Crash of a Beechcraft B200 Super King Air in Chandigarh

Date & Time: Mar 27, 2014 at 1139 LT
Operator:
Registration:
VT-HRA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Chandigarh – New Delhi
MSN:
BB-1906
YOM:
2005
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9888
Captain / Total hours on type:
2165.00
Copilot / Total flying hours:
2147
Copilot / Total hours on type:
1383
Aircraft flight hours:
2010
Circumstances:
On 25.03.2014, the operator received the travel programme for 27.3.2014, of Hon'ble Governor of Haryana from Chandigarh to Delhi. On 26.3.2014, the operations department took the flight clearances and filed the passenger manifest with the ATC and other concerned agencies. The flight plan was filed by a CPL holder, who is working as flight dispatcher with the Government of Haryana. The departure on 27.3.2014 was fixed at 1130 hrs. The cockpit crew reported at 1045 hrs for the flight. Pre flight medical examination including the breath analyzer test was carried out at 1100 hrs. The breath analyzer test for both the cockpit crew members was negative. Pre flight briefing among the crew members was carried out by using the documents prepared by the flight dispatcher. The aircraft was taxied under its own power from Haryana Government Hangar to bay no. D-2 in front of ATC building. No abnormality was observed or reported on the aircraft during this taxiing. The engines were shut down for passenger embarkation. As per the passenger manifest, in addition to the pilot and co-pilot there were 8 passengers. The baggage on board was approx. 50 lbs. There was 2100 lbs. of fuel on board. After boarding of the passengers, the aircraft engines were started at 1130 hrs. The aircraft was cleared for departure abeam „D‟ link. The aircraft was taxied out via taxiway „D‟. After ATC departure clearance the aircraft was lined up for take-off. On clearance from ATC the take off roll was initiated and all the parameters were found normal. As per the pilot just before getting airborne some stiffness was found in rudder control as is felt in yaw damper engagement. The aircraft then pulled slightly to the left which as per the Commander was controllable. As per the pilot, the rotation was initiated at 98 knots. As per the DATCO the aircraft had lifted up to 10-15 feet AGL. The Commander has stated that after lift-off, immediately the left rudder got locked in forward position resulting in the aircraft yawing and rolling to left. The pilots tried to control it with right bank but the aircraft could not be controlled. Within 3-4 seconds of getting airborne the aircraft impacted the ground in left bank attitude. The initial impact was on pucca (tar road) and the wing has taken the first impact loads with lower surface metallic surface rubbing and screeching on ground. After the aircraft came to final halt, the co-pilot opened the door and evacuation was carried out. There was no injury to any of the occupants. The engine conditions lever could not be brought back as these were stuck. The throttle and pitch levers were retarded. The fuel shut off valves were closed. Battery and avionics were put off. Friction lock nuts were found loose. As per the Commander, after ensuring safety of passengers he had gone to cockpit to confirm that all switches were „off‟. At that time he has loosened the friction lock nuts to bring back the condition lever and throttle lever. However even after loosening the nut it was not possible to bring back these levers. Fire fighting vehicles were activated by pressing crash bell and primary alarm. Hand held RT set was used to announce the crash. RCFF vehicles proceeded to the site via runway and reported all the 10 personnel are safe and out of the disabled aircraft. Water and complementary agents (foam and dry chemical powder) were used. After fire was extinguished, the Fire Fighting vehicles reported back at crash bay except one CFT which was held at crash site under instruction of COO. The aircraft was substantially damaged. There was no fire barring burning of small patch of grass due coming in contact with the hot surfaces and oil. There was no injury to any of the occupants. The accident occurred in day light conditions.
Probable cause:
The accident occurred due to stalling of left wing of the aircraft at a very low height.
The contributory factors were:
- Failure on the part of the crew to effectively put off the yaw damp so as to release the rudder stiffness as per the emergency checklist.
- Checklist not being carried out by the crew members.
- Not putting off the Rudder Boost.
- Speeds call outs not made by co-pilot.
- Not abandoning the take-off at lower speed (before V1).
- Failure of CRM in the cockpit in case of emergency.
- Early rotation and haste to take-off.
Final Report:

Crash of a Beechcraft 200C Super King Air in Lake Manyara

Date & Time: Aug 22, 2013
Operator:
Registration:
5H-TZW
Flight Phase:
Survivors:
Yes
Schedule:
Bukoba - Zanzibar - Dar es-Salaam
MSN:
BL-17
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
En route to Zanzibar, while cruising at an altitude of 21,000 feet, the right engine failed. The pilot decided to divert to Arusha Airport when few minutes later, while passing 16,000 feet on descent, the left engine failed as well. The pilot attempted to ditch the aircraft into Lake Manyara. The aircraft belly landed and came to rest in shallow water, bent in two. All seven occupants were rescued by fishermen and the aircraft was damaged beyond repair.

Crash of a Beechcraft B200 Super King Air in Akureyri: 2 killed

Date & Time: Aug 5, 2013 at 1329 LT
Operator:
Registration:
TF-MYX
Flight Type:
Survivors:
Yes
Schedule:
Reykjavik - Akureyri
MSN:
BB-1136
YOM:
1983
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2600
Captain / Total hours on type:
1700.00
Copilot / Total flying hours:
2200
Copilot / Total hours on type:
1100
Aircraft flight hours:
15247
Aircraft flight cycles:
18574
Circumstances:
On 4th of August 2013 the air ambulance operator Mýflug, received a request for an ambulance flight from Höfn (BIHN) to Reykjavík Airport (BIRK). This was a F4 priority request and the operator, in co-operation with the emergency services, planned the flight the next morning. The plan was for the flight crew and the paramedic to meet at the airport at 09:30 AM on the 5th of August. A flight plan was filed from Akureyri (BIAR) to BIHN (positioning flight), then from BIHN to BIRK (ambulance flight) and from BIRK back to BIAR (positioning flight). The planned departure from BIAR was at 10:20. The flight crew consisted of a commander and a co-pilot. In addition to the flight crew was a paramedic, who was listed as a passenger. Around 09:50 on the 5th of August, the flight crew and the paramedic met at the operator’s home base at BIAR. The flight crew prepared the flight and performed a standard pre-flight inspection. There were no findings to the aircraft during the pre-flight inspection. The pre-flight inspection was finished at approximately 10:10. The departure from BIAR was at 10:21 and the flight to BIHN was uneventful. The aircraft landed at BIHN at 11:01. The commander was the pilot flying from BIAR to BIHN. The operator’s common procedure is that the commander and the co-pilot switch every other flight, as the pilot flying. The co-pilot was the pilot flying from BIHN to BIRK and the commander was the pilot flying from BIRK to BIAR, i.e. during the accident flight. The aircraft departed BIHN at 11:18, for the ambulance flight and landed at BIRK at 12:12. At BIRK the aircraft was refueled and departed at 12:44. According to flight radar, the flight from BIRK to BIAR was flown at FL 170. Figure 4 shows the radar track of the aircraft as recorded by Reykjavík Control. There is no radar coverage by Reykjavík Control below 5000 feet, in the area around BIAR. During cruise, the flight crew discussed the commander’s wish to deviate from the planned route to BIAR, in order to fly over a racetrack area near the airport. At the racetrack, a race was about to start at that time. The commander had planned to visit the racetrack area after landing. The aircraft approached BIAR from the south and at 10.5 DME the flight crew cancelled IFR. When passing KN locator (KRISTNES), see Figure 6, the flight crew made a request to BIAR tower to overfly the town of Akureyri, before landing. The request was approved by the tower and the flight crew was informed that a Fokker 50 was ready for departure on RWY 01. The flight crew of TF-MYX responded and informed that they would keep west of the airfield. After passing KN, the altitude was approximately 800’ (MSL), according to the co-pilot’s statement. The co-pilot mentioned to the commander that they were a bit low and recommended a higher altitude. The altitude was then momentarily increased to 1000’. When approaching the racetrack area, the aircraft entered a steep left turn. During the turn, the altitude dropped until the aircraft hit the racetrack.
Probable cause:
The commander was familiar with the racetrack where a race event was going on and he wanted to perform a flyby over the area. The flyby was made at a low altitude. When approaching the racetrack area, the aircraft’s calculated track indicated that the commander’s intention of the flyby was to line up with the racetrack. In order to do that, the commander turned the aircraft to such a bank angle that it was not possible for the aircraft to maintain altitude. The ITSB believes that during the turn, the commander most probably pulled back on the controls instead of levelling the wings. This caused the aircraft to enter a spiral down and increased the loss of altitude. The investigation revealed that the manoeuvre was insufficiently planned and outside the scope of the operator manuals and handbooks. The low-pass was made at such a low altitude and steep bank that a correction was not possible in due time and the aircraft collided with the racetrack. The ITSB believes that human factor played a major role in this accident. Inadequate collaboration and planning of the flyover amongst the flight crew indicates a failure of CRM. This made the flight crew less able to make timely corrections. The commander’s focus was most likely on lining up with the racetrack, resulting in misjudging the approach for the low pass and performing an overly steep turn. The overly steep turn caused the aircraft to lose altitude and collide with the ground. The co-pilot was unable to effectively monitor the flyover/low-pass and react because of failure in CRM i.e. insufficient planning and communication. A contributing factor is considered to be that the flight path of the aircraft was made further west of the airfield, due to traffic, resulting in a steeper turn. The investigation revealed that flight crews were known to deviate occasionally from flight plans.
Causal factors:
- A breakdown in CRM occurred.
- A steep bank angle was needed to line up with the racetrack.
- The discussed flyby was executed as a low pass.
- The maximum calculated bank angle during last phase of flight was 72.9°, which is outside the aircraft manoeuvring limit.
- ITSB believes that the commander’s focus on a flyby that he had not planned thoroughly resulted in a low-pass with a steep bank, causing the aircraft to lose altitude and collide with the ground.
Contributory factors:
- The commander’s attention to the activity at the race club area, and his association with the club was most probably a source of distraction for him and most likely motivated him to execute an unsafe maneuver.
- Deviations from normal procedures were seen to be acceptable by some flight crews.
- A flyby was discussed between the pilots but not planned in details.
- The flight crew reacted to the departing traffic from BIAR by bringing their flight path further west of the airport.
- The approach to the low pass was misjudged.
- The steep turn was most probably made due to the commander’s intention to line up with the race track.
Final Report:

Crash of a Beechcraft 200 Super King Air in Palwaukee

Date & Time: Jun 25, 2013 at 2030 LT
Operator:
Registration:
N92JR
Flight Type:
Survivors:
Yes
Site:
Schedule:
Springfield - Palwaukee
MSN:
BB-751
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7125
Captain / Total hours on type:
572.00
Aircraft flight hours:
6709
Circumstances:
Before departure, the pilot performed fuel calculations and determined that he had enough fuel to fly to the intended destination. While enroute the pilot flew around thunderstorms. On arrival at his destination, the pilot executed the instrument landing system approach for runway 16. While on short final the right engine experienced a total loss of power. The pilot switched the fuel flow from the right tank to the left tank. The left engine then experienced a total loss of power and the pilot made an emergency landing on a road. The airplane received substantial damage to the wings and fuselage when it struck a tree. A postaccident examination revealed only a few gallons of unusable fuel in the left fuel tank. The right fuel tank was breached during the accident sequence but no fuel smell was noticed. The pilot performed another fuel calculation after the accident and determined that there were actually 170 gallons of fuel onboard, not 230 gallons like he originally figured. He reported no preaccident mechanical malfunctions that would have precluded normal operation and determined that he exhausted his entire fuel supply.
Probable cause:
The pilot's improper fuel planning and management, which resulted in a loss of engine power due to fuel exhaustion.
Final Report:

Crash of a Beechcraft B200GT Super King Air in Baker: 1 killed

Date & Time: Jun 7, 2013 at 1310 LT
Operator:
Registration:
N510LD
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Baton Rouge - McComb
MSN:
BY-24
YOM:
2007
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
15925
Captain / Total hours on type:
5200.00
Aircraft flight hours:
974
Circumstances:
The accident pilot and two passengers had just completed a ferry flight on the recently purchased airplane. A review of the airplane’s cockpit voice recorder audio information revealed that, during the ferry flight, one of the passengers, who was also a pilot, was pointing out features of the new airplane, including the avionics suite, to the accident pilot. The pilot had previously flown another similar model airplane, but it was slightly older and had a different avionics package; the new airplane’s avionics and flight management system were new to the pilot. After completing the ferry flight and dropping off the passengers, the pilot departed for a short cross-country flight in the airplane. According to air traffic control recordings, shortly after takeoff, an air traffic controller assigned the pilot a heading and altitude. The pilot acknowledged the transmission and indicated that he would turn to a 045 heading. The radio transmission sounded routine, and no concern was noted in the pilot’s voice. However, an audio tone consistent with the airplane’s stall warning horn was heard in the background of the pilot’s radio transmission. The pilot then made a radio transmission stating that he was going to crash. The audio tone was again heard in the background, and distress was noted in the pilot’s voice. The airplane impacted homes in a residential neighborhood; a postcrash fire ensued. A review of radar data revealed that the airplane made a climbing right turn after departure and then slowed and descended. The final radar return showed the airplane at a ground speed of 102 knots and an altitude of 400 feet. Examination of the engines and propellers indicated that the engines were rotating at the time of impact; however, the amount of power the engines were producing could not be determined. The examination of the airplane did not reveal any abnormalities that would have precluded normal operation. It is likely that the accident pilot failed to maintain adequate airspeed during departure, which resulted in an aerodynamic stall and subsequent impact with terrain, and that his lack of specific knowledge of the airplane’s avionics contributed to the accident.
Probable cause:
The pilot’s failure to maintain adequate airspeed during departure, which resulted in an aerodynamic stall and subsequent impact with terrain. Contributing to the accident was the pilot’s lack of specific knowledge of the airplane’s avionics.
Final Report: