Crash of a Cessna 208B Grand Caravan in Globe

Date & Time: Jul 22, 2005 at 0830 LT
Type of aircraft:
Registration:
N717BT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Phoenix – Globe – Safford
MSN:
208B-0863
YOM:
2000
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5545
Captain / Total hours on type:
203.00
Aircraft flight hours:
4461
Circumstances:
The airplane impacted a road and scrub brush during a forced landing, which was preceded by a total loss of engine power. According to the pilot, he heard a loud "thunk" during takeoff climb and noted a loss of engine power. He manipulated the power lever from the full forward position to the full aft position ("stop-to-stop") and noted he had no power. Post-accident examination of the Pratt & Whitney Canada PT6A -114A engine revealed that the compressor turbine (CT) vane's outer rim liberated a section of metal that damaged the turbine blades downstream. The area of liberated material from the CT vane outer rim was examined by the manufacturer's metallurgists. The fracture surface of the outer rim showed evidence of fatigue with signs of oxidation in some areas indicating the crack had been in existence for some time. The liberated material impact damaged the CT blades and resulted in a loss of power. Review of the operator's records revealed that the engine was approved for an extension beyond the normally recommended 3,600-hour overhaul period, to 5,100 hours. The engine had accumulated 4,461.3 hours at the time of the accident. In addition, the turbine section (hot section) had a recommended overhaul period of 1,800 hours; however, the operator instead elected to utilize an engine trend monitoring program in accordance with a manufacturer issued service bulletin. Many errors were noted with the operator's manually recorded data utilized for the trend monitoring. However, it is not likely that the engine trend data, even had it been correctly recorded and monitored, would have depicted the fatigue cracking in the CT vane outer rim. As a result, the manufacturer issued a service information letter (SIL) PT6A116 in January 27, 2003 (following a similar investigation), which reminded operators to conduct borescope inspections of the CT vane during routine fuel nozzle maintenance, as the manufacturer's maintenance manual recommended. Review of the maintenance record entries for the accident engine revealed no evidence that a borescope inspection had been conducted in conjunction with the fuel nozzle checks.
Probable cause:
The fatigue failure of the compressor turbine stator vane, the liberation of vane material into the compressor turbine, and the total loss of engine power. Also causal was the operator's failure to inspect the compressor turbine vane during fuel nozzle checks.
Final Report:

Crash of a Cessna 208B Caravan in Fazenda Vera Paz

Date & Time: Mar 29, 2005 at 0724 LT
Type of aircraft:
Operator:
Registration:
PT-MPA
Flight Type:
Survivors:
Yes
Schedule:
Itaituba – Fazenda Vera Paz
MSN:
208B-0627
YOM:
1997
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15000
Captain / Total hours on type:
4200.00
Circumstances:
The single engine airplane departed Itaituba-Mundico Coelho Airport on a cargo flight to Fazenda Vera Paz, a private airstrip located 360 km southwest from Itaituba Airport, carrying one pilot and a load of foods. After touchdown on runway 32, the pilot lost control of the aircraft that veered off runway to the left and came to rest in a drainage ditch, bursting into flames. The pilot escaped uninjured while the aircraft was destroyed by fire.
Probable cause:
Loss of control on landing for unknown reasons. It was not possible to determine whether the heavy rainfall that occurred in the region effectively contributed to the loss of control of the aircraft on the ground. In addition to the narrowing of the runway, the position of the drainage ditch became an obstacle, which prevented the aircraft from decelerating safely, culminating in the collision of the front landing gear against it and the impact of the propeller on the ground.
Final Report:

Crash of a Cessna 208B Grand Caravan off Belize City

Date & Time: Mar 9, 2005 at 1720 LT
Type of aircraft:
Operator:
Registration:
V3-HFW
Flight Phase:
Survivors:
Yes
Schedule:
Belize City – San Pedro
MSN:
208B-0791
YOM:
1999
Flight number:
9N2110
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Belize City-Sir Barry Bowen Municipal Airport, while in initial climb, the single engine aircraft went out of control and crashed in the sea, coming to rest upside down in shallow water. All 14 occupants were rescued while the aircraft was damaged beyond repair.
Probable cause:
Loss of control during initial climb due to windshear after weather conditions suddenly changed as a thunderstorm was approaching the airport.

Crash of a Cessna 208B Super Cargomaster in Helsinki

Date & Time: Jan 31, 2005 at 1700 LT
Type of aircraft:
Operator:
Registration:
SE-KYH
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Helsinki-Örebro
MSN:
208B-0817
YOM:
2000
Flight number:
Helsinki – Örebro
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3886
Captain / Total hours on type:
3657.00
Aircraft flight hours:
6126
Circumstances:
The aircraft landed at Helsinki–Vantaa airport at around 02:47 on Monday, 31.1.2005. After landing, the pilot taxied to apron number four in the southeastern corner of the aerodrome and unloaded the cargo from Sweden. After having done that he left the airport and went to a suite the company reserves for the crew to rest before the return leg to Sweden, which was planned for the following afternoon. The pilot has worked for the company for approximately five years. As per standard policy, the company operates the aircraft with a two person crew. On the day in question the co-pilot had taken ill and the pilot had flown alone. The return leg to Sweden was also planned as a one-person crew flight. The following morning the aircraft was refuelled with 420 l of Jet A-1, in accordance with the pilot’s instructions. All in all ca. 725 kg of fuel was reserved for the return leg. According to his account, the pilot checked in for duty at the airport at around 14:30. After arriving, the pilot began to brush the accumulated snow and frozen snow melt off the upper surfaces of the aircraft. He said that there was a great deal of snow and ice on the aircraft. The cargo that was to go to Sweden did not arrive in time for him to fly it to Skavsta, his primary destination. Therefore, he phoned in a change to the flight plan, choosing Örebro instead as his destination. Örebro was a better choice regarding follow-on transport of the freight. The pilot had outdated meteorological information for the return leg and the operational flight plan form was inadequately filed in. The flight plan was inadvertently filed for another tail number. Information which should be included such as date, crew, prevailing upper winds, estimates to different waypoints, fuel calculations and pilot signatures were omitted from the flight plan. The pilot had not left a copy of the operational flight plan for the ground crew. No weight and balance calculation for the flight was to be found in the cockpit. It had been left in the ground handling service’s briefing room but had been correctly calculated. The pilot did not have access to the latest aeronautical information for the return leg. Printouts of aeronautical information for the inbound leg were found in the cockpit of the wreckage. At 16:52:45 the pilot acknowledged on Helsinki Control Tower (TWR) frequency 118.600 MHz that he was taxiing to takeoff position RWY 22L at intersection Y. At 16:54:40 TWR gave him takeoff clearance from that intersection and gave him the wind direction. The pilot later said that he executed a normal takeoff, using 10 degrees of flaps. The aircraft lifted off at the normal speed of 80-90 KT. At 16:56:05 the pilot called TWR on 118.600 MHz saying “TOWER” just once. As per the pilot’s account everything went well until he reached the height of 800-1000 ft (250-300 m) at which point he retracted the trailing edge flaps. Immediately after flap retraction, the pilot lost control of the aircraft, which began turning to the right. The pilot attempted to fly the aircraft to the end section of runway 22R for an emergency landing. Shortly before crashing to the right side of the extension of runway 22L the pilot managed to get the wings level. He lost consciousness in the crash.
Probable cause:
The chain of events can be regarded as having begun when the aeroplane stood overnight on the tarmac, exposed to the weather. Snowfall accumulated on the upper surfaces of the fuselage, wings and stabilizers during the night forming a thick coat of ice and snow as it partly melted during the day and refroze when the ambient temperature dropped towards the evening. The pilot noticed the impurities when he performed a walkaround check. However, he did not order a de-icing. Instead, he tried to remove the ice with a brush. It is only possible to remove dry and loose snow by brushing. In this case the frozen water that had trickled down remained stuck to surfaces. The pilot executed a takeoff with an aircraft whose aerodynamic properties were fundamentally degraded due to impurities. During the initial climb, immediately after flap retraction, airflow separated from the surface of the wing and the pilot did not manage to regain control of the aircraft. The pilot did not recognize the stall for what is was and did not act in the required manner to recover or, then again, it could be that he had not received sufficient training for these kinds of situations. Several factors are considered to have affected the pilot’s actions. He was either ignorant or negligent as to the effect of impurities on the aeroplane’s aerodynamic properties. Furthermore, the pressure of keeping to the schedule during the early preflight briefing activities may have affected his decision, even though a change in the flight plan eliminated the actual rush. It is the impression of the investigation commission that these factors were the principal ones that contributed to the omission of proper deicing. A probable contributing factor, albeit one difficult to verify, could have been the financial aspect. The company may have considered buying deicing services from an external service provider as an additional expense. Investigations showed that the operator in question had ordered aeroplane de-icing at Helsinki–Vantaa airport only once during the previous and ongoing winter season. The company regularly flew to this airport. Processes were in place for pre-flight briefing as well as for freight forwarding. However, the flight schedules with reference to the opening times of the company’s primary destination airport did not allow for long delays in ground operations. This may have partly put pressure on the pilot to complete the other pre-flight activities as soon as possible. As for the flap setting, the pilot’s takeoff technique was not proper for the existing circumstances. Moreover, when the aeroplane stalled, the pilot did not execute any effective corrective action to regain control of the aircraft. These would have been, among other things: having reset the flaps to the position prior to the stall as well as having taken advantage of the engine power reserve. As per his account, the pilot did not utilize all available engine power. Instead, he stuck to the maximum value prescribed for normal operations as specified in the aircraft operations manual. The fact that the said flight was flown, contrary to normal operations with only a one person crew, can be considered a contributing factor.
Final Report:

Crash of a Cessna 208B Grand Caravan near Colquiri

Date & Time: Jan 21, 2005 at 1000 LT
Type of aircraft:
Operator:
Registration:
CP-2412
Flight Phase:
Survivors:
Yes
Site:
Schedule:
La Paz - Sucre
MSN:
208B-0897
YOM:
2001
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft departed La Paz-El Alto Airport at 0915LT on a schedule service to Sucre with 10 passengers and two pilots on board. About 45 minutes into the flight, the crew reported icing conditions. The aircraft lost height and crashed on the slope of Mt Huaricollo. All 12 occupants were rescued and the aircraft was destroyed.
Probable cause:
Loss of control following an excessive accumulation of ice/frost while flying in freezing fog conditions.

Crash of a Cessna 208B Grand Caravan in Hailey: 2 killed

Date & Time: Dec 6, 2004 at 1723 LT
Type of aircraft:
Operator:
Registration:
N25SA
Survivors:
No
Schedule:
Salt Lake City – Hailey
MSN:
208B-0866
YOM:
2000
Flight number:
MBI1860
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
9757
Captain / Total hours on type:
202.00
Aircraft flight hours:
2117
Circumstances:
Weather reporting facilities reported icing conditions in the area of the accident site. The pilot of a Cessna Citation flying the same RNAV approach twenty minutes prior to the accident aircraft reported picking up light to occasional moderate rime ice. The last communication between the local air traffic controller and the accident pilot indicated that the flight was two miles south of the final approach fix. The controller inquired if the pilot had the runway in sight, and the pilot reported "negative, still IMC." A witness on the ground near the accident site reported that he heard the aircraft first then saw it at a low level below the cloud base flying in a southeasterly direction. The witness stated that the right wing was lower than the left as the aircraft continued to descend. The witness then noted that the wings were moving "side to side" (up and down) a couple of times before the nose of the aircraft dropped near vertical to the terrain. This witness reported hearing the sound of the engine running steady throughout the event. The wreckage was located in a flat open field about 3,000 feet south of the final approach fix coordinates. The aircraft was destroyed by impact damage and a post crash fire.
Probable cause:
The pilot's failure to maintain aircraft control while on approach for landing in icing conditions. Inadequate airspeed was a factor.
Final Report:

Crash of a Cessna 208B Super Cargomaster in Gwinner

Date & Time: Sep 23, 2004 at 2345 LT
Type of aircraft:
Registration:
N7392B
Flight Type:
Survivors:
Yes
Schedule:
Fergus Falls – Gwinner
MSN:
208B-0045
YOM:
1987
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17420
Captain / Total hours on type:
50.00
Aircraft flight hours:
11945
Circumstances:
The airplane was substantially damaged when it impacted an open field about 1-1/2 miles south of the destination airport. The pilot had executed an instrument approach and was circling to land when the accident occurred. Night instrument meteorological conditions prevailed at the time. The area south and east of the airport was sparsely populated. The pilot reported that he obtained the Automated Weather Observing System (AWOS) broadcast for the destination via the aircraft radio while en route. He stated the reported visibility was above that required for the Non-Directional Beacon (NDB) approach, however, the ceiling was below the minimum descent altitude (MDA). He reported that he attempted to contact air traffic control (ATC) with the intention of diverting. He was not able to contact ATC and elected to continue to the destination. The pilot reported that he flew the entire NDB approach and stated: "When I arrived at the MDA, I saw the runway, directly below and a little to my left. My plan, at the time, was to circle left and land." He stated after that point he had no further recollection of the events surrounding the accident. The pilot reported that there were no failures or malfunctions associated with the aircraft. Two witnesses reported seeing lights from an airplane near the airport. One recalled that the weather was "foggy and a heavy mist." The other witness stated: "When I saw the plane it was very low but I thought it was going around for the landing because it looked like the plane had its right wing higher, and I could see part of the belly of the plane, which made it look like it was banking around." Flight control continuity was confirmed during a post-accident examination. The airport AWOS recorded an overcast sky at 400 feet above ground level (agl). The MDA for the instrument approach as 694 feet above field elevation.
Probable cause:
The pilot's failure to maintain altitude during the circling maneuver. Contributing factors were the pilot's improper decision to execute the approach when weather conditions were below minimums and the low light (dark night) conditions.
Final Report:

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

Date & Time: Aug 18, 2004 at 1110 LT
Type of aircraft:
Operator:
Registration:
5Y-TWH
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Goma – Walikale
MSN:
208B-0784
YOM:
1999
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine aircraft departed Goma on a cargo flight to Walikale, carrying two passengers, one pilot and a load of ores. About 10 minutes after takeoff, while flying in limited visibility due to poor weather conditions, the aircraft struck the slope of Mt Nyiragongo located about 15 km north of Goma Airport. The wreckage was found at the altitude of 2,590 metres. The minimum safe altitude was fixed at 3,400 metres.
Probable cause:
Controlled flight into terrain.

Crash of a Cessna 208B Grand Caravan in Panama City

Date & Time: Aug 16, 2004 at 0835 LT
Type of aircraft:
Operator:
Registration:
HP-1397APP
Flight Phase:
Survivors:
Yes
Schedule:
Panama City – Chitré
MSN:
208B-0613
YOM:
1997
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Panama City-Marcos A. Gelabert Airport, while climbing, the crew encountered technical problem with the engine and declared an emergency. He realized he could not return to his departure point so he attempted an emergency landing on a road when the aircraft struck a tree and crashed 9 km weat of the airport. All seven occupants escaped uninjured while the aircraft was damaged beyond repair.