Crash of a Britten-Norman BN-2A Islander in Saidor Gap: 1 killed

Date & Time: Dec 23, 2017 at 1010 LT
Type of aircraft:
Operator:
Registration:
P2-ISM
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Derim - Lae
MSN:
227
YOM:
1970
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1982
Captain / Total hours on type:
139.00
Aircraft flight hours:
32232
Circumstances:
On 23 December 2017, at 00:10 UTC (10:10 local), a Britten Norman BN-2A Islander aircraft, registered P2-ISM (ISM), owned and operated by North Coast Aviation, impacted a ridge, at about 9,500 ft (6°11'29"S, 146°46'11"E) that runs down towards the Sapmanga Valley from the Sarawaget Ranges, Morobe Province. The pilot elected to track across the Sarawaget ranges (See figure 1), from Derim Airstrip to Nadzab Airport, Morobe Province, not above 10,000 ft. The track flown from Derim was to the northwest 6.5 nm (12 km) to a point 0.8 nm (1.5 km) westsouthwest of Yalumet Airstrip where the aircraft turned southwest to track to the Saidor Gap. GPS recorded track data immediately prior to the last GPS fix showed that the aircraft was on a shallow descent towards the ridge. The aircraft impacted the ridge about 150 m beyond the last fix. There were no reports of a transmission of an ELT distress signal. During the search for the aircraft, what appeared to be the right aileron was found hanging from a tree near the top of the heavily-timbered, densely-vegetated ridge. The remainder of the wreckage was found about 130 m from the aileron along the projected track. The aircraft impacted the ground in a steep nose-down, right wing-low attitude. The majority of the aircraft wreckage was contained at the ground impact point. The aircraft was destroyed by impact forces. The pilot, the sole occupant, who initially survived, was reported deceased by the rescue team on 27 December 2017 at 22:10. The pilot had made contact with one of the operator’s pilots at 16:15 on 23 December. The pilot’s time of death, recorded on the Death Certificate, was 10:40 am local on 24 December. Rescuers felled trees on the steep heavily timbered, densely vegetated slope about 20 metres from the wreckage and constructed a helipad.
Probable cause:
Cloud build up along the pilot’s chosen route may have forced him to manoeuvre closer than normal to the ridge, in order to avoid flying into the cloud. The aircraft’s right wing struck a tree protruding from the forest canopy during controlled flight into terrain. It is likely that the right aileron mass balance became snagged on the tree and rapidly dislodged the aileron from the wing. The loss of roll control, and the aerodynamic differential, forced the aircraft to descend steeply through the forest and impacted terrain.
Final Report:

Crash of a PZL-Mielec AN-2 in Ekimchan: 1 killed

Date & Time: Nov 7, 2017 at 0825 LT
Type of aircraft:
Operator:
Registration:
RA-02305
Flight Type:
Survivors:
Yes
Schedule:
Ekimchan - Udskoye
MSN:
1G240-07
YOM:
1990
Flight number:
SHA9001
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5253
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
13550
Copilot / Total hours on type:
10000
Aircraft flight hours:
2483
Aircraft flight cycles:
8807
Circumstances:
The single engine airplane depart Ekimchan Airport at 0834LT on a cargo flight to Udskoye, carrying two pilots and a load of 1,199 kilos of various goods. Six minutes after takeoff, while climbing to an altitude of 1,600 metres, the crew noticed a strong smell of fuel in the cockpit and decided to return. During the descent, flames came out from the engine that started to rough and eventually stopped on short final. The airplane stalled, impacted a birch tree and crashed in a wooded area located 132 metres short of runway 06, bursting into flames. The copilot was killed and the captain was seriously injured. The aircraft was totally destroyed by a post crash fire.
Probable cause:
The crash of An-2 RA-02305 aircraft occurred during the forced landing. The necessity of the forced landing was caused by the engine stopping in flight due to the destruction of the cylinder head No.1 of the ASH62-IR engine No.K16509153. The destruction of cylinder head No. 1 is of fatigue nature and occurred due to exhaustion of fatigue life of the cylinder head material and reaching its limit state. Most likely, during the last repair of the engine the crack in the cylinder head was present, but was not through and was not revealed during the inspection. The most likely contributing factor to stopping the engine in flight was the impoverishment of the fuel-air mixture due to icing of the BAC filter mesh and the presence of a rubber plug on the filter flange of the corrector.
Final Report:

Crash of a Cessna 208A Caravan I in the Anavilhanas Archipelago: 1 killed

Date & Time: Oct 17, 2017 at 1240 LT
Type of aircraft:
Operator:
Registration:
PR-MPE
Flight Type:
Survivors:
Yes
Schedule:
Manaus - Anavilhanas Archipelago
MSN:
208A-0510
YOM:
2009
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8535
Captain / Total hours on type:
660.00
Circumstances:
The single engine aircraft departed Manaus-Eduardo Gomes Airport at 1220LT on a flight to the Anavilhanas Archipelago, carrying cargo, four passengers and one pilot. Upon landing on the Rio Negro, the airplane struck the water surface and crashed upside down before coming to rest partially submerged. The pilot and three passengers were rescued while a fourth passenger was killed.
Probable cause:
The aircraft landed on the water with the landing gear in the down position.
Contributing factors:
- Attitude – a contributor
Failure to comply with the checklist during the pre-flight inspection and the flight itself favored the landing with inadequate configuration. This attitude may have been triggered by the pilot's confidence in his operational capability, because of his long experience in aviation.
- Flight indiscipline – a contributor
Failure to comply with the checklist indicated, in addition to the low level of situational awareness, a low level of concern for the safe conduction of the flight by failing to follow basic procedures set forth in the manufacturer's manuals and current regulations.
- Piloting judgement – a contributor
The pilot's choice not to use the checklist during the flight phases revealed an inadequate evaluation of parameters related to the operation of the aircraft. Improper compliance with the items in the Pre-Flight Inspection Sheet prevented the AMPHIB PUMP 1 and 2 circuit breakers from being rearmed.
- Aircraft maintenance – a contributor
After performing the test of landing gear extension and retraction by the emergency system, the AMPHIB PUMP 1 and 2 circuit breakers were not rearmed, being the aircraft delivered to fly in this condition. The setting recorded on the AIRSPEED switch of the landing gear position warning system computer demonstrated that the scheduled speed of 74kt was not in accordance with the recommended in the 9600-1A installation manual of Wipaire Inc. in its revision G.
- Memory – undetermined
The AMPHIB PUMP 1 and 2 circuit breakers were found disarmed after the occurrence, indicating that, after the completion of the maintenance service, the executor of the tasks probably forgot to comply with the procedures for reconfiguring the aircraft. In addition, it is possible that the pilot's automatism in relation to his way of carrying out the air operations, without the use of the checklist, has prevented the correct perception of the circuit breakers condition and the erroneous positioning of the landing gear.
- Perception – a contributor
The accomplishment of the landing on the water with the aircraft in inadequate configuration for the situation denotes a decrease in the level of situational awareness of the pilot, considering that the necessary factors and conditions for the safety of the operation were not observed.
Final Report:

Crash of an Antonov AN-26-100 off Abidjan: 4 killed

Date & Time: Oct 14, 2017 at 0823 LT
Type of aircraft:
Operator:
Registration:
ER-AVB
Flight Type:
Survivors:
Yes
Schedule:
Ouagadougou – Abidjan
MSN:
32 04
YOM:
1975
Flight number:
Kondor 26
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
23766
Captain / Total hours on type:
10133.00
Copilot / Total flying hours:
2250
Copilot / Total hours on type:
2080
Circumstances:
The airplane departed Ouagadougou on a flight to Abidjan, carrying seven passengers, three crew members and military equipment on behalf of the French Army (antiterrorist operation 'Barkhane'). On approach to Abidjan-Félix Houphouët-Boigny Airport, the crew encountered poor visibility due to heavy rain falls. On short final, the aircraft descended below MDA, impacted water and crashed in the sea few hundred metres short of runway 03. Six occupants were rescued while four others including all three crew members were killed. The aircraft was destroyed. At the time of the accident, weather conditions were below minimums.
Probable cause:
The probable cause of this accident is the continuation of the approach below minimums without having established formal visual contact with runway references and without adequate monitoring of the aircraft's glide path. The rigorous application of the company SOPs should have necessarily led to a go-around.
The following factors contributed to the accident:
- Underestimation of adverse weather conditions below minimums;
- A lack of knowledge of the environment of Abidjan airport and insufficient awareness of the aircraft's vertical position;
- Inadequate monitoring of aircraft instruments and flight path (altitude and speed) in degraded weather conditions;
- A high workload due to continued final approach training and distraction from tasks not related to flight operations;
- Disabling EGPWS audible alerts due to unwanted alarms;
- Crew resource management (CRM) probably unbalanced by the authority of the PNF over the rest of the crew.
- Strict non-compliance with company SOPs.
Final Report:

Crash of an Antonov AN-26B in Goma

Date & Time: Sep 10, 2017 at 1130 LT
Type of aircraft:
Operator:
Registration:
9S-AFL
Flight Type:
Survivors:
Yes
Schedule:
Goma – Bunia
MSN:
140 03
YOM:
1985
Location:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Goma Airport, while on a cargo flight to Bunia, the crew reported technical problems with the right engine and was cleared to return for an emergency landing. The crew landed long (about half way down the runway) and after touchdown, the airplane was unable to stop within the remaining distance. It overran and while contacting lava ground, the right main gear and the nose gear collapsed. The airplane came to rest with its right wing bent and all four crew members evacuated safely.

Crash of a Britten Norman BN-2A-26 Islander in Eteringbang: 1 killed

Date & Time: Jul 25, 2017 at 1755 LT
Type of aircraft:
Operator:
Registration:
8R-GRA
Flight Type:
Survivors:
No
Schedule:
Ekereku – Eteringbang
MSN:
3006
YOM:
1982
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4760
Aircraft flight hours:
24716
Circumstances:
The twin engine airplane departed Ekereku on a cargo flight to Eteringbang, carrying fuel drums for local miners. On final approach to Eteringbang Airfield Runway 03, the aircraft was very low and the pilot initiated a right turn when control was lost. The aircraft crashed in a dense wooded area some 200 metres from the runway. The aircraft was destroyed and the pilot, sole on board, was killed. The pilot Collin Martin was the Chief Pilot of Roraima Airways since 2015.
Probable cause:
The pilot flew a non-standard traffic pattern very low and very close to the runway. The excessive and extreme fight manoeuvres to position the aircraft for the landing resulted in a loss of aircraft control.
Contributory Factors:
The pilot’s failure to operate in accordance with established standard operating procedures when approaching the runway to land.
Final Report:

Crash of a Boeing 737-301F in Wamena

Date & Time: Jul 18, 2017 at 1239 LT
Type of aircraft:
Operator:
Registration:
PK-YGG
Flight Type:
Survivors:
Yes
Schedule:
Timika – Wamena
MSN:
23743/1510
YOM:
1988
Flight number:
TMG103
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was performing a cargo flight from Timika, carrying five crew members and a load of various goods including constructioin materials. Upon landing on runway 15, the airplane bounced twice. It went out of control and veered off runway to the left. While contacting soft ground, both main landing gear were torn off and the aircraft slid for few dozen metres before coming to rest. All five crew members evacuated safely while the aircraft was damaged beyond repair.

Crash of a Cessna 207 Stationair in Vinalhaven

Date & Time: Jun 26, 2017 at 0741 LT
Operator:
Registration:
N207GM
Flight Type:
Survivors:
Yes
Schedule:
Rockland - Vinalhaven
MSN:
207-0217
YOM:
1972
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15436
Captain / Total hours on type:
356.00
Aircraft flight hours:
12458
Circumstances:
The pilot reported that the approach appeared normal, but during the landing on the 1,500 feet long gravel strip, the airplane firmly struck the runway and bounced. He added that the bounce was high and that the remaining runway was too short to correct the landing with power. The pilot chose to go around, applying full power and 20° of flaps for the balked landing procedure. During the climb, the airplane drifted left toward 50-ft-tall trees about 150 ft from the departure end of the runway. Unable to climb over the trees, the airplane struck the tree canopy, the nose dropped, and the pilot instinctively reduced power as the airplane descended through the trees and impacted terrain. The wings and fuselage were substantially damaged. The pilot reported no preimpact mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause:
The pilot's failure to maintain a stabilized approach, which resulted in a bounced landing and subsequent go-around with insufficient distance to clear trees during the climb.
Final Report:

Crash of a Swearingen SA227AC Metro III in Tampico

Date & Time: Jun 2, 2017 at 2245 LT
Type of aircraft:
Operator:
Registration:
XA-UAJ
Flight Type:
Survivors:
Yes
Schedule:
Saltillo – Puebla
MSN:
AC-586
YOM:
1984
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3280
Copilot / Total flying hours:
1144
Aircraft flight hours:
35318
Aircraft flight cycles:
43028
Circumstances:
The twin engine aircraft departed Saltillo Airport on a night cargo flight to Puebla, carrying two pilots and a load of 550 kilos of various goods. En route, the crew declared an emergency and reported a low fuel condition before being cleared to divert to Tampico-General Francisco Javier Mina Airport. On final approach, both engines stopped and the aircraft descended into trees and crashed in a wooded area located 850 metres short of runway 31. Both pilots were slightly injured and the aircraft was damaged beyond repair.
Probable cause:
Emergency landing due to an inadequate pre-flight of the aircraft which resulted in the loss of power of both engines during the cruise flight due to exhaustion of fuel on board.
Contributing factors:
- Lack of adherence to flight planning procedures.
- Lack of coordination between captain and operations officer during pre-flight preparation.
- Lack of supervision of dispatcher activities.
Final Report:

Crash of a Let L-410UVP-E20 in Lukla: 2 killed

Date & Time: May 27, 2017 at 1404 LT
Type of aircraft:
Operator:
Registration:
9N-AKY
Flight Type:
Survivors:
Yes
Schedule:
Kathmandu – Lukla
MSN:
14 29 17
YOM:
2014
Flight number:
GO409
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
9687
Captain / Total hours on type:
1897.00
Copilot / Total flying hours:
1311
Copilot / Total hours on type:
1028
Aircraft flight hours:
2550
Aircraft flight cycles:
5467
Circumstances:
On May 27, 2017 9N-AKY, LET 410 UVP-E20 of Goma Air (now Summit Air), a domestic carrier of Nepal had a published program to operate 5 flights to Lukla from Kathmandu. The first flight departed Kathmandu at 0026 UTC. By the time 0647 UTC they had completed 4 flights. The fifth and the last flight departed Kathmandu at 0744 UTC for Lukla as call sign Goma Air 409. Goma Air 409 was the cargo flight carrying 1680 kg cargo for Lukla. There were two cockpit crews, one cabin crew and no passengers on board the flight. It was pre-monsoon period. Lukla weather on that particular day was cloudy since morning. But ceiling and visibility were reported OK. However, CCTV footage shows rapidly deteriorating weather condition before and after the crash. Automatic VHF recorder of Lukla Tower and CVR recording showed Tower was regularly updating pilots of deteriorating weather. All the pre-and post-departure procedure of the flight was completed in normal manner. Before departure from Kathmandu Pilots were found to have obtained latest weather of Lukla, Phaplu and Rumjatar. PIC decided to remain south of track to avoid the terrain and cloud. When Goma 409 was about 11 miles East from Kathmandu they were informed that Lukla was having heavy rain and airport closed. By that time air traffic congestion in TIA was slowly developing. Traffics were holding in the air and in the ground as well. So Goma 409 continued for Lukla. However, after crossing 26 miles from Kathmandu, they were again informed that the rain had ceased and airport was open. An AS350 helicopter, 9N AGU which departed Lukla at 0803 UTC for Kathmandu had reported unstable wind on final Runway 06. Enroute weather reported by 9N AGU upon request of Lukla Tower was good beyond the Lukla valley. However, it was apprehended that for fixed wing, weather might be difficult to enter valley. Lukla Tower relayed all available information when Goma Air 409 had first established contact at time 0810 UTC. Later, Goma Air and 9N AGY, two reciprocal traffics were also in contact each other. 9N AGY relayed the actual weather status to GOMA AIR. Lukla valley's ceiling and visibility was OK for VFR until 0812UTC ( 6 minutes before crash). Weather started to deteriorate very fast. Mountain Ridges were visible through thin layer of foggy cloud until 0814 UTC. After one minute (approx.) Right Base for Runway 06, was covered up and cloud from left base was moving towards final. Duty ATS Officer of Lukla Tower was regularly up dating pilots about deteriorating weather condition. However, Tower was found to be failed to close the runway as per SOP in spite of rapidly deterioratingweather. Pilots ventured to continue though the weather was marginal. Aircraft reported entering valley at 0816. CVR record showed that First Officer sighted the runway at 0817 (64 seconds before the impact). Instantly PIC acknowledged he had also the runway in sight. Aircraft was at 9100 ft (approx.) when the cockpit crews sighted the runway. It maintained 9000 feet (approx.) for further 21 seconds. At time 0817:12i.e. 48 seconds before the impact Tower gave the latest wind as Westerly 04 knots and runway was clear. PIC was still in doubt and asked whether there was rain. Upon confirmation of having no rain from the Tower the aircraft started to descend further. The PIC, who was also the PF, found to have lost situational awareness deviated to the right with continued descend. At 0817:35 (25 seconds before impact) when the flight was descending through 8650 ft First Officer warned PIC that they were too low. PIC did not respond the F/O's call-out and continued descend. On reaching 8500 ft. F/O again warned PIC in panic. Then PIC asked in panic where the runway was. F/O directed towards the runway. But it was already too low and too late. There was initially two short stall warning sound. Then a continuous stall warning sounded till the impact, which lasted for 13 seconds. The last words in CVR records was "w]/ gtfg " (Do not pull too much). Abrupt change in aircraft attitude in an attempt to climb and reach threshold height at 8900 ft. (on Kathmandu QNH) in a landing configuration, with landing gears down and on full flaps, created excessive drag resulting the aircraft to stall. Subsequently, its left wing first hit a small tree branch 180 ft. short of the threshold. Then impacted the sloppy terrain 100ft. short of the runway. After the crash aircraft engine was reported to be running for about a minute. But there was no postcrash fire. Aircraft was totally damaged by the impact.
Crew:
Paras Kumar Rai, pilot, †
Srijan Manandhar, copilot, †
Pragya Maharjan, cabin crew.
Probable cause:
The Commission concludes that the probable cause of this accident was aircraft stall as a result of excessive drag created by sudden increase in angle of attack of the aircraft supplemented by low speed (below Vref) in an attempt to initiate immediate climb on a landing configuration (full flap and landing gear down) warranted by the critical situation of the final phase of flight.
Contributing factors:
- Critical terrain and rapidly deteriorating weather condition.
- Pilot's loss of situational awareness.
- Improper pilot response to stall warning including failure to advance power lever to maximum at appropriate time.
- Violation of SOP by the ATS and Pilot as well.
Final Report: