Country
Crash of a Cessna 208B Grand Caravan EX in Lolat
Date & Time:
Jun 14, 2016 at 0758 LT
Operator:
Registration:
PK-RCK
Survivors:
Yes
Schedule:
Wamena – Lolat
MSN:
208B-5149
YOM:
2014
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
53
Circumstances:
The single engine airplane departed Wamena Airport at 0739LT on a cargo flight to Lolat, carrying two passengers, one pilot and a load of building materials for a total weight of 1,190 kilos. On short final to Lolat Airfield, the aircraft impacted the roof of a wooded house and crashed, bursting into flames. All three occupants of the airplane evacuated safely while three people in the house were injured. The aircraft was totally destroyed by a post crash fire.
Crash of a Cessna 208B Grand Caravan in Akobo
Date & Time:
Jun 3, 2016 at 1000 LT
Operator:
Registration:
5Y-JLL
Survivors:
Yes
Schedule:
Akobo - Juba
MSN:
208B-2158
YOM:
2009
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 3 June 2016, a Cessna 208B of registration 5Y-JLL and serial number 2158 was conducting a charter passenger flight from Akobo Airstrip to Juba with 4 passengers and one flight crew member on board. According to the operator, during takeoff from Akobo Airstrip at approximately 10 a.m. Local Time, the pilot executed a premature takeoff due to animal incursion on the runway. The airplane's right main landing gear clipped the Airstrip perimeter fence and the aircraft crash-landed onto grass-thatched houses and trees near the end of the runway. Damage was substantial with no reported injuries. The runway was reported to have been wet at the time of occurrence.
Final Report:
Crash of a Cessna 208B Grand Caravan in Lodi
Date & Time:
May 12, 2016 at 1413 LT
Registration:
N1114A
Survivors:
Yes
Schedule:
Lodi - Lodi
MSN:
208B-0309
YOM:
1992
Crew on board:
1
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
253.00
Aircraft flight hours:
12848
Circumstances:
The commercial pilot reported that, after takeoff on the local skydiving flight, the engine experienced a total loss of power. He initiated a turn toward the airport, but realized the airplane would not reach the runway and chose to perform a forced landing to an open field. During the landing roll, the airplane exited the field, crossed a road, impacted a truck, and continued into a vineyard, where it nosed over. Postaccident examination of the engine revealed that the fuel pressure line that connects the fuel control unit to the airframe fuel pressure transducer was fractured below the fuel control unit fitting's swaged seat. In addition, a supporting clamp for the fuel pressure fuel line was fractured and separated. The operator reported that the fractured fuel line had been replaced the night before the accident and had accumulated about 4 hours of operational time. The previously-installed line had also fractured. Metallurgical examination of the two fractured fuel lines revealed that both fuel lines fractured due to reverse bending fatigue through the tube wall where a ferrule was brazed to the outside of the tube. There were no apparent anomalies or defects at the crack initiation sites. Examination of the supporting clamp determined that it fractured due to unidirectional bending fatigue where one of the clamp's tabs met the clamp loop, with the crack initiating along the inward-facing side of the clamp. The orientation of the reverse bending fatigue cracks and the spacing of the fatigue striations on the tube fracture surfaces were consistent with high-cycle bending fatigue due to a vibration of the tube. The cushioned support clamp is designed to prevent such vibrations from occurring. However, if the clamp tab is fractured, it cannot properly clamp the tube and will be unable to prevent the vibration. The presence of the fractured clamp combined with the fact that the two pressure tubes failed in similar modes in short succession indicated that the clamp most likely failed first, resulting in the subsequent failure of the tubes. Since the clamp was likely fractured when the first fractured fuel pressure line was replaced, the clamp was either not inspected or inadequately inspected at the time of the maintenance.
Probable cause:
A total loss of engine power due to a fatigue fracture of the fuel pressure line that connected the fuel control unit and the fuel flow transducer due to vibration as the result of a fatigue fracture of an associated support clamp. Contributing to the accident was the mechanic's inadequate inspection of the fuel line support clamp during the previous replacement of the fuel line.
Final Report:
Crash of a Cessna 208B Grand Caravan near Tayoltita: 3 killed
Date & Time:
Apr 1, 2016 at 0917 LT
Operator:
Registration:
XA-ULU
Survivors:
Yes
Schedule:
Tayoltita - Durango
MSN:
208B-2104
YOM:
2009
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
3
Aircraft flight hours:
4027
Aircraft flight cycles:
3479
Circumstances:
The single engine airplane departed Tayoltita Airfield around 0900LT on a charter flight to Durango, carrying nine passengers and one pilot. Twelve minutes into the flight, the pilot encountered engine problems and declared an emergency. Unable to maintain a safe altitude, he attempted an emergency landing when the aircraft crashed in the bed of the Piaxtla River. The wreckage was found about 16 km northeast of Tayoltita Airfield (N 24° 11' 2.65" W 105° 47' 12.57''). The aircraft was destroyed by impact forces and there was no fire. Three passengers were killed and seven other occupants were injured.
Probable cause:
The accident was the consequence of a loss of control following the failure of a turbine compressor disc blade. It was reported that unauthorized repairs had been made on the engine without the approval of the engine manufacturer.
Final Report:
Crash of a Cessna AC-208B Combat Caravan in Hawijah: 3 killed
Date & Time:
Mar 16, 2016
Operator:
Registration:
YI-119
Survivors:
No
Schedule:
Balad - Balad
MSN:
208B-1309
YOM:
2008
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The single engine airplane departed Balad AFB on an exercice with three crew members on board. While flying at low height, it was shot down by a 57 mm antiaircraft gunfire. Out of control, it dove into the ground and crashed in Hawijah, some 160 km north of Balad AFB. The aircraft was destroyed by impact forces and a post crash fire and all three crew occupants were killed.
Probable cause:
Shot down by antiaircraft gunfire.
Crash of a Cessna 208B Grand Caravan near Anaktuvuk Pass
Date & Time:
Jan 2, 2016 at 1205 LT
Operator:
Registration:
N540ME
Survivors:
Yes
Schedule:
Fairbanks - Anaktuvuk Pass
MSN:
208B-0540
YOM:
1996
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
4142.00
Aircraft flight hours:
19555
Circumstances:
The airline transport pilot was conducting a scheduled passenger flight in an area of remote, snow-covered, mountainous terrain with seven passengers on board. The pilot reported that, after receiving a weather briefing, he chose to conduct the flight under visual flight rules (VFR). While en route about 10,000 ft mean sea level (msl), the visibility began "getting fuzzy." The pilot then descended the airplane to 2,500 ft msl (500 ft above ground level) to fly along a river. When the airplane was about 10 miles southwest of the airport, he climbed the airplane to about 3,000 ft msl in order to conduct a straight-in approach to the runway. He added that the visibility was again a little "fuzzy" due to snow and clouds, and that he never saw the airport. The pilot also noted that the flat light conditions limited his ability to determine his distance from the surrounding mountainous, snow-covered terrain. Shortly after climbing to 3,000 ft msl, the airplane collided with the rising terrain about 6 miles southwest of the airport. Another pilot, who had just departed from the airport, confirmed that flat light and low-visibility conditions existed in the area at the time of the accident. Further, camera images of the weather conditions recorded at the airport showed that, although conditions were marginal VFR at the surface at the time of the accident, there was mountain obscuration and reduced visibility due to light snow and clouds along the accident flight path and that the worst conditions were located along and near the higher terrain. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation. It is likely that that the pilot encountered flat light and low-visibility conditions as he neared the airport at 3,000 ft msl while operating under VFR and that he did not see the rising, snow-covered mountainous terrain and subsequently failed to maintain clearance from it.
Probable cause:
The pilot's continued flight into deteriorating, flat light weather conditions, which resulted in impact with mountainous, snow-covered terrain.
Final Report:
Crash of a Cessna 208B Grand Caravan near Pickle Lake: 1 killed
Date & Time:
Dec 11, 2015 at 0909 LT
Operator:
Registration:
C-FKDL
Survivors:
No
Schedule:
Pickle Lake – Angling Lake
MSN:
208B-0240
YOM:
1990
Flight number:
WSG127
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total hours on type:
245.00
Aircraft flight hours:
36073
Aircraft flight cycles:
58324
Circumstances:
On 11 December 2015, the pilot of Wasaya Airways Limited Partnership (Wasaya) flight 127 (WSG127) reported for duty at the Wasaya hangar at Pickle Lake Airport (CYPL), Ontario, at about 0815. The air taxi flight was to be the first of 3 cargo trips in the Cessna 208B Caravan (registration C-FKDL, serial number 208B0240) planned from CYPL to Angling Lake / Wapekeka Airport (CKB6), Ontario. The first flight was planned to depart at 0900. The pilot went to the Wasaya apron and conducted a pre-flight inspection of C-FKDL while a ground crew was loading cargo. A Wasaya aircraft fuel-handling technician confirmed with the pilot that the planned fuel load was 600 pounds per wing of Jet A fuel. After completing the fueling, the technician used the cockpit fuel-quantity indicators to verify that the distribution was 600 pounds per wing. The pilot returned to the hangar and received a briefing from the station manager regarding the planned flights. The pilot was advised that the first officer assigned to the flight had been reassigned to other duties in order to increase the aircraft’s available payload and load a snowmobile on board. The pilot completed and signed a Wasaya flight dispatch clearance (FDC) form for WSG127, and filed a copy of it, along with the flight cargo manifests, in the designated location in the company operations room. The FDC for WSG127 showed that the flight was planned to be conducted under visual flight rules (VFR), under company flight-following, at an altitude of 5500 feet above sea level (ASL). Time en route was calculated to be 66 minutes, with fuel consumption of 413 pounds. The pilot returned to the aircraft on the apron. Loading and fueling were complete, and the pilot conducted a final walk-around inspection of C-FKDL. Before entering the cockpit, the pilot conducted an inspection of the upper wing surface. At 0854, the pilot started the engine of C-FKDL and conducted ground checks for several minutes. At 0858, the pilot advised on the mandatory frequency (MF), 122.2 megahertz (MHz), that WSG127 was taxiing for departure from Runway 09 at CYPL. WSG127 departed from Runway 09 at 0900, and, at 0901, the pilot reported on the MF that the flight was airborne. The flight climbed eastward for several miles and then turned left toward the track to CKB6. At about 3000 feet ASL, WSG127 briefly descended about 100 feet over 10 seconds, and then resumed climbing. At 0905, the pilot reported on the MF that WSG127 was clear of the MF zone. WSG127 intercepted the track to CKB6 and climbed northward until the flight reached a peak altitude of about 4600 feet ASL at 0908:41, and then began descending at 0908:46. At 0909:16, the flight made a sharp right turn of about 120° as it descended through about 4000 feet ASL. At 0909:39, the descent ended at about 2800 feet and the aircraft climbed to about 3000 feet ASL before again beginning to descend. At approximately 0910, WSG127 collided with trees and terrain at an elevation of 1460 feet ASL during daylight hours.
Probable cause:
Findings as to causes and contributing factors:
1. Although the aircraft was prohibited from flying in known or forecast icing conditions, Wasaya Airways Limited Partnership (Wasaya) flight 127 (WSG127) was dispatched into forecast icing conditions.
2. The high take-off weight of WSG127 increased the severity of degraded performance when the flight encountered icing conditions.
3. The pilot of WSG127 continued the flight in icing conditions for about 6 minutes, resulting in progressively degraded performance.
4. WSG127 experienced substantially degraded aircraft performance as a result of ice accumulation, resulting in aerodynamic stall, loss of control, and collision with terrain.
5. The Type C pilot self-dispatch procedures and practices in use at Wasaya at the time of the occurrence did not ensure that operational risk was managed to an acceptable level.
6. Wasaya had not implemented all of the mitigation strategies from its January 2015 risk assessment of Cessna 208B operations in known or forecast icing conditions, and the company remained exposed to some unmitigated hazards that had been identified in the risk assessment.
7. There was a company norm of dispatching Cessna 208B flights into forecast icing conditions, although 4 of Wasaya’s 5 Cessna 208B aircraft were prohibited from operating in these conditions.
Findings as to risk:
1. Without effective risk-management processes, aircraft may continue to be dispatched into forecast or known icing conditions that exceed the operating capabilities of the aircraft, increasing the risk of degraded aircraft performance or loss of control.
2. If pilots operating under self-dispatch do not have adequate tools to complete an operational risk assessment before releasing a flight, there is an increased likelihood that hazards will not be identified or adequately mitigated.
3. If aircraft that are not certified for flight in known or forecast icing conditions are dispatched into, and encounter, such conditions, there is an increased risk of degraded performance or loss of control.
4. If aircraft that are certified for flight in known or forecast icing conditions are dispatched into, and encounter, such conditions, at weights exceeding limitations, there is an increased risk of loss of control.
5. If flights are continued in known icing conditions in aircraft that are not certified to do so, there is an increased risk of degraded aircraft performance and loss of control.
6. If operators exceed aircraft manufacturers’ recommended ICEX II servicing intervals, there is an increased risk of degraded aircraft performance or loss of control resulting from greater accretion of ice on the leading-edge de-icing and propeller blade anti-icing boots.
7. If pilots do not receive the minimum required training, there is an increased risk that they will lack the necessary technical knowledge to operate aircraft safely.
8. If pilots are not provided with the information they need to calculate the aircraft’s centre of gravity accurately, they risk departing with their aircraft’s centre of gravity outside the limits, which can lead to loss of control.
9. If emergency locator transmitter antennas and cable connections are not robust enough to survive impact forces, potentially life-saving search-and-rescue operations may be impaired by the absence of a usable signal.
Other findings:
1. Wasaya’s use of a satellite aircraft flight-following system provided early warning of WSG127’s abnormal status and an accurate last known position for search-and-rescue operations.
2. The investigation could not determine whether the autopilot had been used by the pilot of WSG127 at any time during the flight.
1. Although the aircraft was prohibited from flying in known or forecast icing conditions, Wasaya Airways Limited Partnership (Wasaya) flight 127 (WSG127) was dispatched into forecast icing conditions.
2. The high take-off weight of WSG127 increased the severity of degraded performance when the flight encountered icing conditions.
3. The pilot of WSG127 continued the flight in icing conditions for about 6 minutes, resulting in progressively degraded performance.
4. WSG127 experienced substantially degraded aircraft performance as a result of ice accumulation, resulting in aerodynamic stall, loss of control, and collision with terrain.
5. The Type C pilot self-dispatch procedures and practices in use at Wasaya at the time of the occurrence did not ensure that operational risk was managed to an acceptable level.
6. Wasaya had not implemented all of the mitigation strategies from its January 2015 risk assessment of Cessna 208B operations in known or forecast icing conditions, and the company remained exposed to some unmitigated hazards that had been identified in the risk assessment.
7. There was a company norm of dispatching Cessna 208B flights into forecast icing conditions, although 4 of Wasaya’s 5 Cessna 208B aircraft were prohibited from operating in these conditions.
Findings as to risk:
1. Without effective risk-management processes, aircraft may continue to be dispatched into forecast or known icing conditions that exceed the operating capabilities of the aircraft, increasing the risk of degraded aircraft performance or loss of control.
2. If pilots operating under self-dispatch do not have adequate tools to complete an operational risk assessment before releasing a flight, there is an increased likelihood that hazards will not be identified or adequately mitigated.
3. If aircraft that are not certified for flight in known or forecast icing conditions are dispatched into, and encounter, such conditions, there is an increased risk of degraded performance or loss of control.
4. If aircraft that are certified for flight in known or forecast icing conditions are dispatched into, and encounter, such conditions, at weights exceeding limitations, there is an increased risk of loss of control.
5. If flights are continued in known icing conditions in aircraft that are not certified to do so, there is an increased risk of degraded aircraft performance and loss of control.
6. If operators exceed aircraft manufacturers’ recommended ICEX II servicing intervals, there is an increased risk of degraded aircraft performance or loss of control resulting from greater accretion of ice on the leading-edge de-icing and propeller blade anti-icing boots.
7. If pilots do not receive the minimum required training, there is an increased risk that they will lack the necessary technical knowledge to operate aircraft safely.
8. If pilots are not provided with the information they need to calculate the aircraft’s centre of gravity accurately, they risk departing with their aircraft’s centre of gravity outside the limits, which can lead to loss of control.
9. If emergency locator transmitter antennas and cable connections are not robust enough to survive impact forces, potentially life-saving search-and-rescue operations may be impaired by the absence of a usable signal.
Other findings:
1. Wasaya’s use of a satellite aircraft flight-following system provided early warning of WSG127’s abnormal status and an accurate last known position for search-and-rescue operations.
2. The investigation could not determine whether the autopilot had been used by the pilot of WSG127 at any time during the flight.
Final Report:
Crash of a Cessna 208B Grand Caravan near Yumbo: 3 killed
Date & Time:
Oct 14, 2015 at 1146 LT
Operator:
Registration:
PR-MIC
Survivors:
No
Schedule:
Cali - Cali
MSN:
208B-0841
YOM:
2000
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total hours on type:
4155.00
Copilot / Total hours on type:
1029
Aircraft flight hours:
10519
Circumstances:
The single engine airplane departed Cali-Alfonso Bonilla Aragón Airport on an geophysical exploration mission of the south part of Chocó, carrying three crew members, two pilots and one operator in charge of the LIDAR equipment. At 1144LT, the crew reported his altitude at 5,600 feet. Two minutes later, while cruising in poor visibility, the aircraft struck trees and crashed in wooded and hilly terrain near Yambo. The wreckage was found few hours later and all three occupants were killed.
Probable cause:
The following factors were identified:
- Controlled flight into terrain,
- Execution of a VFR flight in reduced visibility weather conditions,
- Poor decision making by the crew in continuing VFR operation as they were in an environment of significantly reduced visibility,
- Inadequate operational risk assessment due to the lack of familiarity of the foreign crew with the topography and meteorological evolution of the sector.
- Controlled flight into terrain,
- Execution of a VFR flight in reduced visibility weather conditions,
- Poor decision making by the crew in continuing VFR operation as they were in an environment of significantly reduced visibility,
- Inadequate operational risk assessment due to the lack of familiarity of the foreign crew with the topography and meteorological evolution of the sector.
Final Report:
