Cessna 208B Grand Caravan

The airline transport pilot was conducting an air taxi commuter flight between two Hawaiian islands with eight passengers on board. Several passengers stated that the pilot did not provide a safety briefing before the flight. One passenger stated that the pilot asked how many of the passengers had flown over that morning and then said, “you know the procedures.” The pilot reported that, shortly after takeoff and passing through about 500 ft over the water, he heard a loud “bang,” followed by a total loss of engine power. The pilot attempted to return to the airport; however, he realized that the airplane would not be able to reach land, and he subsequently ditched the airplane in the ocean. All of the passengers and the pilot exited the airplane uneventfully. One passenger swam to shore, and rescue personnel recovered the pilot and the other seven passengers from the water about 80 minutes after the ditching. However, one of these passengers died before the rescue personnel arrived. Postaccident examination of the recovered engine revealed that multiple compressor turbine (CT) blades were fractured and exhibited thermal damage. In addition, the CT shroud exhibited evidence of high-energy impact marks consistent with the liberation of one or more of the CT blades. The thermal damage to the CT blades likely occurred secondary to the initial blade fractures and resulted from a rapid increase in fuel flow by the engine fuel control in response to the sudden loss of compressor speed due to the blade fractures. The extent of the secondary thermal damage to the CT blades precluded a determination of the cause of the initial fractures. Review of airframe and engine logbooks revealed that, about 1 1/2 years before the accident, the engine had reached its manufacturer-recommended time between overhaul (TBO) of 3,600 hours; however, the operator obtained a factory-authorized, 200-hour TBO increase. Subsequently, at an engine total time since new of 3,752.3 hours, the engine was placed under the Maintenance on Reliable Engines (MORE) Supplemental Type Certificate (STC) inspection program, which allowed an immediate increase in the manufacturer recommended TBO from 3,600 to 8,000 hours. The MORE STC inspection program documents stated that the MORE STC was meant to supplement, not replace, the engine manufacturer’s Instructions for Continued Airworthiness and its maintenance program. Although the MORE STC inspection program required more frequent borescope inspections of the hot section, periodic inspections of the compressor and exhaust duct areas, and periodic power plant adjustment/tests, it did not require a compressor blade metallurgical evaluation of two compressor turbine blades; however, this evaluation was contained in the engine maintenance manual and an engine manufacturer service bulletin (SB). The review of the airframe and engine maintenance logbooks revealed no evidence that a compressor turbine metallurgical evaluation of two blades had been conducted. The operator reported that the combined guidance documentation was confusing, and, as a result, the operator did not think that the compressor turbine blade evaluation was necessary. It is likely that, if the SB had been complied with or specifically required as part of the MORE STC inspection program, possible metal creep or abnormalities in the turbine compressor blades might have been discovered and the accident prevented. The passenger who died before the first responders arrived was found wearing a partially inflated infant life vest. The autopsy of the passenger did not reveal any significant traumatic injuries, and the autopsy report noted that her cause of death was “acute cardiac arrhythmia due to hyperventilation.” Another passenger reported that he also inadvertently used an infant life vest, which he said seemed “small or tight” but “worked fine.” If the pilot had provided a safety briefing, as required by Federal Aviation Administration regulations, to the passengers that included the ditching procedures and location and usage of floatation equipment, the passengers might have been able to find and use the correct size floatation device.

The scheduled commuter flight departed 40 minutes late for a two-stop flight. During the first leg of the night visual flight rules (VFR) flight, weather at the first destination airport deteriorated, so the pilot diverted to the second destination airport. The pilot requested and received a special VFR clearance from an air route traffic controller into the diversion airport area. Review of automatic dependent surveillance-broadcast data transmitted by the airplane showed that, after the clearance was issued, the airplane's track changed and proceeded in a direct line to the diversion airport. Postaccident examination of the pilot's radio showed that his audio panel was selected to the air route traffic control (ARTCC) frequency rather than the destination airport frequency; therefore, although the pilot attempted to activate the pilot-controlled lighting at the destination airport, as heard on the ARTCC frequency, it did not activate. Further, witnesses on the ground at St. Mary's reported that the airport lighting system was not activated when they saw the accident airplane fly over, and then proceed away from the airport. Witnesses in the area described the weather at the airport as deteriorating with fog and ice. About 1 mile from the runway, the airplane began to descend, followed by a descending right turn and controlled flight into terrain. The pilot appeared to be in control of the airplane up to the point of the right descending turn. Given the lack of runway lighting, the restricted visibility due to fog, and the witness statements, the pilot likely lost situational awareness of the airplane's geographic position, which led to his subsequent controlled flight into terrain. After the airplane proceeded away from the airport, the witnesses attempted to contact the pilot by radio. When the pilot did not respond, they accessed the company's flight tracking software and noted that the airplane's last reported position was in the area of the airplane's observed flightpath. They proceeded to search the area where they believed the airplane was located and found the airplane about 1 hour later. Postaccident examination of the airframe and engine revealed no mechanical malfunctions or anomalies that would have precluded normal operation. About 3/4 inch of ice was noted on the nonprotected surfaces of the empennage. However, ice formation on the airplane's inflatable leading edge de-ice boots was consistent with normal operation of the de-ice system, and structural icing likely was not a factor in the accident. According to the company's General Operations Manual (GOM), operational control was held by the flight coordinator for the accident flight, and the flight coordinator and pilot-in-command (PIC) were jointly responsible for preflight planning, flight delay, and release of the flight, which included the risk assessment process. The flight coordinator assigned the flight a risk level of 2 (on a scale of 1 to 4) due to instrument meteorological and night conditions and contaminated runways at both of the destination airports. The first flight coordinator assigned another flight coordinator to create the manifest, which listed eight passengers and a risk assessment level of 2. According to company risk assessment and operational control procedures, a risk level of 2 required a discussion between the PIC and flight coordinator about the risks involved. However, the flight coordinators did not discuss with the pilot the risks and weather conditions associated with the flight. Neither of the flight coordinators working the flight had received company training on the risk assessment program. At the time of the accident, no signoff was required for flight coordinators or pilots on the risk assessment form, and the form was not integrated into the company manuals. A review of Federal Aviation Administration (FAA) surveillance activities revealed that aviation safety inspectors had performed numerous operational control inspections and repeatedly noted deficiencies within the company's training, risk management, and operational control procedures. Enforcement Information System records indicated that FAA inspectors observed multiple incidences of the operator's noncompliance related to flight operations and that they opened investigations; however, the investigations were closed after only administrative action had been taken. Therefore, although FAA inspectors were providing surveillance and noting discrepancies within the company's procedures and processes, the FAA did not hold the operator sufficiently accountable for correcting the types of operational deficiencies evident in this accident, such as the operator's failure to comply with its operations specifications, operations training manual, and GOM and applicable federal regulations.

On 25 November 2013, a Cessna Aircraft Company C208B Grand Caravan, registered P2-SAH and operated by Tropicair, departed Kamusi, Western Province, for Purari River, Gulf Province, at 0312 UTC on a charter flight under the instrument flight rules (IFR). There were 10 persons on board; one pilot and nine passengers . Earlier in the day, the aircraft had departed Port Moresby for Kamusi from where it flew to Hivaro and back to Kamusi before the accident flight. SAH was due to continue from Purari River to Vailala and Port Moresby. The pilot reported that the takeoff and climb from Kamusi were normal and he levelled off at 9,000 ft and completed the top-of-climb checklist. Between Kamusi and Purari River the terrain is mostly flat and forest covered, with areas of swampland and slow-moving tidal rivers. Habitation is very sparse with occasional small villages along the rivers. The pilot recalled that the weather was generally good in the area with a cloud base of 3,000 ft and good visibility between build-ups. The pilot reported that approximately 2 minutes into the cruise there was a loud ‘pop’ sound followed by a complete loss of engine power. After configuring the aircraft for best glide speed at 95 kts, the pilot turned the aircraft right towards the coast and rivers to the south, and completed the Phase-1 memory recall items for engine failure in flight. He was assisted by the passenger in the right pilot seat who switched on the Emergency Locator Transmitter (ELT) and at 0332 broadcast MAYDAY due engine failure on the area frequency. Checking the database in the on-board Global Positioning System (GPS), the pilot found the airstrip at Kibeni on the eastern side of the Palbuna River. The pilot, assisted by the passenger next to him, tried unsuccessfully to restart the engine using the procedure in the aircraft’s Quick Reference Handbook (QRH). The passenger continued to give position reports and to communicate with other aircraft. At about 3,000 ft AMSL the pilot asked for radio silence on the area frequency so he could concentrate on the approach to Kibeni airstrip, flying a left hand circuit to land in a south westerly direction. He selected full flaps during the final stages of the approach, which arrested the aircraft’s rate of descent, but the higher than normal speed of the aircraft during the approach and landing flare caused it to float and touch down half way along the airstrip. The disused 430 metre long Kibeni airstrip was overgrown with grass and weeds. It was about 60 ft above the river and 120 ft above mean sea level, with trees and other vegetation on the slope down to the river. The aircraft bounced three times and, because the aircraft’s speed had not decayed sufficiently to stop in the available length, the pilot elected to pull back on the control column in order to clear the trees that were growing on the slope between the airstrip and the river. The aircraft became airborne, impacting the crown of a coconut palm (that was almost level with the airstrip) as it passed over the trees. The pilot banked the aircraft hard left in an attempt to land/ditch along the river and avoid trees on the opposite bank. He then pushed forward on the control column to avoid stalling the aircraft and levelled the wings before the aircraft impacted the water. The aircraft came to rest inverted with the cockpit and forward cabin submerged and immediately filled with water. After a short delay while he gained his bearings under water, the pilot was able to undo his harness and open the left cockpit door. He swam to the rear of the aircraft, opened the right rear cabin door, and helped the surviving passengers to safety on the river bank. He made several attempts to reach those still inside the aircraft. When he had determined there was nothing further he could do to reach them, he administered first aid to the survivors with materials from the aircraft’s first aid kit. After approximately 20 minutes, villagers arrived in a canoe and transported the pilot and surviving passengers to Kibeni village across the river. About 90 minutes after the accident, rescuers airlifted the survivors by helicopter to Kopi, located 44 km north east of Kibeni.

The single engine aircraft departed Loreto Airport at 0901LT on a flight to Ciudad Constitución, carrying 13 passengers and one pilot. Weather conditions were poor with limited visibility and heavy rain falls due to the presence of the tropical storm 'Octave'. Six minutes after takeoff, while cruising at an altitude of 3,900 feet, the airplane impacted the slope of a rocky mountain located in the Sierra de La Giganta. The wreckage was found two days later some 26 km west of Loreto. The aircraft disintegrated on impact and all 14 occupants were killed.

The single engine aircraft was engaged in a charter flight from Likawage to Dar es Salaam, carrying one passenger and two pilots. Ready for takeoff at threshold, the crew applied full power and maintained brakes. Despite the engine did not reach the takeoff power, the captain released brakes and initiated the takeoff roll. The aircraft rolled for about three-quarters of the runway when the engine reached the takeoff power. But the aircraft failed to rotate, continued, overran and eventually collided with trees, bursting into flames. All three occupants were slightly injured and the aircraft was partially destroyed by fire.

On behalf of Morningstar Air Express, the pilot departed Sault Sainte Marie Airport, south Ontario, in the morning, for a local training flight. For unknown reasons, the pilot did not maintain any radio contact with his base or ATC and continued to the north for about 1,200 km when the aircraft crashed in unknown circumstances in the Hudson Bay, some 500 km east of Churchill, Manitoba. The aircraft was destroyed and the pilot was killed.

The pilot landed at the airport to refuel the airplane and pick up cargo. The pilot spoke with three employees of the fixed base operator who stated that he seemed alert and awake but wanted to make a "quick turn." After the airplane was fueled and the cargo was loaded, the pilot departed; the airplane crashed 1 minute later. Night visual meteorological conditions prevailed at the time. An aircraft performance GPS and simulation study indicated that the airplane entered a right bank almost immediately after takeoff and then made a 42 degree right turn and that it was accelerating throughout the flight, from about 75 knots groundspeed shortly after liftoff to about 145 knots groundspeed at impact. The airplane was climbing about 500 to 700 feet per minute to a peak altitude of about 260 feet above the ground before descending. The simulation showed a gas generator speed of about 93 percent throughout the flight. The study indicated that the load factor vectors, which were the forces felt by the pilot, could have produced a somatogravic illusion of a climb, even while the airplane was descending. The postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Based on the findings from the aircraft performance GPS and simulation study, the degraded visual reference conditions present about the time of the accident, and the forces felt by the pilot, it is likely that he experienced spatial disorientation, which led to his inadvertent controlled descent into terrain.