Crash of a Cessna 208B Grand Caravan near Mayo: 2 killed

Date & Time: Aug 6, 2019 at 1113 LT
Type of aircraft:
Operator:
Registration:
C-FSKF
Flight Phase:
Survivors:
No
Site:
Schedule:
Rackla - Mayo
MSN:
208B-0673
YOM:
1998
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1694
Captain / Total hours on type:
212.00
Aircraft flight hours:
19060
Circumstances:
At 1101 Pacific Daylight Time on 06 August 2019, the Alkan Air Ltd. Cessna 208B Grand Caravan aircraft (registration C‐FSKF, serial number 208B0673) departed Rau Strip, Yukon, on a visual flight rules company flight itinerary to Mayo Airport, Yukon. The aircraft had 1 pilot, 1 passenger, and cargo on board. At 1113, the aircraft entered instrument meteorological conditions and struck rising terrain in a box canyon shortly after. The crash occurred approximately 25 nautical miles east‐northeast of Mayo Airport, at an elevation of 5500 feet above sea level. The Canadian Mission Control Centre did not receive a signal from the aircraft’s 406 MHz emergency locator transmitter. Eyewitnesses from a nearby exploration camp arrived at the site after approximately 1 hour. Royal Canadian Mounted Police and emergency medical services arrived on site approximately 90 minutes after the accident. The pilot and passenger received fatal injuries. The aircraft was destroyed; there was a brief post‐impact fire.
Probable cause:
Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. The pilot’s decision making was influenced by several biases and, as a result, the flight departed and subsequently continued into poor weather conditions in mountainous terrain.
2. The high speed at low altitude and low forward visibility reduced the opportunities for the pilot to take alternative action to avoid terrain.
3. Within the box canyon, the canyon floor elevation increased abruptly within less than 1 NM and the low visibility prevented the pilot from detecting this and taking sufficient actions to prevent collision with terrain.
4. When the pilot turned into the box canyon, the terrain awareness and warning system aural alerts were ineffective in warning the pilot about the rising terrain either because he had already heard multiple similar alerts in the preceding minutes, or because he had silenced the alerts.

Findings as to risk:
These are conditions, unsafe acts, or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
1. If administrative safety defences are not used as intended, it increases the risk that the hazards associated with the flight will not be identified and mitigated.

Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
1. The pilot held a valid instrument rating and the aircraft was equipped to fly in instrument meteorological conditions. However, there were no scenarios in the pilot’s flying history on the Cessna 208B Grand Caravan or in his training where a transition from visual flight rules to a flight under instrument flight rules in an emergency was performed.
Final Report:

Crash of a Cessna 208B Grand Caravan in Kilindoni

Date & Time: Aug 6, 2019
Type of aircraft:
Operator:
Registration:
5H-NOW
Flight Phase:
Survivors:
Yes
Schedule:
Kilindoni - Dar es Salaam
MSN:
208B-2209
YOM:
2010
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Kilindoni Airport, the single engine airplane crashed in flames. All nine occupants were able to evacuate the cabin and six of them were injured and transported to local hospital. The aircraft was completely destroyed by fire.

Crash of a Cessna 208B Grand Caravan in Bethel

Date & Time: Jul 8, 2019 at 1505 LT
Type of aircraft:
Operator:
Registration:
N9448B
Survivors:
Yes
Schedule:
Newtok – Bethel
MSN:
208B-0121
YOM:
1988
Flight number:
GV262
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2258
Captain / Total hours on type:
787.00
Aircraft flight hours:
21206
Circumstances:
The commercial pilot was conducting a visual flight rules scheduled passenger flight with five passengers. During the return leg to the company’s base airport, the pilot requested, and was given clearance to, a short gravel runway of 1,858 ft that terminated at parallel cross-runways and had inbound airplanes. The wind was reported as variable at 3 knots, and the outside air temperature was 88°F which was 25° warmer than usual. The pilot stated that he conducted a steeper than normal approach and performed a normal 30° flap landing flare; however, the airplane floated halfway down the runway. He initiated a go-around by advancing the throttle to takeoff power and retracting the flaps to 20° as the main landing gear briefly touched down. Automatic dependent surveillance-broadcast (ADS-B) data indicated that the airplane arrived 0.1 mile from the runway threshold at 149 ft above ground level (agl) and 110 knots of ground speed, which was 32 knots faster than the short field landing approach speed listed in the pilot operating handbook. A witness in the air traffic control tower (the ground controller) stated that the airplane “bled off a lot of airspeed,” during the landing attempt and climbed out in a very flat profile. The tower local controller stated that after liftoff, the airplane’s right wing dropped and the airplane appeared to be turning right into conflicting landing traffic, so he twice instructed the airplane to “left turn out immediately.” The pilot stated that he attempted to comply with the tower controller’s instruction, but when he applied left aileron, the airplane appeared to stall, rolled rapidly right, and descended in a right-wing-low attitude. It subsequently impacted the surface between runways. A postimpact fire ensued, and the pilot helped the passengers egress. The airplane was destroyed by postimpact fire. Given the evidence, it is likely that the pilot decided to land on the short runway to expedite the arrival and did not perform an appropriate short field landing approach, which resulted in excessive airspeed and altitude over the runway threshold, a long landing flare, rapid deceleration, and a self-initiated go-around from a slow airspeed. Had the pilot initiated the go-around as he approached the runway with indications of an unstable visual approach, the airspeed would have been well above stall speed, which would have allowed for the desired positive climb out on runway heading. The pilot likely attempted to comply with the tower local controller’s urgent commands to turn while the airplane was near the limit of performance (the temperature was about 25 degrees warmer than average, which would have resulted in a higher density altitude than the pilot was accustomed to and degraded aircraft and engine performance). The pilot’s maneuvering resulted in the exceedance of the critical angle-of-attack of the high wing (right wing) during the left turn, and an aerodynamic stall.
Probable cause:
The pilot’s failure to maintain adequate airspeed while maneuvering during an attempted go around, which resulted in an exceedance of the airplane's critical angle of attack and an aerodynamic stall at low altitude. Contributing to the accident, was the pilot’s decision to perform an approach to a short runway at an excessive airspeed and his late decision to perform a go-around, which resulted in a slow climb at a reduced safe margin above stall airspeed.
Final Report:

Crash of a Cessna 208B Supervan 900 in the Pacific Ocean: 1 killed

Date & Time: Sep 27, 2018 at 1528 LT
Type of aircraft:
Operator:
Registration:
VH-FAY
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Saipan - Sapporo
MSN:
208B-0884
YOM:
2001
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
13600
Aircraft flight hours:
9291
Circumstances:
The pilot of a Cessna 208B aircraft, registered VH-FAY (FAY), was contracted to ferry the aircraft from Jandakot Airport, Western Australia (WA), to Greenwood, Mississippi in the United States (US). The pilot planned to fly via the ‘North Pacific Route’. At 0146 Coordinated Universal Time (UTC) on 15 September 2018, the aircraft took off from Jandakot Airport, WA, and landed in Alice Springs, Northern Territory at 0743. After landing, the pilot advised the aircraft operator that the aircraft had a standby alternator fault indication. In response, two company licenced aircraft maintenance engineers went to Alice Springs and changed the alternator control unit, which fixed the problem. Late the next morning, the aircraft departed Alice Springs for Weipa, Queensland, where the pilot refuelled the aircraft and stayed overnight. On the morning of 17 September, the pilot conducted a 1-hour flight to Horn Island, Queensland. About an hour later, the aircraft departed Horn Island with the planned destination of Guam, Micronesia. While en route, the pilot sent a message to the aircraft operator advising that he would not land in Guam, but would continue another 218 km (118 NM) to Saipan, Northern Mariana Islands. At 1003, the aircraft landed at Saipan International Airport. The next morning, the pilot refuelled the aircraft and detected damage to the propeller anti-ice boot. The aircraft was delayed for more than a week while a company engineer travelled to Saipan and replaced the anti-ice boot. At 2300 UTC on 26 September, the aircraft departed Saipan, bound for New Chitose Airport, Hokkaido, Japan. Once airborne, the pilot sent a message from his Garmin device, indicating that the weather was clear and that he had an expected flight time of 9.5 hours. About an hour after departure, the aircraft levelled out at flight level (FL) 220. Once in the cruise, the pilot sent a message that he was at 22,000 feet, had a tailwind and the weather was clear. This was followed by a message at 0010 that he was at FL 220, with a true airspeed of 167 kt and fuel flow of 288 lb/hr (163 L/hr). At 0121, while overhead reporting point TEGOD, the pilot contacted Tokyo Radio flight information service on HF radio. The pilot was next due to report when the aircraft reached reporting point SAGOP, which the pilot estimated would occur at 0244. GPS recorded track showed that the aircraft passed SAGOP at 0241, but the pilot did not contact Tokyo Radio as expected. At 0249, Tokyo Radio made several attempts to communicate with the pilot on two different HF frequencies, but did not receive a response. Tokyo Radio made further attempts to contact the pilot between 0249 and 0251, and at 0341, 0351 and 0405. About 4.5 hours after the pilot’s last communication, two Japan Air Self-Defense Force (JASDF) aircraft intercepted FAY. The pilot did not respond to the intercept in accordance with international intercept protocols, either by rocking the aircraft wings or turning, and the aircraft continued to track at FL 220 on its planned flight route. The JASDF pilots were unable to see into the cockpit to determine whether the pilot was in his seat or whether there was any indication that he was incapacitated. The JASDF pilots flew around FAY for about 30 minutes, until the aircraft descended into cloud. At 0626 UTC, the aircraft’s GPS tracker stopped reporting, with the last recorded position at FL 220, about 100 km off the Japanese coast and 589 km (318 NM) short of the destination airport. Radar data showed that the aircraft descended rapidly from this point and collided with water approximately 2 minutes later. The Japanese authorities launched a search and rescue mission and, within 2 hours, searchers found the aircraft’s rear passenger door. The search continued until the next day, when a typhoon passed through the area and the search was suspended for two days. After resuming, the search continued until 27 October with no further parts of the aircraft found. The pilot was not located.
Probable cause:
From the evidence available, the following findings are made with respect to the uncontrolled flight into water involving a Cessna Aircraft Company 208B, registered VH-FAY, that occurred 260 km north-east of Narita International Airport, Japan, on 27 September 2018. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing factors:
• During the cruise between Saipan and New Chitose, the pilot very likely became incapacitated and could no longer operate the aircraft.
• The aircraft’s engine most likely stopped due to fuel starvation from pilot inaction, which resulted in the aircraft entering an uncontrolled descent into the ocean.
Other factors that increased risk:
• The pilot was operating alone in the unpressurised aircraft at 22,000 ft and probably not using the oxygen system appropriately, which increased the risk of experiencing hypoxia and being unable to recover.
Final Report:

Crash of a Cessna 208B Grand Caravan in Mt Aberdare: 10 killed

Date & Time: Jun 5, 2018 at 1702 LT
Type of aircraft:
Operator:
Registration:
5Y-CAC
Flight Phase:
Survivors:
No
Site:
Schedule:
Kitale – Nairobi
MSN:
208B-0525
YOM:
1996
Flight number:
EXZ102
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
2352
Circumstances:
The aircraft took-off from Kitale Airstrip (HKKT) at 16.05 hours and set course to Jomo Kenyatta International Airport (HKJK) after climbing to FL 110 with ten onboard. Once established, there were slight peripheral variations in groundspeed and track. The aircraft Flight Level was sustained at 110 with some occasional deviations. Aircraft height above ground level (AGL) varied between 1,102 feet and 4,187 feet. One minute before its impact with the cliff, the aircraft was at 11,100 feet or 3,000 feet AGL, 159 knots ground speed, and tracking radial 338 NV. Immediately before radar signal was lost, the elevation of the highest ground level was 12,876 feet, the aircraft altitude was 11,200 feet, the ground speed was 156 knots, and track was radial 339 NV. Information retrieved from the Radar transcript recorded various parameters of the aircraft from 1605hrs up to 1702hrs, the time radar signal was lost. This information was consistent with information extracted from the on-board equipment the ST3400 and the aera GPS. The radar system transmits information including aircraft position in relation to NV VOR, Flight Level or altitude, ground speed, vertical speed and heading. Information retrieved from the GPS captured the last recorded time, date and location as 14:00:52, on 06/05/2018 and elevation 3,555.57 metres. The aircraft impacted the bamboo-covered terrain at an elevation of 3,645 metres at 0.36’56’’S 36 42’44’’ where the wreckage was sited. The aircraft was totally destroyed by impact forces and all 10 occupants were killed.
Probable cause:
The flight crew's inadequate flight planning and the decision to fly instrument flight rules (IFR) at an altitude below the published Minimum Sector Altitude in the Standard Instrument Arrival Chart under instrument meteorological conditions (IMC), and their failure to perform an immediate escape maneuver following TAWS alert, which resulted in controlled flight into terrain (CFIT).
Contributing Factors:
1. Contributing to the accident were the operator's inadequate crew resource management (CRM) training, inadequate procedures for operational control and flight release.
2. Also contributing to the accident was the Kenya Civil Aviation Authority's failure to hold the operator accountable for correcting known operational deficiencies and ensuring compliance with its operational control procedures.
3. There was no requirement for crew to be trained in CFIT avoidance ground training tailored to the company’s operations that need to address current CFIT-avoidance technologies.
4. Use of non-documented procedure and Clearance by the ATC to fly below the published minimum sector altitude.
5. Lack of situational awareness by the radar safety controller while monitoring flights within the radar service section.
Final Report: