Crash of a Beechcraft 350 Super King Air in Porto Seguro: 14 killed

Date & Time: May 22, 2009 at 2053 LT
Registration:
PR-MOZ
Flight Type:
Survivors:
No
Schedule:
São Paulo – Porto Seguro
MSN:
FL-237
YOM:
1999
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
14
Captain / Total flying hours:
20000
Captain / Total hours on type:
5000.00
Copilot / Total flying hours:
357
Copilot / Total hours on type:
107
Circumstances:
The twin engine aircraft departed São Paulo-Congonhas Airport at 1831LT on a private flight to Porto Seguro, carrying 12 passengers and two pilots, among them the Brazilian Businessman Roger Wright, his wife, children and grandchildren. On approach to Porto Seguro-Terravista Golf Club Airport, the crew encountered poor weather conditions and the visibility was low due to the night. On final approach to runway 15, the aircraft impacted trees located 900 metres from the runway threshold. The aircraft continued for about 700 metres then struck others trees and crashed 200 metres short of runway, bursting into flames. The aircraft was totally destroyed and all 14 occupants were killed.
Probable cause:
The crew's decision to continue the approach in poor weather conditions following a high motivation to land at destination.
The following contributing factors were identified:
- The crew failed to follow the published procedures,
- The crew did not take the bad weather conditions into consideration and took the decision to land,
- Limited visibility due to rain falls and night,
- Weather conditions affected the perception of the pilots who suffered a loss of situational awareness,
- Poor judgment of the situation and flight conditions on part of the crew,
- The crew continued the approach under VFR mode in IMC conditions,
- The crew carried out an improvised VFR approach via a GPS system,
- Excessive approach speed,
- Poor crew coordination,
- Lack of crew discipline.
Final Report:

Crash of an Epic LT off Astoria

Date & Time: Apr 24, 2009 at 1645 LT
Type of aircraft:
Registration:
N653SB
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Astoria – Seattle
MSN:
025
YOM:
2008
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1550
Captain / Total hours on type:
75.00
Aircraft flight hours:
72
Circumstances:
The single engine aircraft departed Astoria Airport at 1637LT on a private flight to Seattle-Boeing Field, carrying one passenger (a female passenger aged 84) and one pilot. During a climb to en route cruise, the airplane's engine lost almost all power, and the pilot elected to ditch the airplane into the Columbia River off Astoria. The airplane crash landed eight minutes later, nosed down in water and came to rest partially submerged. Both occupants were quickly rescued and were uninjured. The aircraft was damaged beyond repair.
Probable cause:
The partial loss of engine power during climb to cruise due to the failure of the engine's fuel control unit. Contributing to the accident was the incorrect machining of an internal component of the fuel control unit, and the failure of the assembling technician to correctly inspect the unit's assembly.
Final Report:

Crash of a Rockwell Aero Commander 500 in Gaborone

Date & Time: Apr 6, 2009
Operator:
Registration:
A2-ATI
Flight Type:
Survivors:
Yes
Schedule:
Kasane – Gaborone
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing at Gaborone-Seretse Khama Airport, the twin engine aircraft went out of control, flipped over and crashed, coming to rest upside down on the runway edge. All five occupants were injured and the aircraft was destroyed. The aircraft type is not confirmed.

Crash of a Pilatus PC-12/45 in Butte: 14 killed

Date & Time: Mar 22, 2009 at 1430 LT
Type of aircraft:
Registration:
N128CM
Flight Type:
Survivors:
No
Schedule:
Oroville - Bozeman
MSN:
403
YOM:
2001
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
14
Captain / Total flying hours:
8840
Captain / Total hours on type:
1760.00
Aircraft flight hours:
1916
Circumstances:
On March 22, 2009, about 1432 mountain daylight time, a Pilatus PC-12/45, N128CM, was diverting to Bert Mooney Airport (BTM), Butte, Montana, when it crashed about 2,100 feet west of runway 33 at BTM. The pilot and the 13 airplane passengers were fatally injured, and the airplane was substantially damaged by impact forces and a post crash fire. The airplane was owned by Eagle Cap Leasing of Enterprise, Oregon, and was operating as a personal flight under the provisions of 14 Code of Federal Regulations Part 91. The flight departed Oroville Municipal Airport, Oroville, California, on an instrument flight rules flight plan with a destination of Gallatin Field, Bozeman, Montana. Visual meteorological conditions prevailed at the time of the accident.
Probable cause:
(1) the pilot’s failure to ensure that a fuel system icing inhibitor was added to the fuel before the flights on the day of the accident;
(2) his failure to take appropriate remedial actions after a low fuel pressure state (resulting from icing within the fuel system) and a lateral fuel imbalance developed, including diverting to a suitable airport before the fuel imbalance became extreme; and
(3) a loss of control while the pilot was maneuvering the left-wing-heavy airplane near the approach end of the runway.
Final Report:

Crash of a Dassault Falcon 100 in Samedan: 2 killed

Date & Time: Feb 12, 2009 at 1612 LT
Type of aircraft:
Operator:
Registration:
VP-BAF
Flight Type:
Survivors:
Yes
Schedule:
Vienna - Samedan
MSN:
210
YOM:
1987
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
17269
Captain / Total hours on type:
739.00
Copilot / Total flying hours:
2591
Copilot / Total hours on type:
119
Aircraft flight hours:
6386
Circumstances:
On 12 February 2009, the Marcel Dassault/Bréguet Aviation Falcon 10 aircraft, registration VP-BAF, took off at 14:06 UTC from Vienna (LOWW) on a private flight under instrument flight rules (IFR) and an ATC flight plan Y, to Samedan (LSZS). Two crew members and one passenger were on board. After an uneventful flight, the IFR flight plan was cancelled at 14:56:32 UTC and the flight continued under visual flight rules (VFR). Over Samedan the crew were informed by the Samedan airport flight information service officer (FISO) that snow clearance work would be taking place on the runway and that they should expect a ten-minute delay. After approximately 15 minutes the crew initiated the approach. On landing, the aircraft made first contact with the ground by scraping the right wing on the left half of the runway and subsequently touched down with the right, and then the left main landing gear. It then drifted to the left and the left wing tip scraped a bank of snow running parallel to the runway. As a result it rotated anti-clockwise around its vertical axis and crashed into a frozen bank of snow about four metres high. The aircraft broke into two pieces as a result of the force of the impact. The two pilots suffered fatal injuries on the impact. The passenger was seriously injured. The aircraft was destroyed. Fire did not break out.
Probable cause:
The accident is attributable to the fact that the crew wanted to make a landing with inadequate visual references from an unfavorable initial position and as a result, after touchdown the aircraft collided with a snowbank running along the runway.
The following factors contributed to the accident:
• The rapidly changing weather conditions on the mountain aerodrome of Samedan were misjudged by the crew.
• A coordinated crew working method in terms of crew resource manage-ment was missing.
• The deactivation of the EGPWS, which meant that acoustic messages con-cerning the aircraft’s height above ground and bank angle were no longer available in the final phase of the approach up to the first contact with the runway.
• A snowbank up to four metres high ran along the edge of the runway.
Final Report:

Crash of a Pilatus PC-12/45 in Hayden: 2 killed

Date & Time: Jan 11, 2009 at 0942 LT
Type of aircraft:
Registration:
N604WP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hayden - Chino
MSN:
604
YOM:
2004
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
867
Captain / Total hours on type:
82.00
Aircraft flight hours:
558
Circumstances:
The pilot had filed an instrument flight rules flight plan with a planned departure time of 0700 in order to arrive at his intended destination in time for a planned engagement. He and his passenger arrived at the airport approximately 0800 and requested that the airplane be fueled. The airplane was pulled from its heated hangar into heavy snowfall and fueled at 0917. As the airplane sat outside in the heavy snowfall, a measurable amount of wet slushy snow accumulated on the airplane. The Fixed Base Operator manager suggested to the pilot that the airplane be deiced, but he declined. The airplane was then pulled out to the taxiway in an effort to prevent it from becoming stuck in the snow. At 0939, approximately 22 minutes after the airplane was pulled out if its hangar, the pilot departed with a visibility of 3/4 of a mile in snow and with a 4-knot direct tailwind. The pilot then made a right turn and announced that he was heading to his first waypoint. The airplane continued into an ever tightening right turn until it impacted the ground while in an inverted position about one mile north-northwest of the runway. An examination of the airplane’s wreckage revealed no anomalies with either the engine or airframe that would have contributed to the loss of control. The airplane’s Pilot Operating Handbook and Airplane Flight Manual contained the following limitation: "The aircraft must be clear of all deposits of snow, ice and frost adhering to the lifting surfaces immediately prior to takeoff."
Probable cause:
The pilot's loss of control due to snow/ice contamination on the airplane's lifting surfaces as a result of his decision not to deice the airplane before departure.
Final Report:

Crash of a Raytheon 390 Premier in Lewistown

Date & Time: Dec 23, 2008 at 1500 LT
Type of aircraft:
Registration:
N20NL
Flight Type:
Survivors:
Yes
Schedule:
Kansas City - Lewistown
MSN:
RB-106
YOM:
2004
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13750
Captain / Total hours on type:
1927.00
Aircraft flight hours:
1927
Circumstances:
Prior to departure, the pilot was informed that it had been raining; the roads were wet, but no mention of ice at his destination. During the approach to the destination airport, the runway appeared "wet", and a normal approach and landing was attempted. The airplane touched down at 110 knots, the pilot "then deployed lift dump and [then applied the] brakes". Unable to get braking action, the pilot tried to slide the airplane "left and right" to get traction, but could not. The airplane departed the south end of the 4,370-foot-long runway, went over the edge of an embankment and stopped next to a levee. There were no reported pre-impact malfunctions with the airplane. The Manufacturer Approved Airplane Flight Manual Supplement for Airplanes Operating on Wet and contaminated Runways; General Information Section, states operations on runways contaminated with ice or wet ice are not recommended and no operational information is provided. Using the supplement, the anticipated landing distance on a wet runway was calculated to be about 3,400 feet, the anticipated landing distance on an uncontaminated runway was calculated to be approximately 2,800 feet, and the prescribed landing speed (Vref) was determined to be about 111 knots. A braking action (runway condition) report for the private airfield's runway did not exist, nor was one required.
Probable cause:
The pilot's loss of directional control during landing on an ice-contaminated runway.
Final Report:

Crash of a Piper PA-46-310P Malibu in Hayden: 2 killed

Date & Time: Dec 22, 2008 at 1218 LT
Registration:
N46SB
Flight Type:
Survivors:
No
Schedule:
Hutchinson – Hayden
MSN:
46-8608039
YOM:
1986
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1967
Captain / Total hours on type:
823.00
Copilot / Total flying hours:
2067
Copilot / Total hours on type:
798
Aircraft flight hours:
3302
Circumstances:
Radar data showed the airplane proceeding outbound for the procedure turn. The pilot reported that they were having trouble extending the landing gear and stated, " ... we’re trying to turn back in and do our gear here all at the same time." Shortly thereafter, the other pilot reported that they had extended the gear and had "three good, three green lights, so we’re hoping the gear is down." The pilot also said, "we are now turned inbound." She was told to contact Unicom. This was the last recorded radio transmission from the flight. The Unicom operator said that she heard the pilot say that they were "coming in." Radar data indicated the airplane crossed the localizer at almost a 90-degree angle and continued turning right until it started to intercept the localizer. The data then indicated that the airplane made a left turn away from the localizer that continued and terminated near the accident site. The turn was captured by six plots. The first plot showed the airplane had descended from 9,400 feet to 9,200 feet and its ground speed had increased from 85 knots to 152 knots. The second plot showed the altitude had increased to 9,700 feet and ground speed had decreased to 132 knots. The third plot showed the altitude had increased further to 10,200 feet and ground speed had dropped to 76 knots. The fourth plot showed the airplane had made almost a 180-degree turn and was at 8,900 feet and at a ground speed of 120 knots. The fifth plot showed the airplane was at 8,700 feet and 20 knots. The sixth and final plot showed the airplane at 8,400 feet and 38 knots. An examination of the airplane showed both wing flap jackscrews retracted and the landing gear actuators extended. The landing gear control switch was in the down position and the emergency gear extension knob was pulled out to full travel. Reduced visibility and clouds were in the vicinity of the airport at the time of the accident.
Probable cause:
The pilot's loss of situational awareness while maneuvering in adverse weather conditions, resulting in spatial disorientation.
Final Report:

Crash of a Piper PA-31T-500 Cheyenne I in Buenos Aires: 2 killed

Date & Time: Dec 18, 2008 at 0619 LT
Type of aircraft:
Operator:
Registration:
LV-MYX
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Buenos Aires – Victoria
MSN:
31-7904045
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
13109
Captain / Total hours on type:
31.00
Circumstances:
Shortly after a night takeoff from runway 05 at Buenos Aires-San Fernando Airport, the pilot initiated a left turn at low altitude when the twin engine aircraft collided with two poles and two parked trucks then crashed on the ground, bursting into flames. The aircraft was totally destroyed and both occupants were killed.
Probable cause:
A loss of power on the left engine shortly after takeoff for undetermined reasons.
The following contributing factors were identified:
- A probable inadequate compliance with emergency procedures,
- Probable little and discontinuous flight activity on the aircraft type during the year 2008,
- Low turn.
Final Report:

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

Date & Time: Dec 1, 2008 at 2000 LT
Operator:
Registration:
N9095K
Flight Type:
Survivors:
Yes
Schedule:
Mexico City – Cali
MSN:
46-08023
YOM:
1986
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft was completing a flight from Mexico City to Cali, carrying five passengers and one pilot on behalf of the Cristina Adventista Congregation. While approaching León-Fanor Urroz Airport, the aircraft crashed by a wooded area. All six occupants were seriously injured and the aircraft was destroyed.