North America

On June 03, 2022, about 1347 Pacific daylight time, a Cessna C208B Supervan 900 airplane, N7581F, was substantially damaged when it was involved in an accident near Bob Maxwell Memorial Airfield, Oceanside, California. The left-seated pilot was fatally injured and right seated pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 skydiving flight. On the day of the accident, the pilots were performing skydiving flights while the right-seated pilot was training the left-seated pilot on the operation. A flight would consist of the pilots taking a group of approximately 17 skydivers to an altitude of about 11,500 feet mean sea level (msl) to jump out and then they would land back at the airport. The flights started about 1015 and were an average of 17 minutes in duration with about 15 minutes on the ground between each flight; the airplane’s engine was operating the entire duration. The pilots completed six flights without incident and departed on the accident flight at 1331. The right-seated pilot stated that he could not recall many of the details leading up to the accident. He remembered that on the accident flight everything was normal with the departure and the unloading of the skydivers. The airplane was descending as expected with the power at idle. As the airplane turned onto final approach, about 3 miles from the approach end of runway 25, the right-seated pilot attempted to increase the power by slightly nudging the throttle forward. He noticed that the engine power did not increase as expected and moved the throttle lever further forward. The lever was still unresponsive, and he estimated the airplane was about 400 ft above ground level (agl). He aimed for an open dirt field and observed a berm in the immediate flight path. In an effort to avoid the berm, the pilot maneuvered the airplane into a right turn.Investigators reviewed Federal Aviation Administration (FAA) provided Automatic Dependent Surveillance-Broadcast (ADS-B) flight track data covering the area of the accident during the time surrounding the accident. After departing from runway 25, the airplane made a gradual climb to 11,575 ft msl as it circled to the right, back to the airport. The airspeed was reduced (presumably to unload the skydivers) and then the airplane made a steep, turning decent reaching 133 kts when transitioning to the downwind leg of the traffic pattern. The airplane was at an altitude of about 2,400 ft msl and 2.6 nautical miles (nm) from the approach end of runway 25 when it turned onto final approach. When the airplane was about 2 nm from the runway, it made a 360° right turn which was about 0.5 nm in diameter. At 1346:10, about 1,025 ft msl, the airplane rolled out of the 360° turn and continue west toward the runway. The airplane was roughly following Highway 76 making a gradual decent (see Figure 2 below). About 33 seconds later the airplane’s speed dropped to 92 kts as it passed through 500 ft msl. The last recorded hit was at 1347:10 and located about 975 feet east of the accident site. At that time, the data indicated that the airplane was at 100 msl (equivalent to 60 feet above ground level) at a speed of 68 kts. Witness stated that they observed the airplane flying at a very low altitude (see Figure 3). The airplane then pitched down in a nose-low attitude and bank to the right. The airplane impacted terrain and collided with the side of a berm.

The purpose of the flight was to transport three passengers and cargo. The pilot reported that, during takeoff, the airplane’s tail came up slightly lowered to the runway when he attempted to raise the tail by applying forward elevator. He stated that he thought this was unusual and attributed it to an aft-loaded airplane. He applied additional nose-down trim and departed without incident. While en route, the tail of the airplane seemed to move up and down, which the pilot attributed to turbulence. Upon arrival at his destination, the pilot entered a left downwind, reduced the power and extended the flaps to 10° abeam the end of the runway. He turned onto the base leg about ½ mile from the approach end of the runway and slowed the airplane to 80 mph. Turning final, he noticed the airplane seemed to pitch up, so he applied full nose-down pitch trim and extended the flaps an additional 10°. On short final he applied full flaps, and the airplane abruptly pitched up to about a 45° angle. He stated that he applied full nose-down elevator, verified the pitch trim, and reduced the power to idle. When the airplane was about 300 ft above ground level, the airplane stalled, the left wing dropped slightly, and the airplane entered about a 45° nose-down dive. After allowing the airplane to gain airspeed, the pilot applied full back elevator. The airplane impacted forested terrain near the approach end of runway 23 at an elevation of about 18 ft. A postaccident examination of the airframe and engine revealed no evidence of preaccident mechanical malfunctions or failures that would have precluded normal operation. Elevator and rudder control continuity was confirmed from the cockpit to the respective control surfaces. The airplane's estimated gross weight at the time of the accident was about 7,796 lbs and the airplane's estimated center of gravity was about 3.2 to 5.6 inches beyond the approved aft limit. Maximum gross weight for the airplane is 8,000 lbs.

The pilot and passenger departed on a cross-country flight. Automatic dependent surveillance – broadcast (ADS-B) data indicated that the airplane flew at a cruise altitude between 11,000 ft and 13,000 ft mean sea level (msl) on a north to northeast heading consistent with its planned destination for most of the flight. About 30 minutes before the end of the flight, the airplane began a descent and then turned east. Shortly thereafter, the pilot of the airplane declared minimum fuel with air traffic control (ATC). A few minutes later the pilot declared critical fuel due to a fuel leak. The pilot stated in his last communication that he would attempt to make a nearby airport. Subsequently, the airplane impacted hilly, desert terrain at an elevation of about 5,780 ft and on a heading of about 034°. An acquaintance of the pilot who was a flight instructor stated that, on the two previous flights he had flown with the pilot, the left wing of the airplane felt heavy. The accident pilot thought it was because of a fuel imbalance. The postaccident examination revealed that the left tank fuel valve was positioned ON and the right tank valve was positioned OFF, consistent with the pilot balancing the fuel by feeding from the left-wing fuel tank. It is possible that when the pilot noticed the minimum fuel status, he failed to recall that he had previously selected the rightside fuel tank OFF, and thus did not have this fuel available. Given that the cruise altitudes on the accident flight were similar to what the previous owner used to make his fuel range and duration estimates, even with about a 20% reduction in fuel due to the pilot allowing 2 inches from the top of the fuel tanks during refueling, the airplane should have had adequate fuel to make its destination. A strong smell of fuel and fuel staining were also observed at the accident site. Page 2 of 11 WPR22FA173 A review of radar imagery from Boise, Idaho, revealed that the airplane flew through several areas of light to moderate intensity echoes as it proceeded northward, and then after turning eastward, the airplane’s fight track was through an area of moderate to heavy intensity echoes. The accident site was located on the southeast edge of the echo. Light-to-moderate icing conditions in the clouds with clear to mixed type icing below 12,000 ft msl were expected. Thus, it is likely that the airplane, which was not certified for flight in icing, encountered icing in the final portion of the flight. The pilot was flying with insulin-dependent diabetes, having type 1 diabetes mellitus. Given the urine glucose level of 29mg/dL, no detectable glucose in vitreous fluid, and ongoing verbal communication, it is unlikely that the pilot was experiencing significant metabolic disturbance from high blood glucose. Whether he was experiencing less severe effects of high blood sugar could not be determined. Whether he had symptoms of low blood glucose, such as diminished concentration or increased nervousness, is unknown. The pilot’s use of diphenhydramine (Benadryl), which can cause sleepiness, was likely not a factor due to fact that it was detected only in the urine and not in the blood. Thus, it is unlikely that effects of the pilot’s diphenhydramine use contributed to the accident. Accident site signatures and a review of the weather were consistent with a loss of control of the airplane. In addition, an examination of the airframe and engine revealed no evidence of any preimpact mechanical failures or malfunctions that would have precluded normal operation. It is likely that, while maneuvering to an alternate airport due to a critical fuel situation, in icing conditions, the pilot failed to maintain the proper airspeed, which resulted in the exceedance of the airplane’s critical angle of attack and the airplane experiencing an aerodynamic stall.

The pilot reported that, before the flight, the airplane was fueled with 140 gallons of Jet A fuel. Shortly after takeoff, both engines lost total power. Because the airplane had insufficient altitude to return to the airport, the pilot executed a forced landing to a field and the left wing sustained substantial damage. A postcrash fire ensued. The investigation determined that the airplane was inadvertently fueled with Jet A fuel rather than AVGAS, which was required for the airplane’s reciprocating engines. The line service worker who fueled the airplane reported that there were no decals at the airplane fuel ports; however, postaccident examination of the airplane found that a decal specifying AVGAS was present at the right-wing fuel port. The investigation could not determine whether the same or a similar decal was present at the left-wing fuel port because the left wing was partially consumed during the postimpact fire.

The student pilot, who was the new owner of the multi-engine airplane, and a private pilot flew commercially to Lubbock, Texas, utilized a ride-hailing service to drive to Portales, New Mexico; they met with the former owner of the airplane to finalize the purchase of the airplane and flew it back to Georgia the same day. The next day, the student pilot commenced flight training with the private pilot who offered to provide flight instruction to the student pilot in the student pilot’s newly acquired multi-engine airplane, even though he did not possess a flight instructor’s rating or a multi-engine airplane rating. Radar data showed that the track of the accident airplane's route consisted of their departure airport, a midway stop, and the third leg of the flight, where it crashed during the approach to their destination airport. Witnesses observed a sharp right turn before the airplane’s spiraling descent and impact with terrain and unoccupied semi-trailers. Surveillance footage from a parking lot security camera captured the airplane in a right spiral turn just before the accident. The airplane was destroyed by impact forces and the postimpact fire. The postaccident examination of the airframe, engines, and propellers revealed no anomalies that would preclude normal engine and airplane performance. Additionally, a review of the maintenance logbook revealed that the airplane was overdue for its annual maintenance inspection; no special flight permit (ferry permit) was obtained from the Federal Aviation Administration (FAA) for its return flight to Georgia. Toxicological testing of the student pilot revealed the presence amphetamine, a prescription Schedule II controlled substance that may result in cognitive deficits that pose a risk to aviation safety; however, its effect, if any on the accident flight could not be determined. It is likely that the private pilot’s failure to maintain aircraft control was exacerbated by his lack of a multi-engine airplane rating, his lack of a flight instructor rating, and his poor decision making.

The pilot flew two RNAV (GPS) runway 20 instrument approaches at the Burley Municipal Airport, Burley, Idaho in instrument meteorological conditions (IMC). The accident occurred during the second approach. For the first instrument approach, the pilot configured the airplane with flaps up and flew the final approach segment at speeds above the operator’s training standard of 120 knots indicated airspeed (KIAS).The pilot flew a low pass over the runway, most likely to assess the landing conditions in accordance with company policy, determined the conditions were acceptable, initiated the missed approach and requested to return flying the same approach. The pilot elected to not use flaps during the second approach but slowed the approach speed during the final approach leg. Reported weather had improved and visibility had increased to about 2.5 miles. During this approach, the airplane intercepted and remained on the glide path to the stepdown fix. The last automatic dependent surveillance - broadcast (ADS-B) equipment plot recorded the airplane about a mile past this fix, or about 0.6 nautical miles (nm) from the displaced threshold, on the glide path, and at an estimated 85 knots calibrated airspeed (KCAS), which was slower than the airplane’s 95-knot minimum speed for flaps up in icing conditions. Shortly afterward, the airplane descended about 130 ft below the glide path, striking an agglomerate stack atop a potato processing plant, fatally injuring the pilot and substantially damaging the airplane. A witness reported seeing the airplane come out of the clouds and immediately enter a steam cloud coming from six other stacks before striking the accident stack. A security camera at the processing plant captured the last moments of the airplane’s flight as it came into view in a wings-level, flaps-up, nose-high descent and just before it impacted the stack. While snow and visible moisture were present, the agglomerate stack was always in clear view during the Page 2 of 24 WPR22FA151 video, with only partial sections obscured. The witness’s account of hearing the engine noise increase and then the nose lift-up may have been the pilot’s attempt to avoid the obstacle. The Federal Aviation Administration’s (FAA) Aeronautical Information Manual advises pilots to avoid overflight of exhaust stacks; however, the accident stack was directly underneath the instrument approach course and overflight would be expected. Postaccident examination of the airplane, conducted hours after the accident, revealed no structural icing on the wings and empennage. Examination of the airframe and powerplant revealed no mechanical malfunctions or failures that would have precluded normal operation. The flaps were up, and a review of the manifest revealed the airplane was loaded within the specifications of the manifest and within the center of gravity limits. Between 2016 and 2017, the FAA conducted two aeronautical studies regarding the stack structures. In the first study, the FAA determined that many of the stack structures were a hazard to air navigation that required mitigation by the processing plant. As an interim measure, the FAA placed the runway 20 visual approach slope indicator (VASI) out of service because the stacks penetrated the obstruction clearance surface and were deemed hazardous to aviation. After determining that they needed to increase the height of the stacks, the plant then modified their proposal; the proposed height increase necessitated a second study. The second study determined the agglomerate stack and the row-of-six stacks exceeded the Code of Federal Regulations (CFR) section 77 standards and provided mitigating actions that included painting the stacks with high visibility white and aviation orange paint and equipping the stacks with red flashing warning lights. The control measures also included the permanent removal of the VASI. On the day of the accident, the agglomerate stack and row-of-six stacks had not been painted to the standard required by the FAA. The warning lights had been installed, and five of the row-of-six stacks were equipped with flashing red lights. The agglomerate stack warning light was stolen following the accident, so an accurate determination of its operating status could not be made. The existing paint scheme and the visible moisture emitted by the stacks provided a low contrast to the environmental background. This low contrast and the lack of a visual glide slope indicator may have caused difficulty for the pilot in maintaining a safe altitude during the visual portion of the approach to the runway. A white and aviation orange paint scheme, as identified in the regulations, may have offered a higher contrast and thus an adequate warning once the pilot transitioned to visual conditions.

The flight crew of the jet obtained weather information for the destination airport, which indicated quartering tailwind conditions for the runway in use at the time, with wind at 3 knots gusting to 16 knots. The crew determined the wind to be within limitations. The cockpit voice recorder transcript and airport surveillance video indicated that the landing approach was normal. The captain, who was the pilot flying, stated that, after touchdown, the thrust reversers were deployed and the airplane turned “sharply to the right.” He reported that remedial control inputs were ineffective in maintaining directional control. Airport surveillance video footage of the landing roll and accident sequence showed that, about 9 seconds into the landing roll, the airplane turned sharply to its right. The airplane departed the runway, its left wingtip struck the ground, the entire wing structure (left wing/right wing/wingbox) separated from the airplane as one assembly, and the fuselage continued a short distance before it came to rest upright. The thrust reversers on each engine were deployed and their extended positions were about equal. A windsock could be seen in the surveillance video footage nearly parallel to the ground, indicating nearly a direct crosswind to the landing runway that would have been towards the airplane’s right side. Recorded wind shortly after the accident was consistent with a 90° right crosswind for the landing runway at 6 knots with gusts to 14 knots. A detailed examination of the airplane and system components revealed that all flight control, steering, and braking systems and their actuator components operated as designed. Although the copilot's yaw force sensor did not meet manufacturer acceptance testing during post accident examination, this would not have affected the directional controllability of the airplane. Based on the available information, it is likely that the pilot’s compensation for the crosswind conditions was inadequate, which resulted in a loss of directional control and runway excursion.

The crew departed Norfolk-Chambers Field NAS on a local mission. En route, the airplane crashed in unknown circumstances in the Chincoteague Bay, off Wallops Island. The aircraft came to rest partially submerged in shallow waters. Two crew members were rescued while the pilot Lt Hyrum Hanlon was killed.

On 08 March 2022, the Bamaji Air Inc. (Bamaji) wheel-equipped Cessna 208 Caravan aircraft (registration C-GIPR, serial number 20800343) was conducting a series of visual flight rules (VFR) flights from Sioux Lookout Airport (CYXL), Ontario. At 1031, after checking the aerodrome forecast (TAF) valid from 0900 to 2000, and the graphic area forecast (GFA) valid from 0600 to 1800, the pilot departed on a flight to an ice runway on Springpole Lake, Ontario, about 78 nautical miles (NM) north-northwest of CYXL. The aircraft returned to CYXL with 2 passengers at 1200. In preparation for a second flight to Springpole Lake, the pilot loaded approximately 900 pounds of freight into the cabin and secured it under a cargo net. The aircraft had 750 pounds of fuel remaining on board, which was sufficient for the planned flight. The pilot and 1 passenger boarded the aircraft. The pilot occupied the left cockpit seat and the passenger occupied the right cockpit seat. Both occupants were wearing the available 5-point-harness safety belt system. At 1250, a snow squall began to move across CYXL, reducing ground visibility. The pilot taxied the aircraft to a position on the apron and waited for the fast-moving snow squall to pass. At 1301, the pilot taxied the aircraft to Runway 34 and took off in visual meteorological conditions. The aircraft climbed to approximately 1800 feet above sea level (ASL), then, once clear of the control zone, it descended to approximately 1600 to 1700 feet ASL, roughly 500 to 600 feet above ground level (AGL), to remain below the overcast ceiling. As the aircraft began to cross Lac Seul, Ontario, the visibility straight ahead and to the west was good. However, when the aircraft was roughly midway across the lake, it encountered turbulence and immediately became enveloped in whiteout conditions generated by a snow squall. The pilot turned his head to inspect the left wing and saw that ice appeared to be accumulating on the leading edge. He turned his attention back to the flight instruments and saw that the altimeter was descending rapidly. He then pulled back on the control column to stop the descent; however, within a few seconds, the aircraft struck the frozen surface of Lac Seul, approximately 17 NM north-northwest of CYXL. The aircraft was substantially damaged. There was no fire. The aircraft occupants received minor injuries. The Artex Model Me406 emergency locator transmitter (ELT) activated on impact and the signal was detected by the Cospas-Sarsat satellite system. The Joint Rescue Coordination Centre in Trenton, Ontario, re-tasked a Royal Canadian Air Force aircraft that was in the area and 3 search and rescue technicians (SAR Techs) parachuted into the site within 1 hour of the accident. The aircraft occupants and the SAR Techs were extracted from the site by a civilian helicopter later that day.

Before departing on the flight, the pilot of the turbo-propeller-equipped, single-engine airplane and student pilot-rated passenger seated in the right front seat of the airplane attempted to enter a flight plan into the airplane’s integrated flight management system. They ultimately did not complete this task prior to takeoff with the pilot remarking, “we’ll get to it later.” The pilot subsequently departed and climbed into instrument meteorological conditions (IMC) without an instrument flight rules (IFR) flight plan. After entering IMC, he contacted air traffic control and asked for visual flight rules (VFR) flight following services and an IFR clearance to the destination airport. From shortly after when the airplane leveled after takeoff through the final seconds of the flight, the pilot attempted to program, delete, reprogram, and activate a flight plan into the airplane’s flight management system as evidenced by his comments recorded on the airplane’s cockpit voice recorder (CVR). After departing, the pilot also attempted to navigate around restricted airspace that the airplane had flown into. The CVR audio showed that during the final 10 minutes of the flight, the pilot was unsure of the spelling of the fix he should have been navigating to in order to begin the instrument approach at the destination airport, and more generally expressed frustration and confusion while attempting to program the integrated flight management system. As the pilot continued to fixate on programming the airplane’s flight management system and change the altimeter setting, the airplane’s pitch attitude increased to 10° nose up, while the airspeed had decayed to 109 knots. As a result of his inattention to this airspeed decay, the stall warning system activated and the autopilot disconnected. During this time the airplane began climbing and turning to the right and then to the left before entering a steep descending right turn that continued until the airplane impacted the ocean. For the final 2 and 1/2 minutes of the flight, the pilot was provided with stall warnings, stick shaker activations, autopilot disconnect warnings, and terrain avoidance warning system alerts. The airplane impacted the ocean about 3 miles from the coast. Examination of the recovered sections of the airplane did not reveal evidence of any mechanical failures or malfunctions of the airframe or engine that would have precluded normal operation. The instrument meteorological conditions present in the area at the time of the accident were conducive to the development of spatial disorientation. The airplane’s erratic flight track in the final 2 minutes of flight, culminating in the final rapidly descending right turn, were consistent with the known effects of spatial disorientation. It is likely that the pilot’s inadequate preflight planning, and his subsequent distraction while he unsuccessfully attempted to program the airplane’s flight management system during the flight resulted in his failure to adequately monitor the airplane’s speed. This led to the activation of the airplane’s stall protection and warning systems as the airplane approached and entered an aerodynamic stall. The resulting sudden deactivation of the autopilot, combined with his inattention to the airplane’s flight attitude and speed, likely surprised the pilot. Ultimately, the pilot failed to regain control of the airplane following the aerodynamic stall, likely due to spatial disorientation. The pilot had a history of mantle cell lymphoma that was in remission and his maintenance treatment with a rituximab infusion was over 60 days prior to the accident. The pilot also had a history of back pain and had received steroid injections and nonsteroidal anti-inflammatory drugs. By self-report, he had taken oxycodone for pain management; it is unknown how frequently he used this medication or if he had used the medication on the day of the accident. While oxycodone can result in fatigue and dizziness, and may interfere with reaction time, given the information from the CVR, it could not be determined if the pilot had these side effects. A few weeks prior to the accident, the pilot reported having COVID-19 and receiving a 5-day treatment course of hydroxychloroquine and ivermectin. While there are some impairing side effects associated with the use of those medications, enough time had elapsed that no adverse effects would be expected. There is an increased risk of a sudden incapacitating cardiovascular event such as a dysrhythmia, stroke, or pulmonary embolism in people who have recovered from their COVID-19 infection. The risk is slight for those not hospitalized for the infection. The pilot did not have an underlying cardiovascular disease that would pose an increased risk for a sudden incapacitating event and the CVR did not provide evidence of a sudden incapacitating event occurring. Thus, it could not be determined if the pilot’s medical conditions of mantle cell lymphoma, back pain, and recent history of COVID-19 and the medications used to treat these conditions, including rituximab, oxycodone, hydroxychloroquine, and ivermectin, were contributing factors to this accident.