Crash of an Embraer EMB-110P1 Bandeirante in Pownal: 1 killed

Date & Time: Aug 4, 2006 at 0918 LT
Operator:
Registration:
N59BA
Flight Type:
Survivors:
No
Site:
Schedule:
Binghamton - Bennington
MSN:
110-396
YOM:
1982
Flight number:
BEN059
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2877
Captain / Total hours on type:
47.00
Aircraft flight hours:
40043
Circumstances:
The airport's instrument approach procedures included a very high frequency, omnidirectional range (VOR) approach, and a global positioning system (GPS) approach that was not an overlay. The VOR approach procedure included an inbound course to the VOR, and after passage, a descent along the same course to a missed approach point. The missed approach point was defined as 6 nautical miles beyond the VOR, as well as by timing. The pilot twice attempted the VOR approach in instrument meteorological conditions. He flew the first approach to the missed approach point, initiated a missed approach, contacted the controller, and requested a second VOR approach. He then received vectors to rejoin the approach course inbound to the VOR. The airplane subsequently passed over the VOR, on course, about 100 feet above the minimum altitude. However, instead of descending as described in the procedure, the airplane maintained that altitude until reaching the airport, then began a descent. The airplane continued to travel outbound along the same approach course until it impacted rising terrain about 6.5 miles beyond the airport. There was no dedicated distance measuring equipment (DME) onboard the airplane. Instead, distance was determined by the use of an instrument flight rules (IFR)-approved GPS unit. Due to the non-storage capability of the unit, historical waypoint selection could not be determined. The pilot could have selected the airport as a "direct to" waypoint, or, if he had entered flight plan waypoints, the unit would have sequenced from the VOR to the airport during the first approach. In either case, unless the pilot reprogrammed the unit, the last waypoint entered would have remained at the airport, rather than the VOR. The pilot then most likely mistook the airport position for the VOR position, and displaced the beginning of the descent by 6 nautical miles. Also noted, was that once the airplane passed over the VOR en route to the airport, the HSI would have indicated a change of "to" to "from". There were no medical anomalies noted with the pilot and no mechanical anomalies noted with the airplane.
Probable cause:
The pilot's misinterpretation of the airplane's position relative to the final approach fix, which resulted in the displacement of the descent profile by 6 nautical miles and the subsequent controlled flight into rising terrain. Contributing to the accident were the low clouds.
Final Report:

Crash of a PZL-Mielec AN-28 in Bukavu: 17 killed

Date & Time: Aug 3, 2006
Type of aircraft:
Operator:
Registration:
9Q-COM
Survivors:
No
Site:
Schedule:
Lugushwa - Bukavu
MSN:
1AJ008-21
YOM:
1990
Location:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
17
Circumstances:
While descending to Bukavu-Kamembe Airport, the crew encountered stormy weather with limited visibility due to rain falls. Too low, the twin engine aircraft impacted trees and crashed on hilly and wooded terrain located about 15 km from Bukavu Airport. The aircraft was destroyed and all 17 occupants were killed.
Probable cause:
Controlled flight into terrain.

Crash of an Antonov AN-12B near Sake: 6 killed

Date & Time: Jul 7, 2006 at 1540 LT
Type of aircraft:
Operator:
Registration:
9Q-CVT
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Goma - Kisangani
MSN:
3 3 415 06
YOM:
1963
Location:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
Few minutes after takeoff from Goma Airport, en route to Kisangani, the crew informed ATC about engine problem and was cleared to return to Goma for an emergency landing. Shortly later, the aircraft lost height, hit trees and crashed in hilly terrain located near Sake, about 20 km northwest of Goma. The aircraft was destroyed and all 6 occupants were killed.
Probable cause:
Loss of control following an engine failure. According to Antonov Design Bureau, the airworthiness certificate expired on March 30, 2001. Also, the aircraft was operated without valid documentation and the airworthiness certificate was still registered to the old operator with the registration 9U-BHN.

Crash of a Cessna T207A Turbo Stationair 7 II in Pemberton: 1 killed

Date & Time: May 18, 2006 at 1506 LT
Operator:
Registration:
C-GGQR
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Pemberton – Edmonton
MSN:
207-0499
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1500
Circumstances:
The aircraft departed from Pemberton Airport, British Columbia, at about 1500 Pacific daylight time on a visual flight rules flight to Edmonton, Alberta. The aircraft initially climbed out to the east and subsequently turned northeast to follow a mountain pass route. The pilot was alone on this aircraft repositioning flight. The pilot had been conducting air quality surveys for Environment Canada’s Air Quality Research Section in the Pemberton area. The aircraft was operating on a flight permit and was highly modified to accept various types of probes in equipment pods suspended under the wings, a camera hatch type provision in the centre belly area, and carried internal electronic equipment. About 30 minutes after the aircraft took off, the Coastal Fire Service responded to a spot fire and discovered the aircraft wreckage in the fire zone. A post-crash fire consumed most of the airframe, and the pilot was fatally injured. The accident occurred at about 1506 Pacific daylight time.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot entered the valley at an altitude above ground that did not provide sufficient terrain clearance given the aircraft’s performance.
2. The pilot encountered steeply rising terrain, where false horizon and relative scale illusions in the climb are likely. Realizing that the aircraft would not likely be able to out-climb the approaching terrain, he turned to reverse his course.
3. The aircraft’s configuration, relatively high weight, combined with the effects of increased drag from the equipment, density altitude, down-flowing winds, and manoeuvring resulted in the aircraft colliding with terrain during the turn.
Findings as to Risk:
1. A detailed flight plan was not filed and special equipment, such as laser radiation emitting devices and/or hazardous substances were not reported. The absence of flight plan information regarding these devices could delay search and rescue efforts and expose first responders to unknown risks.
2. Transport Canada (TC) does not issue a rating/endorsement for mountain flying training. There are no standards established to ascertain the proficiency of a pilot in this environment. Pilots who complete a mountain flying course may not acquire the required skill sets.
3. There was no emergency locator transmitter (ELT) signal received. The ELT was destroyed in the impact and subsequent fire. Present standards do not require that ELTs resist crash damage.
4. “Flight permits – specific purpose” are issued for aircraft that do not perform as per the original type design but are deemed capable of safe flight. Placards are not required; therefore, pilots and observers approved to board may be unaware of the limitations of the aircraft and the associated risks.
5. The TC approval process allowed the continued operation of this modified aircraft for sustained environmental research missions under a flight permit authority. This circumvented the requirement to meet the latest airworthiness standards and removed the risk mitigation built into the approval process for a modification to a type design.
Other Findings:
1. The fuel system obstruction found during disassembly was a result of the post-crash fire.
2. The aircraft was operated at an increased weight allowance proposed by the design approval representative (DAR). Such operation was to be approved only in accordance with a suitably worded flight permit and instructions contained in the proposed document CN-MSC-011; however, this increased weight allowance was not incorporated to any flight authority issued by TC.
Final Report:

Crash of a PZL-Mielec AN-2P in Göktepe

Date & Time: May 6, 2006 at 2000 LT
Type of aircraft:
Operator:
Registration:
ER-35538
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Izmir – Adana
MSN:
1G114-50
YOM:
1970
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft was leased by a regional Turkish operator to perform a flight from Izmir to Adana with 4 pilots and 2 engineers from the Moldovan Company. En route, the crew encountered bad weather conditions with limited visibility due to heavy rain falls, and elected to make an emergency landing. The aircraft crash landed in a hilly terrain located near Göktepe. All 6 occupants were slightly injured while the aircraft was damaged beyond repair.

Crash of an IAI Arava 201 in El Cedrito: 5 killed

Date & Time: May 5, 2006 at 1535 LT
Type of aircraft:
Operator:
Registration:
GN-8168
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Puerto Ayacucho – Caracas
MSN:
071
YOM:
1981
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
While cruising at an altitude of 6,700 feet in marginal weather conditions, the crew started the descent to Caracas-Maiquetía-Simón Bolívar and descended to 5,000 feet when the aircraft struck trees and crashed on the slope of a mountain located near the village of El Cedrito, about 29 km southwest of the airport. The wreckage was found two day later, in the morning of May 7. The aircraft was totally destroyed and all five occupants were killed.
Probable cause:
Controlled flight into terrain after the crew started the descent prematurely.

Crash of a Cessna 208B Grand Caravan on Mt Margherita: 3 killed

Date & Time: Apr 28, 2006 at 0647 LT
Type of aircraft:
Operator:
Registration:
ZS-ADL
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Goma - Bunia
MSN:
208B-0381
YOM:
1994
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The single engine aircraft departed Goma on a humanitarian flight to Bunia, carrying one passenger, two pilots and a load consisting of 300 kilos of various goods on behalf of the World Food Programme. En route, the crew decided to follow a direct route via GPS instead of the one mentioned on the flight plan. While cruising at an altitude of 12,500 feet in poor weather conditions, the aircraft struck the slope of Mt Margherita (5,109 metres high) located in the Ruwenzori Mountain Range, western Uganda. The wreckage was found two days later and all three occupants were killed.
Probable cause:
Controlled flight into terrain after the crew failed to follow the prescribed route and executed a direct route over the mountains at an unsafe altitude in poor visibility due to weather.

Crash of a Harbin Yunsunji Y-12 II in Marsabit: 14 killed

Date & Time: Apr 10, 2006 at 1000 LT
Type of aircraft:
Operator:
Registration:
KAF132
Flight Type:
Survivors:
Yes
Site:
Schedule:
Nairobi - Marsabit
MSN:
0098
YOM:
2000
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
14
Aircraft flight hours:
1032
Circumstances:
The twin engine aircraft departed Moi Air Base in Nairobi on a flight to Marsabit, carrying a delegation of the Kenyan Government including two ministers. They were flying to Marsabit as part of a mediation mission between communities in dispute, in particular over grazing rights and water points. On approach to Marsabit Airport, the crew encountered poor visibility due to low clouds when the aircraft crashed on the slope of a hill located few km from the airport. Three passengers were seriously injured while 14 other occupants were killed.
Probable cause:
Controlled flight into terrain after the crew continued the approach at an unsafe altitude in marginal weather conditions.

Crash of a Let L-410UVP-E20 near Rio Bonito: 19 killed

Date & Time: Mar 31, 2006 at 1739 LT
Type of aircraft:
Operator:
Registration:
PT-FSE
Flight Phase:
Survivors:
No
Site:
Schedule:
Macaé – Rio de Janeiro
MSN:
91 25 32
YOM:
1991
Flight number:
TIM6865
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
19
Captain / Total flying hours:
10000
Captain / Total hours on type:
39.00
Copilot / Total flying hours:
5220
Copilot / Total hours on type:
1719
Aircraft flight hours:
2739
Aircraft flight cycles:
3960
Circumstances:
The twin engine aircraft departed Macaé Airport at 1719LT on a flight to Rio de Janeiro-Santos Dumont Airport with 17 passengers and two pilots on board. Few minutes later, the copilot cancelled the IFR flight plan and continued under VFR mode at an altitude of 4,500 feet. Approaching São Pedro da Aldeia, the copilot was cleared to descend to 2,000 feet to avoid poor weather conditions. Later, while approaching Saquarema, the crew initiated a left turn to avoid clouds when shortly later, at an altitude of 1,920 feet, the aircraft struck the Pedra Bonita Peak. The wreckage was found six km southeast of Rio Bonito in a dense wooded area. The aircraft was totally destroyed and all 19 occupants were killed.
Probable cause:
Controlled flight into terrain after the crew decided to continue under VFR mode in IMC conditions. The following contributing factors were identified:
- Overconfidence on part of the captain who was familiar with the area,
- The organizational culture of the company proved to be complacent by not inhibiting the adoption of procedures incompatible with flight safety, such as the low altitude flights made by the instructor captain,
- There was inadequate assessment of the situation by the crew, causing them to fly at a lower altitude than the safe limits under visual conditions unsuitable for visual flight, resulting in the collision of the aircraft with high ground,
- The use of human resources for the operation of the aircraft was unsuitable because of failure to comply with operational standards, leading the crew to perform a passenger flight to the lower altitude limits of safety, under inadequate visual conditions,
- The preparation for the flight proved inadequate because the crew did not have a meteorological analysis of the appropriate level of flight performed, considering that the conditions for the region were overshadowing the Serra do Mar and surrounding areas of low clouds and / or mist, especially on the slopes of the mountain,
- The weather conditions prevailing in the region made visual flight impossible, resulting in the concealment of the elevation at which the aircraft crashed,
- The pilots intentionally not complying with rules of air traffic and civil aviation rules, without grounds, performing flight at low altitude, under conditions of visibility below the limits established for VFR flight, colliding with high grounD,
- The company has not taken appropriate supervisory measures, enabling the existence of a culture of undeveloped flight safety, which prevented advance identification of actions taken by the crew and injured misconception exists in the CRM business, which represented a potential risk to their operations, as well as by the failure of some educational measures provided for in its PPAA (Plan for the Prevention of Aeronautical Accidents).
Final Report:

Crash of a Fletcher FU-24-950 near Kaitaia: 1 killed

Date & Time: Mar 31, 2006 at 1345 LT
Type of aircraft:
Operator:
Registration:
ZK-EGP
Flight Phase:
Survivors:
No
Site:
Schedule:
Kaitaia - Kaitaia
MSN:
238
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1347
Captain / Total hours on type:
864.00
Aircraft flight hours:
11230
Circumstances:
On Friday 31 March 2006 the pilot intended to carry out topdressing on properties near a steep hill range nine kilometres to the south-west of Kaitaia. The day’s activities commenced at approximately 0600 hours when the pilot and loaderdriver met at Kaitaia aerodrome. The pilot and loader-driver flew in the aircraft from the aerodrome to a farm airstrip located on the back of a hill range near the Pukepoto Quarry where the fertiliser-loading truck had been parked overnight. The topdressing operation began in the morning with spreading approximately 25 tonnes of superphosphate on nearby farmland which was stored in the fertiliser bins next to the airstrip. As the last of the superphosphate was being spread, a consignment of fresh lime was delivered by a trucking contractor. The topdressing operation continued with the spreading of the lime on another property near the base of the hill range, about three kilometres from the airstrip. At around 1000 hours, while waiting on another delivery of lime by the trucking contractor, the pilot and loader-driver flew in the aircraft to another airstrip about 20 km to the south-east near Broadwood. They repositioned a fertiliser-loading truck located at this airstrip to another airstrip near Pawarenga, in anticipation of the next day’s topdressing. The pilot and loader-driver then flew back to the original farm airstrip near the Pukepoto Quarry, arriving at approximately 1100 hours. At about this time the pilot received a cell phone call from his supervising Chief Pilot. During the conversation he asked the Chief Pilot for his advice about the best direction for spreading lime on the land that he was currently working on. The pilot also commented about how the lime was ‘hanging up’ and not flowing easily from the aircraft’s hopper. The Chief Pilot cautioned the pilot about the poor flow properties of new lime and advised him to spread the lime in line with the hill range, not up the slope. The topdressing operation then resumed until all the lime in the fertiliser bin had been used. The pilot and loader-driver then stopped for lunch during which time the aircraft was refuelled and another truckload of lime was delivered. The pilot had commented to the loader-driver during lunch that the lime was still hanging up in the aircraft’s hopper. He was finding that he needed to complete about two passes to clear the entire load from the hopper. Just before starting the afternoon’s topdressing flights, the pilot had a conversation on his cell phone with a bank manager in Auckland. The conversation concerned the financial position of his topdressing business. The loader-driver reported that the pilot became very agitated during the conversation, but appeared to calm down prior to beginning the afternoon’s flying. The farm-owner observed the aircraft on its first flight of the afternoon as it completed the first two passes. He was aware that the aircraft had flown further away after these two passes and assumed the aircraft was returning to the airstrip for a second load of lime. He did not notice anything abnormal about the aircraft. Other witnesses reported that the aircraft flew parallel with a plantation of 30-40 metre high trees towards the rising hill range. The closest eye witness reported seeing what appeared to be fertiliser dropping from the aircraft as it flew along the tree line up the slope. The dropping of the fertiliser then stopped at which point the aircraft was seen entering a steep right hand turn away from the slope whilst descending towards the ground. The aircraft disappeared in to tall bush on the hillside and witnesses heard the aircraft impact the ground. A large smoke-like cloud was then seen rising up through the bush. On hearing the impact, the farm-owner and a local share-milker from a nearby farm searched the hillside for the aircraft. The aircraft was obscured by the tall bush and was initially difficult to locate. The share-milker made his way down the hillside through the bush to the aircraft. He quickly realised that the pilot was deceased. The farmer-owner went to alert the emergency services, however another property owner who had heard the aircraft strike the ground and seen the smoke had already telephoned the New Zealand Police. The accident occurred in daylight, at approximately 1345 hours NZDT, 9 km south-west of Kaitaia at an elevation of 880 feet AMSL. Latitude: S 35° 10' 26.1", longitude: E 173° 11' 29.4"; grid reference: NZMS 260 N05 283698.
Probable cause:
Conclusions:
- The pilot was appropriately licensed and was being supervised as required by Civil Aviation Rules.
- The aircraft had been maintained in accordance with the requirements of Civil Aviation Rules, and had a valid airworthiness certificate.
- There was no evidence that the aircraft had suffered any mechanical problem which may have contributed to the accident.
- The probable initiator of the accident was a hung load of lime which would have limited the climb performance of the aircraft. Factors contributing to the accident were the steep rising terrain and a high tree line which restricted the turning options for the pilot.
- The pilot flew the aircraft into a situation where he had limited recovery options. Due to his limited agricultural flying experience, he may not have appreciated his predicament until it was too late or taken recovery action early enough. The aircraft appears to have aerodynamically stalled during a right hand turn from which there was insufficient height to recover.
- In addition, the pilot’s decision making ability and concentration may have been impaired to some degree by various distractions and fatigue.
- The accident was not survivable.
- The standard sight (observation) window installed on Fletcher aircraft is an impractical method for pilots to monitor the upper level of the hopper contents during flight, particularly with a product like lime which has a higher relative density compared to other fertiliser products.
Final Report: