 0.3 mile north-northwest of the accident site showed the airplane in a left descending turn near the television tower. After it passed the television tower, multiple bright flashes of light were observed, which were consistent with the airplane impacting the television tower guy wire and then the power lines. Further, the radar track and accident wreckage were consistent with a rapid, descending left turn to impact. Weather conditions were conducive to the accumulation of ice at the destination airport about the time that the pilot initiated the left turn. It is likely that the airplane accumulated at least light structural icing during the descent and that this affected the airplane's controllability. Also, the airplane likely encountered wind gusting up to 31 knots as it was turning; this also could have affected the airplane's controllability. The night, instrument meteorological conditions at the time of the accident were conducive to the development of spatial disorientation, and the airplane's rapid, descending left turn to impact is consistent with the pilot's loss of airplane control due to spatial disorientation. Therefore, based on the available evidence, it is likely that, while initiating the climbing left turn, the pilot became spatially disoriented, which resulted in his loss of airplane control and his failure to see and avoid the tower guy wire, and that light ice accumulation on the airplane and the gusting wind negatively affected the airplane's controllability.
Probable cause:
The pilot's loss of airplane control due to spatial disorientation and light ice accumulation while operating in night, instrument meteorological conditions with gusting wind.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage JetProp DLX in Sézenove: 1 killed

Date & Time: Jan 30, 2015 at 1201 LT
Operator:
Registration:
N246PR
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Geneva - Genk
MSN:
46-36063
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1073
Captain / Total hours on type:
89.00
Aircraft flight hours:
1997
Circumstances:
The pilot, sole on board, departed Geneva-Cointrin Airport on a private flight to Genk-Zwartberg Airport where the aircraft was supposed to follow a maintenance program. The single engine aircraft departed runway 23 at 1157LT and continued to climb in IMC conditions. About 30 seconds after he was transferred to the departure frequency, the pilot was cleared to climb to FL090. At an altitude of 4,200 feet and at a speed of 142 knots, the aircraft climbed steeply then veered to the left. About 12 seconds later, the aircraft stopped to climb and another period of 8 seconds was necessary to stabilize and to follow the route. At 1159LT, the aircraft deviated to the left during 20 seconds, drifting about 555 metres from the runway axis. After following various headings with huge variations in ground speed and altitude, the aircraft entered an uncontrolled descent and crashed in an open field located in Sézenove, about 7,8 km southwest from Geneva-Cointrin Airport runway 05 threshold. The aircraft disintegrated on impact and the pilot was killed.
Probable cause:
The accident was due to a loss of control that brought the aircraft into unusual attitudes, which the pilot was unable to restore and which led to his fall. The insufficient skills of the pilot when faced with a high performance aircraft, whose systems are complex, contributed to the occurrence of the accident.
Final Report: