Crash of a Beechcraft B200 Super King Air in Melbourne: 5 killed

Date & Time: Feb 21, 2017 at 0858 LT
Registration:
VH-ZCR
Flight Phase:
Survivors:
No
Site:
Schedule:
Melbourne - King Island
MSN:
BB-1544
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
7681
Captain / Total hours on type:
2400.00
Aircraft flight hours:
6997
Circumstances:
On 21 February 2017, the pilot of a Beechcraft B200 King Air aircraft, registered VH-ZCR (ZCR), and operated by Corporate & Leisure Aviation, was conducting a charter passenger flight from Essendon Airport, Victoria to King Island, Tasmania. There were four passengers on board. ZCR had been removed from a hangar and parked on the apron the previous afternoon in preparation for the flight. The pilot was first seen on the apron at about 0706 Eastern Daylight-saving Time. Closed-circuit television recorded the pilot walking around the aircraft and entering the cabin, consistent with conducting a pre-flight inspection of the aircraft. At about 0712, the pilot entered ZCR’s maintenance provider’s hangar. A member of staff working in the hangar reported that the pilot had a conversation with him that was unrelated to the accident flight. The pilot exited the hangar about 0715 and had a conversation with another member of staff who reported that their conversation was also unrelated to the accident flight. The pilot then returned to ZCR, and over the next 4 minutes he was observed walking around the aircraft. The pilot went into the cabin and re-appeared with an undistinguishable item. The pilot then walked around the aircraft one more time before re-entering the cabin and closing the air stair cabin door. At about 0729, the right engine was started and, shortly after, the left engine was started. Airservices Australia (Airservices) audio recordings indicated that, at 0736, the pilot requested a clearance from Essendon air traffic control (ATC) to reposition ZCR to the southern end of the passenger terminal. ATC provided the clearance and the pilot commenced taxiing to the terminal. At the terminal, ZCR was refueled and the pilot was observed on CCTV to walk around the aircraft, stopping at the left and right engines before entering the cabin. The pilot was then observed to leave the aircraft and wait for the passengers at the terminal. The passengers arrived at the terminal at 0841 and were escorted by the pilot directly to the aircraft. At 0849, the left engine was started and, shortly after, the right engine was started. At 0853, the pilot requested a taxi clearance for King Island, with five persons onboard, under the instrument flight rules. ATC instructed the pilot to taxi to holding point 'TANGO' for runway 17, and provided an airways clearance for the aircraft to King Island with a visual departure. The pilot read back the clearance. Airservices Automatic Dependent Surveillance Broadcast (ADS-B) data (refer to section titled Air traffic services information - Automatic Dependent Surveillance Broadcast data) indicated that, at 0854, ZCR was taxied from the terminal directly to the holding point. The aircraft did not enter the designated engine run-up bay positioned near holding point TANGO. At 0855, while holding at TANGO, the pilot requested a transponder code. The controller replied that he did not have one to issue yet. Two minutes later the pilot contacted ATC and stated that he was ready and waiting for a transponder code. The controller responded with the transponder code and a clearance to lineup on runway 17. At 0858, ATC cleared ZCR for take-off on runway 17 with departure instructions to turn right onto a heading of 200°. The pilot read back the instruction and commenced the takeoff roll. The aircraft’s take-off roll along runway 17 was longer than expected. Witnesses familiar with the aircraft type observed a noticeable yaw to the left after the aircraft became airborne. The aircraft entered a relatively shallow climb and the landing gear remained down. The shallow climb was followed by a substantial left sideslip, while maintaining a roll attitude of less than 10° to the left. Airservices ADS-B data indicated the aircraft reached a maximum height of approximately 160 ft above ground level while tracking in an arc to the left of the runway centreline. The aircraft’s track began diverging to the left of the runway centreline before rotation and the divergence increased as the flight progressed. Following the sustained left sideslip, the aircraft began to descend and at 0858:48 the pilot transmitted on the Essendon Tower frequency repeating the word ‘MAYDAY’ seven times in rapid succession. Approximately 10 seconds after the aircraft became airborne, and 2 seconds after the transmission was completed, the aircraft collided with the roof of a building in the Essendon Airport Bulla Road Precinct - Retail Outlet Centre (outlet centre), coming to rest in a loading area at the rear of the building. CCTV footage from a camera positioned at the rear of the building showed the final part of the accident sequence with post-impact fire evident; about 2 minutes later, first responders arrived onsite. At about 0905 and 0908 respectively, Victoria Police and the Metropolitan Fire Brigade arrived. The pilot and passengers were fatally injured and the aircraft was destroyed. There was significant structural, fire and water damage to the building. Additionally, two people on the ground received minor injuries and a number of parked vehicles were damaged.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain involving Beechcraft B200 King Air, registered VH-ZCR that occurred at Essendon Airport, Victoria on 21 February 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Contributing factors:
- The aircraft's rudder trim was likely in the full nose-left position at the commencement of the take-off.
- The aircraft's full nose-left rudder trim setting was not detected by the pilot prior to take-off.
- Following a longer than expected ground roll, the pilot took-off with full left rudder trim selected. This configuration adversely affected the aircraft's climb performance and controllability, resulting in a collision with terrain.

Other factors that increased risk:
- The flight check system approval process did not identify that the incorrect checklist was nominated in the operator’s procedures manual and it did not ensure the required checks, related to the use of the cockpit voice recorder, were incorporated.
- The aircraft's cockpit voice recorder did not record the accident flight, resulting in a valuable source of safety related information not being available.
- The aircraft's maximum take-off weight was likely exceeded by about 240 kilograms.
- Two of the four buildings within the Bulla Road Precinct Retail Outlet Centre exceeded the obstacle limitation surface (OLS) for Essendon Airport, however, the OLS for the departure runway was not infringed and VH-ZCR did not collide with those buildings.

Other findings:
- The presence of the building struck by the aircraft was unlikely to have increased the severity of the outcome of this accident.
- Both of the aircraft’s engines were likely to have been producing high power at impact.
Final Report:

Crash of a BAe 125-800B in São Paulo

Date & Time: Feb 9, 2017 at 2211 LT
Type of aircraft:
Operator:
Registration:
PT-OTC
Survivors:
Yes
Schedule:
Brasília – São Paulo
MSN:
258194
YOM:
1991
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The airplane departed Brasilía-Presidente Juscelino Kubitschek Airport in the evening on a charter flight to São Paulo-Congonhas, carrying two pilots and one passenger, the Senator Aécio Neves da Cunha. During the takeoff roll, a tire on one of the main landing gear failed. The crew continued the flight, informed ATC about his situation and preferred to divert to São Paulo-Guarulhos Airport that offered longer runway for an emergency landing. After touchdown by night, the aircraft deviated to the right then veered off runway. The left main gear collapsed and the aircraft came to rest in a grassy area. All three occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of a Reims/Cessna F406 Caravan II in Sasakwa

Date & Time: Jan 2, 2017
Type of aircraft:
Operator:
Registration:
5H-WOW
Flight Phase:
Survivors:
Yes
MSN:
406-0060
YOM:
1991
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While taking off from runway 12/30 at Sasakwa Airfield, the twin engine aircraft went out of control and crashed, bursting into flames. All six occupants were injured, some seriously, and the aircraft burnt out.

Crash of an Avro RJ85 in La Ceja: 71 killed

Date & Time: Nov 28, 2016 at 2158 LT
Type of aircraft:
Operator:
Registration:
CP-2933
Survivors:
Yes
Site:
Schedule:
Santa Cruz - Medellín
MSN:
E.2348
YOM:
1999
Flight number:
LMI2933
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
73
Pax fatalities:
Other fatalities:
Total fatalities:
71
Captain / Total flying hours:
6692
Captain / Total hours on type:
3417.00
Copilot / Total flying hours:
6923
Copilot / Total hours on type:
1474
Aircraft flight hours:
21640
Aircraft flight cycles:
19737
Circumstances:
The aircraft was performing a charter flight from Santa Cruz-Viru Viru to Medellín-José María Córdova (Rionegro) Airport, carrying members of the Chapecoense Real soccer team from Brazil who were traveling to Medellín to play against Atletico Nacional for a Copa Sudamericana game. The descent to Medellín was started by night and in good weather conditions when it seems that the encountered electrical problem. At 2156LT, while descending to FL155, the four engine aircraft hit tree tops and crashed in a wooded area located on the slope of a mountain located in the Cerro Gordo, near the city of La Ceja, about 17 km south from runway 01 threshold. The aircraft was totally destroyed upon impact but there was no fire. Six (two crew member and four passengers) were injured and evacuated while 71 other occupants were killed. According to first investigations, the crew encountered electrical problems and the aircraft may have suffered a fuel exhaustion. Due to the combination of several factors and findings that were detected during initial investigations, it was determined that the primary cause of the accident may have been a fuel exhaustion. The board of investigation was then in a process to determine the exact circumstances of the occurrence and to understand the course of events and the exact behavior and flight supervision (instruments, fuel jauges, flight preparation, operations, permission, ground assistance) on part of the flight crew and the operator. On December 2, the Civil Aviation Authority of Bolivia revoked with immediate effect the Air Operator Certificate of LAMIA. All flights have been suspended since.
Probable cause:
It was determined that the accident was the consequence of an inappropriate planning and execution of the flight, since the amount of fuel required to fly from the airport of destination to an alternate airport was not considered, nor was the amount of reserve fuel, nor the contingency fuel, nor the minimum landing fuel, quantities of fuel required by aeronautical regulations for the execution of the type of international flight that the aircraft CP-2339 was performing. The following factors were considered as contributing:
- Loss of situational awareness,
– Premature configuration of the aircraft for landing,
– Latent deficiencies,
– Lack of operational supervision and control of part of Operator,
– Organizational and operational deviation on the part of the Operator (non compliant to standard procedures).
Final Report:

Crash of a Beechcraft 200 Super King Air in Moorhead

Date & Time: Nov 23, 2016 at 1759 LT
Registration:
N80RT
Survivors:
Yes
Schedule:
Baudette - Moorhead
MSN:
BB-370
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5630
Captain / Total hours on type:
89.00
Circumstances:
The commercial pilot was conducting an on-demand passenger flight at night in instrument meteorological conditions that were at/near straight-in approach minimums for the runway. The pilot flew the approach as a non precision LNAV approach, and he reported that the approach was stabilized and that he did not notice anything unusual. A few seconds after leveling the airplane at the missed approach altitude, he saw the runway end lights, the strobe lights, and the precision approach path indicator. He then disconnected the autopilot and took his hand off the throttles to turn on the landing lights. However, before he could turn on the landing lights, the runway became obscured by clouds. The pilot immediately decided to conduct a missed approach and applied engine power, but the airplane subsequently impacted terrain short of the runway in a nose-up level attitude. The pilot reported that there were no mechanical anomalies with the airplane that would have precluded normal operation. It is likely the pilot lost sight of the runway due to the visibility being at/near the straight-in approach minimums and that the airplane got too low for a missed approach, which resulted in controlled flight into terrain. A passenger stated that he and the pilot were not wearing available shoulder harnesses. The passenger said that he was not informed that the airplane was equipped with shoulder harnesses or told how to adjust the seats. The pilot sustained injuries to his face in the accident.
Probable cause:
The pilot's failure to attain a positive climb rate during an attempted missed approach in night instrument meteorological conditions that were at/near approach minimums, which resulted in controlled flight into terrain.
Final Report:

Crash of a Cessna T207A Turbo Stationair 8 near Uchuquinua: 3 killed

Date & Time: Oct 9, 2016 at 0900 LT
Operator:
Registration:
OB-1936-P
Flight Phase:
Survivors:
No
Site:
Schedule:
Trujillo - Pucallpa
MSN:
207-0767
YOM:
1984
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The single engine aircraft was completing a charter flight from Trujillo to Pucallpa, carrying two pilots and pilot. While cruising over the Cajamarca Province, the pilot encountered poor weather conditions with heavy rain falls. He modified his route and was able to continue under VFR mode in good weather conditions. Nevertheless, he continued at an insufficient altitude when the aircraft impacted ground and crashed in a mountainous area. The aircraft was destroyed by impact forces and all three occupants were killed. There was no fire.
Probable cause:
The accident was the consequence of a loss of situational awareness of the pilots, by not making a continuous surveillance during the VFR flight in good weather conditions, not determining timely the corrections of direction or altitude, which finally led them to fail to fly over the ground of the new route adopted in flight, generating a probable aerodynamic loss at the limit of the performance of the aircraft, occurring a CFIT accident.
Contributing factors:
- Limited or poor use of the available GPS Terrain Proximity Warning system.
- Poor or erroneous appreciation of the weather conditions at the beginning of the flight, which led them to vary the route to fly over terrain with higher elevation.
- Limited appreciation of terrain height on the new route in relation to the selected cruising altitude.
Final Report:

Crash of a Cessna 208B Grand Caravan in San Antonio de Prado: 4 killed

Date & Time: Sep 30, 2016 at 1204 LT
Type of aircraft:
Registration:
HK-3804
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Medellín – Juradó
MSN:
208B-0315
YOM:
1992
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3534
Captain / Total hours on type:
335.00
Copilot / Total flying hours:
6378
Copilot / Total hours on type:
1245
Aircraft flight hours:
2867
Circumstances:
The single engine aircraft departed Medellín-Enrique Olaya Herrera Airport on a charter flight to Juradó, carrying nine passengers and two pilots. Shortly after takeoff, the crew encountered difficulties to gain sufficient altitude and apparently attempted an emergency landing when the aircraft impacted a hill and eventually crashed into trees. The copilot and three passengers were killed and seven others occupants were injured, some seriously. The aircraft was destroyed.
Probable cause:
The following findings were identified:
- Execution of a take-off with a weight approximately 17% higher than the maximum gross operating weight (MTOW) established for the C208B aircraft.
- Limited climb rate with signs of lift loss due to the low performance given by the overweight during the initial climb phase.
- Forced landing in mountainous terrain due to loss of lift caused by overweight during the initial climb.
- Absence in the identification of the risks associated to an overweight operation of the aircraft.
- Lack of supervision by the Aircraft Operator in relation to the dispatch of aircraft operating from the outside at the main base of operation.
Final Report:

Crash of a De Havilland DHC-2 Beaver I off Lopez Island

Date & Time: Sep 30, 2016 at 0837 LT
Type of aircraft:
Operator:
Registration:
N6781L
Survivors:
Yes
Schedule:
Kenmore – Roche Harbor
MSN:
788
YOM:
1955
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
25000
Captain / Total hours on type:
1630.00
Aircraft flight hours:
7395
Circumstances:
While maneuvering at low altitude for a water landing, the commercial pilot of the float equipped airplane encountered low visibility due to ground fog. The pilot initiated a go-around, but the airplane impacted the water, bounced, and impacted the water a second time before coming to rest upright. The airplane subsequently sank, and all four occupants were later rescued. The pilot reported that there were no mechanical anomalies with the airplane that would have precluded normal operation. The operator further reported that other company pilots who were flying on the day of the accident stated that the low visibility conditions were easily avoided by a slight course deviation.
Probable cause:
The pilot's decision to land in an area of low visibility and ground fog, which resulted in collision with water.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Iliamna

Date & Time: Aug 8, 2016 at 1651 LT
Type of aircraft:
Operator:
Registration:
N95RC
Flight Phase:
Survivors:
Yes
Schedule:
Crosswind Lake - King Salmon
MSN:
970
YOM:
1956
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9780
Captain / Total hours on type:
535.00
Aircraft flight hours:
7632
Circumstances:
The airline transport pilot of the float-equipped airplane was attempting a takeoff with the load of passengers that he had flown to the lake earlier in the day. The pilot's calculated takeoff distances for the water run and over a 50-ft obstacle were 1,050 ft and 2,210 ft, respectively. The pilot did not add a safety margin to his takeoff distance calculations. The approximate shore-to-shore distance of the takeoff path was 1,800 ft. During taxi, the pilot retracted the wing flaps, where they remained for the takeoff. GPS data showed that the airplane attained a speed of about 49 knots before impacting terrain just beyond the shoreline. The airplane's stall speed with flaps retracted was about 52 knots. Postaccident examination revealed that the left wing flap was in the fully retracted position; the right wing flap assembly was damaged. The airplane flight manual takeoff checklist stated that flaps were to be selected to the "TAKE-OFF" position before takeoff. Additionally, the takeoff performance data contained in the flight manual was dependent upon the use of "TAKE-OFF" flaps and did not account for no-flaps takeoffs. Even if the pilot had used the correct flap setting for takeoff, the calculated takeoff distances were near the available takeoff distance, and it is likely that the airplane would still not have been able to avoid a collision with terrain. The pilot stated that there was no mechanical malfunction/failure with the airplane, and he should have "done the right thing," which was to conduct two flights, each with a half load of passengers.
Probable cause:
The pilot's decision to perform the takeoff despite calculations showing that the distance available was inadequate, which resulted in impact with terrain.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Bangkok: 1 killed

Date & Time: Aug 1, 2016 at 1605 LT
Operator:
Registration:
HS-FGB
Survivors:
Yes
Site:
Schedule:
Nakhon Ratchasima – Bangkok
MSN:
31-7652156
YOM:
1976
Flight number:
TRB106
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
While descending to Bangkok-Suvarnabhumi Airport, the twin engine aircraft crashed in unknown circumstances in a swamp and came to rest against a wood bridge. The wreckage was found about 15 km from the airport, along the borders of Nong Chok and Min Buri districts. The captain was killed while three other occupants were injured.