Beechcraft 200 Super King Air

The twin engine aircraft departed Lima-Jorge Chávez Airport at 0625LT on a charter flight to Pias, carrying two pilots and seven employees of the Peruvian company MARSA (Minera Aurífera Retamas) en route to Pias gold mine. On approach to Pias Airport, the crew encountered limited visibility due to foggy conditions. Heading 320° on approach, the crew descended too low when the aircraft collided with power cables, stalled and crashed on the slope of a mountain located 4,5 km from the airport, bursting into flames. The aircraft was destroyed by impact forces and a post crash fire and all 9 occupants were killed.

The twin engine aircraft departed Belo Horizonte-Pampulha Airport at 0700LT on a flight to Juiz de Fora, carrying six passengers and two pilots. In contact with Juiz de Fora Radio, the crew learned that the weather conditions at the aerodrome were below the IFR minima due to mist, and decided to maintain the route towards the destination and perform a non-precision RNAV (GNSS) IFR approach for landing on runway 03. During the final approach, the aircraft collided first with obstacles and then with the ground, at a distance of 245 meters from the runway 03 threshold, and exploded on impact. The aircraft was totally destroyed and all 8 occupants were killed, among them both President and Vice-President of the Vilmas Alimentos Group.

The pilot had worked a 10-hour shift the day of the accident and had been off duty about 2 hours when the chief pilot called him around midnight to transport a patient. The pilot accepted the flight and, about 2 hours later, was on an instrument approach to the airport to pick up the patient. While on the instrument approach, all of the anti-ice and deice systems were turned on. The pilot said that the deice boots seemed to be shedding the ice almost completely. He extended the flaps and lowered the landing gear to descend; he then added power, but the airspeed continued to decrease. The airplane continued to descend, and he raised the flaps and landing gear and applied full climb power. The airplane shuddered as it climbed, and the airspeed continued to decrease. The stall warning horn came on, and the pilot lowered the nose to increase the airspeed. The airplane descended until it impacted level, snow-covered terrain. The airplane was equipped with satellite tracking and engine and flight control monitoring. The minimum safe operating speed for the airplane in continuous icing conditions is 140 knots indicated airspeed. The airplane's IAS dropped below 140 knots 4 minutes prior to impact. During the last 1 minute of flight, the indicated airspeed varied from a high of 124.5 knots to a low of 64.6 knots, and the vertical speed varied from 1,965 feet per minute to -2,464 feet per minute. The last data recorded prior to the impact showed that the airplane was at an indicated airspeed of 68 knots, descending at 1,651 feet per minute, and the nose was pitched up at 20 degrees. The pilot did not indicate that there were any mechanical issues with the airplane. The chief pilot reported that pilots are on call for 14 consecutive 24-hour periods before receiving two weeks off. He said that the accident pilot had worked the previous day but that the pilot stated that he was rested enough to accept the mission. The chief pilot indicated he was aware that sleep cycles and circadian rhythms are disturbed by varied and prolonged activity. An NTSB study found that pilots with more than 12 hours of time since waking made significantly more procedural and tactical decision errors than pilots with less than 12 hours of time since waking. A 2000 FAA study found accidents to be more prevalent among pilots who had been on duty for more than 10 hours, and a study by the U.S. Naval Safety Center found that pilots who were on duty for more than 10 of the last 24 hours were more likely to be involved in pilot-at-fault accidents than pilots who had less duty time. The operator’s management stated that they do not prioritize patient transportation with regard to their medical condition but base their decision to transport on a request from medical staff and availability of a pilot and aircraft, and suitable weather. The morning of the accident, the patient subsequently took a commercial flight to another hospital to receive medical treatment for his non-critical injury/illness. Given the long duty day and the early morning departure time of the flight, it is likely the pilot experienced significant levels of fatigue that substantially degraded his ability to monitor the airplane during a dark night instrument flight in icing conditions. The NTSB has issued numerous recommendations to improve emergency medical services aviation operations. One safety recommendation (A-06-13) addresses the importance of conducting a thorough risk assessment before accepting a flight. The safety recommendation asked the Federal Aviation Administration to "require all emergency medical services (EMS) operators to develop and implement flight risk evaluation programs that include training all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in EMS flight operations if the risks reach a predefined level." Had such a thorough risk assessment been performed, the decision to launch a fatigued pilot into icing conditions late at night may have been different or additional precautions may have been taken to alleviate the risk. The NTSB is also concerned that the pressure to conduct EMS operations safely and quickly in various environmental conditions (for example, in inclement weather and at night) increases the risk of accidents when compared to other types of patient transport methods, including ground ambulances or commercial flights. However, guidelines vary greatly for determining the mode of and need for transportation. Thus, the NTSB recommended, in safety recommendation A-09-103, that the Federal Interagency Committee on Emergency Medical Services (FICEMS) "develop national guidelines for the selection of appropriate emergency transportation modes for urgent care." The most recent correspondence from FICEMS indicated that the guidelines are close to being finalized and distributed to members. Such guidance will help hospitals and physicians assess the appropriate mode of transport for patients.

Witnesses reported that the airplane’s takeoff ground roll appeared to be normal. Shortly after the airplane lifted off, it stopped climbing and yawed to the left. Several witnesses heard abnormal sounds, which they attributed to propeller blade angle changes. The airplane’s flight path deteriorated to a left skid and its airspeed began to slow. The airplane’s left bank angle increased to between 45 and 90 degrees, and its nose dropped to a nearly vertical attitude. Just before impact, the airplane’s bank angle and pitch began to flatten out. The airplane had turned left about 100 degrees when it impacted the ground about 1,500 feet from the midpoint of the 10,000-foot runway. A fire then erupted, which consumed the fuselage. Review of a security camera video of the takeoff revealed that the airplane was near the midpoint of the runway, about 140 feet above the ground, and at a ground speed of about 130 knots when it began to yaw left. The left yaw coincided with the appearance, behind the airplane, of a dark grayish area that appeared to be smoke. A witness, who was an aviation mechanic with extensive experience working on airplanes of the same make and model as the accident airplane, reported hearing two loud “pops” about the time the smoke appeared, which he believed were generated by one of the engines intermittently relighting and extinguishing. Post accident examination of the airframe, the engines, and the propellers did not identify any anomalies that would have precluded normal operation. Both engines and propellers sustained nearly symmetrical damage, indicating that the two engines were operating at similar low- to mid-range power settings at impact. The airplane’s fuel system was comprised of two separate fuel systems (one for each engine) that consisted of multiple wing fuel tanks feeding into a nacelle tank and then to the engine. The left and right nacelle tanks were breached during the impact sequence and no fuel was found in either tank. Samples taken from the fuel truck, which supplied the airplane's fuel, tested negative for contamination. However, a fuels research engineer with the United States Air Force Fuels Engineering Research Laboratory stated that water contamination can result from condensation in the air cavity above a partially full fuel tank. Both diurnal temperature variations and the atmospheric pressure variations experienced with normal flight cycles can contribute to this type of condensation. He stated that the simplest preventive action is to drain the airplane’s fuel tank sumps before every flight. There were six fuel drains on each wing that the Pilot’s Operating Handbook (POH) for the airplane dictated should be drained before every flight. The investigation revealed that the pilot’s previous employer, where he had acquired most of his King Air 200 flight experience, did not have its pilots drain the fuel tank sumps before every flight. Instead, maintenance personnel drained the sumps at some unknown interval. No witnesses were identified who observed the pilot conduct the preflight inspection of the airplane before the accident flight, and it could not be determined whether the pilot had drained the airplane’s fuel tank sumps. He had been the only pilot of the airplane for its previous 40 flights. Because the airplane was not on a Part 135 certificate or a continuous maintenance program, it is unlikely that a mechanic was routinely draining the airplane's fuel sumps. The witness observations, video evidence, and the postaccident examination indicated that the left engine experienced a momentary power interruption during the takeoff initial climb, which was consistent with a power interruption resulting from water contamination of the left engine's fuel supply. It is likely that, during the takeoff rotation and initial climb, water present in the bottom of the left nacelle tank was drawn into the left engine. When the water flowed through the engine's fuel nozzles into the burner can, it momentarily extinguished the engine’s fire. The engine then stopped producing power, and its propeller changed pitch, resulting in the propeller noises heard by witnesses. Subsequently, a mixture of water and fuel reached the nozzles and the engine intermittently relighted and extinguished, which produced the grayish smoke observed in the video and the “pop” noises heard by the mechanic witness. Finally, uncontaminated fuel flow was reestablished, and the engine resumed normal operation. About 5 months before the accident, the pilot successfully completed a 14 Code of Federal Regulations Part 135 pilot-in-command check flight in a King Air 90. However, no documentation was found indicating that he had ever received training in a full-motion King Air simulator. Although simulator training was not required, if the pilot had received this type of training, it is likely that he would have been better prepared to maintain directional control in response to the left yaw from asymmetrical power. Given that the airplane’s airspeed was more than 40 knots above the minimum control speed of 86 knots when the left yaw began, the pilot should have been able to maintain directional control during the momentary power interruption. Although the airplane’s estimated weight at the time of the accident was about 650 pounds over the maximum allowable gross takeoff weight of 12,500 pounds, the investigation determined that the additional weight would not have precluded the pilot from maintaining directional control of the airplane.

Following an uneventful flight from Brasília, the pilot started the descent to Goiânia-Santa Genoveva Airport in poor weather visibility with heavy rain falls and turbulences. On final approach, the twin engine aircraft descended below the glide until it impact the slope of Mt Santo Antônio located 10,7 km short of runway 32. The aircraft was destroyed by impact forces and a post crash fire and all six occupants were killed.

The crew was performing a charter flight from Pointe Noire to Luanda with one passenger on board, the Mauritanian businessman Rashid Mustapha who was candidate to the Presidential elections in Mauritania in 2007. The pax called his bodyguard just before takeoff, asking them to be ready upon arrival at Luanda-4 de Fevereiro Airport. The twin engine aircraft departed Pointe Noire Airport at 2321LT for a 75-90 minutes flight to Luanda. Just before it started the descent, while cruising over the area of Caxito, some 50 km northeast of Luanda, the aircraft disappeared from radar screens at 0020LT. SAR operations were abandoned after few days as no trace of the aircraft nor the three occupants was found. It is possible that the aircraft crashed by night in the ocean off the Angolan coast but this was not confirmed as the wreckage was never found. Three years later, in March 2013, unconfirmed reports and rumors in Africa said that the aircraft never crashed anywhere and that Rashid Mustapha was in fact hostage by a terrorist group somewhere in Africa, but this was not confirmed by Officials in Mauritania or Angola. Without any trace of the aircraft, all hypothesis remains open.