Crash of a De Havilland DH.84 Dragon near Borumba Dam: 6 killed

Date & Time: Oct 1, 2012 at 1413 LT
Type of aircraft:
Operator:
Registration:
VH-UXG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Monto - Caboolture
MSN:
6077
YOM:
1934
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
1134
Captain / Total hours on type:
662.00
Circumstances:
At about 1107 Eastern Standard Time on 01OCT2012, a de Havilland Aircraft Pty Ltd DH-84 Dragon, registered VH-UXG (UXG), took off from Monto on a private flight to Caboolture, Queensland under the visual flight rules (VFR). On board the aircraft were the pilot/owner and five passengers. The weather conditions on departure were reported to include a light south-easterly wind with a high overcast and good visibility. Sometime after about 1230, the aircraft was seen near Tansey, about 150 km north-west of Caboolture on the direct track from Monto to Caboolture. The aircraft was reported flying in a south-easterly direction at the time, at an estimated height of 3,000 ft and in fine but overcast conditions. At 1315, the pilot contacted Brisbane Radar air traffic control (ATC) and advised that the aircraft’s position was about 37 NM (69 km) north of Caboolture and requested navigation assistance. At 1318, the pilot advised ATC that the aircraft was in ‘full cloud’. For most of the remainder of the flight, the pilot and ATC exchanged communications, at times relayed through a commercial flight and a rescue flight in the area due to the limited ATC radio coverage in the area at low altitude. At about 1320, a friend of one of the aircraft’s passengers received a telephone call from the passenger to say that she was in an aircraft and that they were ‘lost in a cloud’ and kept losing altitude. Witnesses in the Borumba Dam, Imbil and Kandanga areas 70 to 80 km north-north-west of Caboolture later reported that they heard and briefly saw the aircraft flying in and out of low cloud between about 1315 and 1415. At 1348, the pilot advised ATC that the aircraft had about an hour’s endurance remaining. The pilot’s last recorded transmission was at 1404. A search for the aircraft was coordinated by Australian Search and Rescue (AusSAR). The aircraft wreckage was located on 3 October 2012, about 87 km north-west of Caboolture on the northern side of a steep, densely wooded ridge about 500 m above mean sea level. The Australian Transport Safety Bureau (ATSB) later determined that the aircraft probably impacted terrain at about 1421 on 01OCT2012. Preliminary analysis indicated that the aircraft collided with trees and terrain at a moderate to high speed, with a left angle of bank. The aircraft’s direction of travel at impact was toward the south-south-west.
Probable cause:
From the evidence available, the following findings are made with respect to the visual flight rules into instrument meteorological conditions accident involving de Havilland Aircraft Pty Ltd DH-84 Dragon, registered VH-UXG, that occurred 36 km south-west of Gympie, Queensland, on 1 October 2012. These findings should not be read as apportioning blame or liability to any particular organisation or individual. Safety issues, or system problems, are highlighted in bold to emphasize their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.
Contributing factors:
- The pilot unintentionally entered instrument meteorological conditions and was unable to reattain and maintain visual conditions.
- It is likely that the pilot became spatially disoriented and lost control due to a combination of factors such as the absence of a visible horizon, cumulative workload, stress and/or distraction.
Other factors that increased risk:
- Though it probably did not have a significant bearing on the event, the aircraft was almost certainly above its maximum take-off weight (MTOW) on take-off, and around the MTOW at the time of the accident.
- Though airborne search and rescue service providers were regularly tasked to provide assistance to pilots in distress, there was limited specific guidance on the conduct of such assistance. Other findings:
- The aircraft wreckage was not located for 2 days as the search was hindered by difficult local weather conditions and terrain, and the cessation of the aircraft’s emergency beacon due to impact damage.
Final Report:

Crash of a Cessna 414A Chancellor in Ellbögen: 6 killed

Date & Time: Sep 30, 2012 at 0658 LT
Type of aircraft:
Operator:
Registration:
N738W
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Innsbruck - Valencia
MSN:
414A-0027
YOM:
1978
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
12000
Captain / Total hours on type:
1200.00
Aircraft flight hours:
8600
Circumstances:
The twin engine aircraft departed Innsbruck-Kranebitten Airport at 0654LT on a private flight to Valencia, Spain, carrying seven passengers and one pilot. VFR conditions prevailed at the time of departure. After takeoff from runway 26, the pilot turn to the south when he encountered limited visibility due to foggy conditions. In IMC conditions, the aircraft contacted trees, lost height and crashed in a wooded area located near the village of Ellbögen, about 15 km southeast of Innsbruck Airport, bursting into flames. The wreckage was found at an altitude of 1,612 metres. Two passengers were seriously injure while six other occupants were killed. The aircraft was totally destroyed by a post impact fire.
Probable cause:
Controlled flight into terrain after the pilot continued under VFR mode in IMC conditions.
Final Report:

Crash of a Learjet 24D in Rønne

Date & Time: Sep 15, 2012 at 1340 LT
Type of aircraft:
Operator:
Registration:
D-CMMM
Flight Type:
Survivors:
Yes
Schedule:
Strausberg - Rønne
MSN:
24-328
YOM:
1976
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The accident occurred during a private IFR flight from Strausberg Airport (EDAY), Germany, to Bornholm Airport (EKRN), Denmark. Before the flight, an ATS flight plan was filed. Before takeoff at EDAY, the aircraft was refueled with 200 liters of jet fuel. According to the ATS flight plan, the pilot stated the total endurance to be 01:30 hrs and the Estimated Elapsed Time (EET) to be 00:30 hrs. The pilot informed the AIB DK that the estimated total endurance before takeoff at EDAY was approximately 01:00 hrs. The aircraft departed EDAY at 10:58. Enroute, the pilot observed a low fuel quantity warning light. Otherwise, the flight was uneventful until the approach to EKRN. At 11:32:00 hrs and at a distance of approximately18 nm southwest of EKRN, the pilot cancelled the IFR flight plan and continued VFR for a visual approach to runway 29. While descending inbound EKRN, the airspeed was decreasing. At 11:37:08 hrs, the pilot reported to Roenne Tower that the aircraft was turning final for runway 29. The aircraft was cleared to land. The wind conditions were reported to be 280° 19 knots maximum 29 knots. The aircraft was configured for landing (the landing gear was down and the flaps extended to 40°). On a left base to runway 29, both engines suffered from fuel starvation. At 11:39:18 hrs, the pilot three times declared an emergency. The aircraft entered a stall and impacted terrain in a field of sweet corn. A search and rescue mission was immediately initiated.
Probable cause:
CONCLUSION:
Inadequate en route fuel management resulted in fuel starvation of both engines, while the aircraft was flying at low altitude and the airspeed was decreasing. The dual engine flame out and the subsequent aircraft speed control led to an unrecoverable stall and consequently caused the accident.
FINDINGS:
On board the aircraft in the pilot’s personal belongings, the AIB DK found 2 Airline Transport Pilot Licenses (ATPL) issued by the US Federal Aviation Administration (FAA). The 2 US ATPL licenses had the same FAA license number but the names of the license holders were different. The names of the license holders were inconsistent with the pilot’s Iranian identity.
The BFU informed the AIB DK that the pilot was neither in possession of a valid German pilot license nor a German validation of an US license, which was required to operate a German registered aircraft.
The NTSB informed the AIB DK that the pilot was not in possession of a valid US pilot license.
It has not been possible for the AIB DK to determine whether or not the pilot was in possession of valid pilot license issued by another state.
The BFU informed the AIB DK that the certificate of aircraft registration was cancelled in 2009. Later on in the investigation, the BFU corrected this information. On February 2nd , 2012 and due to a missing airworthiness certificate, the Luftfahrt-Bundesamt (CAA - Germany) revoked the certificate of aircraft registration.
The latest valid airworthiness certificate was issued on the 8th of March 2004 and expired on the 31st of March 2005.
At the time of the accident, the aircraft was not recorded to be maintained by a JAR 145 maintenance organization, a maintenance program or a Continuing Airworthiness Management Organization (CAMO).
Final Report:

Crash of a Cessna 421B Golden Eagle II in Fort Worth

Date & Time: Sep 5, 2012 at 0949 LT
Operator:
Registration:
N69924
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Fort Worth - San Antonio
MSN:
421B-0553
YOM:
1973
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3800
Captain / Total hours on type:
897.00
Aircraft flight hours:
10056
Circumstances:
The commercial pilot was distracted by the nose cargo door popping open during takeoff; the airplane stalled and collided with trees off the end of the runway. The pilot said there were no mechanical problems with the airplane or engines and that he was fixated on the cargo door and lost control of the airplane. He also said that due to stress, he was not mentally prepared to handle the emergency situation.
Probable cause:
The pilot's failure to maintain airplane control on takeoff, which resulted in an inadvertent stall. Contributing to the accident were the unlatched nose cargo door, the pilot’s diverted attention, and the pilot's mental ability to handle the emergency situation.
Final Report:

Crash of a Piper PA-46R-350T Matrix off Jacarepaguá: 2 killed

Date & Time: Aug 21, 2012 at 1935 LT
Registration:
PT-FEM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Jacarepaguá – Campo de Marte
MSN:
46-92158
YOM:
2010
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after a night takeoff from Jacarepaguá Airport, the single engine aircraft entered an uncontrolled descent and crashed in the sea. Few debris were found several days later. The pilot's body was found on September 4 on a beach in Barra de Tijuca. The wreckage and the copilot's body were never found. It was reported that the crew did not activate the transponder after takeoff and did not contact ATC for unknown reasons.

Crash of a Beechcraft B60 Duke in Sedona: 3 killed

Date & Time: Jul 26, 2012 at 0830 LT
Type of aircraft:
Registration:
N880LY
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sedona – Albuquerque
MSN:
P-524
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
663
Captain / Total hours on type:
94.00
Aircraft flight hours:
3924
Circumstances:
Several witnesses observed the airplane before and during its takeoff roll on the morning of the accident. One witness observed the airplane for the entire event and stated that the run-up of the engines sounded normal. During the takeoff roll, the acceleration of the airplane appeared a little slower but the engines continued to sound normal. Directional control was maintained, and at midfield, the airplane had still not rotated. As the airplane continued down the 5,132-foot-long runway, it did not appear to be accelerating, and, about 100 yards from the end of the runway, it appeared that it was not going to stop. The airplane maintained contact with the runway and turned slightly right before it overran the end of the runway. The airplane was subsequently destroyed by impact forces and a postaccident fire. The wreckage was located at the bottom of a deep gully off the end of the runway. Postaccident examination of the area at the end of the runway revealed two distinct tire tracks, both of which crossed the asphalt and dirt overrun of 175 feet. A review of the airplane's weight and balance and performance data revealed that it was within its maximum gross takeoff weight and center of gravity limits. At the time of the accident, the density altitude was calculated to be 7,100 feet; the airport's elevation is 4,830 feet. For the weight of the airplane and density altitude at the time of the accident, it should have lifted off 2,805 feet down the runway; the distance to accelerate to takeoff speed and then to safely abort the takeoff and stop the airplane was calculated to be 4,900 feet. It is unknown whether the pilot completed performance calculations accounting for the density altitude. All flight control components were accounted for at the accident site. Although three witnesses indicated that the engines did not sound right at some point during the runup or takeoff, examination of the engine and airframe revealed no evidence of any preexisting mechanical malfunctions or failures that would have precluded normal operation. Propeller signatures were consistent with rotational forces being applied at the time of impact. No conclusive evidence was found to explain why the airplane did not rotate or why the pilot did not abort the takeoff once reaching the point to safely stop the airplane.
Probable cause:
The airplane's failure to rotate and the pilot's failure to reject the takeoff, which resulted in a runway overrun for reasons that could not be undetermined because postaccident examination of the airplane and engines did not reveal any malfunctions or failures that would have precluded normal operation.
Final Report:

Crash of a PZL-Mielec AN-2R near Serov: 13 killed

Date & Time: Jun 11, 2012 at 2211 LT
Type of aircraft:
Operator:
Registration:
RA-40312
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Serov - Serov
MSN:
1G221-48
YOM:
1986
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
13
Captain / Total flying hours:
8281
Captain / Total hours on type:
5977.00
Aircraft flight hours:
3966
Aircraft flight cycles:
12000
Circumstances:
In the evening of 11JUN2012, a group of 13 people departed Serov Airport at 2200LT on an illegal trip with an unknown destination, maybe for fishing, sauna or any other party. The aircraft failed to return and was lost without trace. Local Authorities performed search and rescue on more than 275,000 square km until 23JUL2012 without success. It seems that all occupants were intoxicated when they took the airplane, among them the Chief of Serov City Police, three of his deputies, an airport guard and several others. On Saturday 05MAY2013, local hunters found the burnt wreckage and the skeletonized remains of the bodies on a marshland, some 10 km southwest of Serov Airport.
Probable cause:
It is believed that the airplane was flying at low height when its left lower wing impacted tree tops. The aircraft then rolled to the left to an angle of 90° and crashed, bursting into flames. At the time of the accident, the pilot and other occupants were intoxicated.
Final Report:

Crash of a Pilatus PC-12/47 in Lake Wales: 6 killed

Date & Time: Jun 7, 2012 at 1235 LT
Type of aircraft:
Registration:
N950KA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Fort Pierce - Junction City
MSN:
730
YOM:
2006
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
755
Captain / Total hours on type:
38.00
Aircraft flight hours:
1263
Circumstances:
The airplane, registered to and operated by Roadside Ventures, LLC, departed controlled flight followed by subsequent inflight breakup near Lake Wales, Florida. Instrument meteorological conditions prevailed at the altitude and location of the departure from controlled flight and an instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight from St Lucie County International Airport (FPR), Fort Pierce, Florida, to Freeman Field Airport (3JC), Junction City, Kansas. The airplane was substantially damaged and the private pilot and five passengers were fatally injured. The flight originated from FPR about 1205. After departure while proceeding in a west-northwesterly direction and climbing, air traffic control communications were transferred to Miami Air Route Traffic Control Center (Miami ARTCC). The pilot remained in contact with various sectors of that facility from 1206:41, to the last communication at 1233:16. About 6 minutes after takeoff the pilot was advised by the Miami ARTCC Stoop Sector radar controller of an area of moderate to heavy precipitation twelve to two o'clock 15 miles ahead of the airplane's position; the returns were reported to be 30 miles in diameter. The pilot asked the controller if he needed to circumnavigate the weather, to which the controller replied that deviations north of course were approved and when able to proceed direct LAL, which he acknowledged. A trainee controller and a controller providing oversight discussed off frequency that deviation to the south would be better. The controller then questioned the pilot about his route, to which he replied, and the controller then advised the pilot that deviations south of course were approved, which he acknowledged. The flight continued in generally a west-northwesterly direction, or about 290 degrees, and at 1230:11, while at flight level (FL) 235, the controller cleared the flight to FL260, which the pilot acknowledged. At 1232:26, the aircraft's central advisory and warning system (CAWS) recorded that the pusher system went into "ice mode" indicating the pilot had selected the propeller heat on and inertial separator open. At that time the aircraft's engine information system (EIS) recorded the airplane at 24,668 feet pressure altitude, 110 knots indicated airspeed (KIAS), and an outside air temperature of minus 11 degrees Celsius. At 1232:36, the Miami ARTCC Avon Sector radar controller advised the pilot of a large area of precipitation northwest of Lakeland, with moderate, heavy and extreme echoes in the northwest, and asked him to look at it and to advise what direction he needed to deviate, then suggested deviation right of course until north of the adverse weather. The pilot responded that he agreed, and the controller asked the pilot what heading from his position would keep the airplane clear, to which he responded at 1233:04 with, 320 degrees. At 1233:08, the Miami ARTCC Avon Sector radar controller cleared the pilot to fly heading 320 degrees or to deviate right of course when necessary, and when able proceed direct to Seminole, which he acknowledged at 1233:16. There was no further recorded communication from the pilot with the Miami ARTCC. Radar data showed that between 1233:08, and 1233:26, the airplane flew on a heading of approximately 290 degrees, and climbed from FL250 to FL251, while the EIS recorded for the same time the airplane was at either 109 or 110 KIAS and the outside air temperature was minus 12 degrees Celsius. The radar data indicated that between 1233:26 and 1233:31, the airplane climbed to FL252 (highest recorded altitude from secondary radar returns). At 1233:30, while at slightly less than 25 degrees of right bank based on the NTSB Radar Performance Study based on the radar returns, 109 KIAS, 25,188 feet and total air temperature of minus 12 degrees Celsius based on the data downloaded from the CAWS, autopilot disengagement occurred. This was recorded on the CAWS 3 seconds later. The NTSB Performance Study also indicates that based on radar returns between 1233:30, and 1233:40, the bank angle increased from less than approximately 25 degrees to 50 degrees, while the radar data for the approximate same time period indicates the airplane descended to FL249. The NTSB Performance Study indicates that based on radar returns between 1233:40 and 1234:00, the bank angle increased from 50 degrees to approximately 100 degrees, while the radar data indicates that for the approximate same time frames, the airplane descended from FL249 to FL226. The right descending turn continued and between 1233:59, and 1234:12, the airplane descended from 22,600 to 16,700, and a change to a southerly heading was noted. The NTSB Performance Study indicates that the maximum positive load factor of 4.6 occurred at 1234:08, while the NTSB Electronic Device Factual Report indicates that the maximum recorded airspeed value of 338 knots recorded by the EIS occurred at 1234:14. The next recoded airspeed value 1 second later was noted to be zero. Simultaneous to the zero airspeed a near level altitude of 15,292 feet was noted. Between 1234:22, and 1234:40, the radar data indicated a change in direction to a northeast occurred and the airplane descended from 13,300 to 9,900 feet. The airplane continued generally in a northeasterly direction and between 1234:40 and 1235:40 (last secondary radar return), the airplane descended from 9,900 to 800 feet. The last secondary radar return was located at 27 degrees 49.35 minutes North latitude and 081 degrees 28.6332 minutes West longitude. Plots of the radar targets of the accident site including the final radar targets are depicted in the NTSB Radar Study which is contained in the NTSB public docket. At 1235:27, the controller asked the pilot to report his altitude but there was no reply. The controller enlisted the aid of the flight crew of another airplane to attempt to establish contact with the pilot on the current frequency and also 121.5 MHz. The flight crew attempted on both frequencies but there was no reply. At 1236:30, the pilot of a nearby airplane advised the controller that he was picking up an emergency locator transmitter (ELT) signal. The pilot of that airplane advised the controller at 1237:19, that, "right before we heard that ELT we heard a mayday mayday." The controller inquired whether the pilot had heard the mayday on the current frequency or 121.5 MHz, to which he replied that he was not sure because he was monitoring both frequencies. The controller inquired with the flight crews of other airplanes if they heard the mayday call on the frequency and the response was negative, though they did report hearing the ELT on 121.5 MHz. The controller verified with the flight crew's that were monitoring 121.5 MHz whether they heard the mayday call on that frequency and they advised they did not. A witness who was located about 1.5 nautical miles south-southwest from the crash site reported that on the date and time of the accident, he was inside his house and first heard a sound he attributed to a propeller feathering or later described as flutter of a flight control surface. The sound lasted 3 to 4 cycles of a whooshing high to low sound, followed by a sound he described as an energy release. He was clear the sound he heard was not an explosion, but more like mechanical fracture of parts. He ran outside, and first saw the airplane below the clouds (ceiling was estimated to be 10,000 feet). He noted by silhouette that parts of the airplane were missing, but he did not see any parts separate from the airplane during the time he saw it. At that time it was not raining at his location. He went inside his house, and got a digital camera, then ran back outside to his pool deck, and videotaped the descent. He reported the airplane was in a spin but could not recall the direction. The engine sound was consistent the whole time; there was no revving; he reported there was no forward movement. He called 911 and reported the accident. Another witness who was located about .4 nautical mile east-southeast of from the crash site reported hearing a boom sound that he attributed to a lawn mower which he thought odd because it had just been raining, though it was not raining at the time of the accident. He saw black smoke trailing the airplane which was spinning in what he described as a clockwise direction and flat. He ran to the side of their house, and noted the airplane was still spinning; the smoke he observed continued until he lost sight. His brother came by their back door, heard a thud, and both ran direct to the location of where they thought the airplane had crashed. When they arrived at the wreckage, they saw fire in front of the airplane which one individual attempted to extinguish by throwing sand on it, but he was unable. The other individual reported the left forward door was hard to open, but he pushed it up and then was able to open it. Both attempted to render assistance, and one individual called 911 to report the accident. One individual then guided local first responders to the accident site. The airplane crashed in an open field during daylight conditions. The location of the main wreckage was determined to be within approximately 100 feet from the last secondary radar return. Law Enforcement personnel responded to the site and accounted for five occupants. A search for the sixth occupant was immediately initiated by numerous personnel from several state agencies; he was located the following day about 1420. During that search, parts from the airplane located away from the main wreckage were documented and secured in-situ.
Probable cause:
The failure of the pilot to maintain control of the airplane while climbing to cruise altitude in instrument meteorological conditions (IMC) following disconnect of the autopilot. The reason for the autopilot disconnect could not be determined during postaccident testing. Contributing to the accident was the pilot's lack of experience in high-performance, turbo-propeller airplanes and in IMC.
Final Report:

Crash of a Learjet 60 in Aspen

Date & Time: Jun 7, 2012 at 1224 LT
Type of aircraft:
Registration:
N500SW
Flight Type:
Survivors:
Yes
Schedule:
Miami-Opa Locka - Aspen
MSN:
60-017
YOM:
1993
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18000
Captain / Total hours on type:
600.00
Copilot / Total flying hours:
13500
Aircraft flight hours:
6456
Circumstances:
While the first officer was flying the airplane on a visual approach to the airport located in a steep mountain valley, the tower controller informed him that the pilot of a Citation that had landed about 10 minutes earlier had reported low-level windshear with a 15-knot loss of airspeed on short final. The first officer used the spoilers while on the left base leg and then maneuvered the airplane in an "S-turn" on the final leg to correct for a too-steep approach. Just as the airplane was about to touch down with the airspeed decreasing, the captain made several calls for "power" and then called for a "go around." However, the first officer did not add power for a go-around, and the captain did not take control of the airplane. Both pilots reported that, when the airplane was about 30 ft above ground level (agl), they felt a sensation that the airplane had "stopped flying" with a simultaneous left roll, which is indicative of an aerodynamic stall, followed by an immediate impact with terrain. After striking obstructions that completely separated the right main landing gear and the right flap, the airplane came to rest upright in the dirt on the side of the runway about 4,000 ft from the initial impact point. The airplane sustained substantial damage to the fuselage and both wings. All eight occupants evacuated through the main cabin door. There was a substantial fuel spill but no postimpact fire. Both pilots reported no mechanical malfunctions or failures of the airplane, and neither pilot reported an uncommanded loss of engine power. Data from the enhanced ground proximity warning system showed that seven warning events occurred in the last 3 minutes before the accident. The first warning was for "sink rate," and it occurred when the airplane was about 1,317 ft agl and in a 3,400-ft-per-minute descent. The last warning was for "bank angle," and it occurred about 10 seconds before touchdown as the airplane exceeded 42 degrees of bank when it was about 200 ft agl. The wind recorded at the airport at the time of the accident would have resulted in a 12-knot variable tailwind with gusts to 18 knots. The evidence is consistent with the first officer flying a non stabilized approach with a decreasing airspeed during low-level windshear conditions. The first officer did not properly compensate for the known low-level windshear conditions and allowed the airspeed to continue to decrease and the bank angle to increase until the airplane experienced an aerodynamic stall.
Probable cause:
The first officer's failure to maintain adequate airspeed and his exceedance of the airplane's critical angle-of-attack during the final approach in known low-level windshear conditions, which resulted in an aerodynamic stall. Contributing to the accident were the first officer's failure to initiate a go-around when commanded and the captain's lack of remedial action when he recognized that the approach was unstabilized.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Peachland: 3 killed

Date & Time: May 13, 2012 at 1845 LT
Type of aircraft:
Operator:
Registration:
C-GCZA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Okanagan Lake - Pitt Meadows
MSN:
1667
YOM:
1966
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
420
Captain / Total hours on type:
50.00
Circumstances:
The privately operated de Havilland DHC-2 MK 1 amphibious floatplane (registration C-GCZA, serial number 1667) departed Okanagan Lake, near Kelowna, for a daytime flight under visual flight rules to Pitt Meadows, British Columbia, with the pilot and 2 passengers on board. While enroute, the aircraft struck trees and collided with terrain close to and 100 feet below the level of Highway 97C, near the Brenda Mines tailings hill. At 1850 Pacific Daylight Time, a brief 406-megahertz emergency-locator-transmitter signal was detected, which identified the aircraft; however, a location could not be determined. Most of the aircraft was consumed by a post-impact fire. The 3 occupants were fatally injured.
Probable cause:
There was no indication that an aircraft system malfunction contributed to this occurrence. There were no drastic changes in the aircraft’s flight path, and no emergency calls from the pilot to indicate that an in-flight emergency was experienced. The constant ground speed and flight path would also suggest that the aircraft was under the control of the pilot. As a result, this analysis will focus on the phenomenon of controlled flight into terrain (CFIT).
Findings as to Causes and Contributing Factors:
1. The combination of relatively high weight, effects of density altitude, and down-flowing air likely reduced the climb performance of the aircraft, resulting in the aircraft’s altitude being lower than anticipated at that stage in the flight.
2. The pilot’s vision was likely impaired by the sun, and the pilot may have been exposed to visual illusions; both were factors that contributed to the pilot not noticing the trees and the rising terrain, and colliding with them.
Findings as to Risk:
1. Visual illusions cause false impressions or misconceptions of actual conditions. Unrecognized and uncorrected spatial disorientation, caused by illusions, carries a high risk of incident or accident.
2. When there are no special departure procedures published for airports in mountainous regions surrounded by high terrain, there is a risk of pilots departing the valley at an altitude too low for terrain clearance.
Other Findings:
1. Information from the Wide Area Multilateration system was not preserved following the occurrence, as local NAV CANADA personnel were not aware that unfiltered data were only available for a limited time.
Final Report: