Crash of a Cessna 441 Conquest II in Climax: 2 killed

Date & Time: Nov 9, 2015 at 1016 LT
Type of aircraft:
Operator:
Registration:
N164GP
Flight Phase:
Survivors:
No
Schedule:
Lakeland - Cairo
MSN:
441-0164
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1150
Captain / Total hours on type:
150.00
Aircraft flight hours:
18422
Circumstances:
The purpose of the flight was for the commercial pilot/owner to pick up passengers at the destination airport and return to the departure airport. The airplane was 33 miles from its destination in cruise flight at 3,300 ft mean sea level (msl) and above a solid cloud layer when the pilot declared to air traffic control (ATC) that he had the destination airport "in sight" and cancelled his instrument flight rules (IFR) clearance. During the 13 minutes after cancellation of the IFR clearance, the airplane's radar track made an erratic sequence of left, right, and 360° turns that moved the airplane away from the destination airport in a westerly direction. The altitudes varied between about 4,000 and 900 ft msl. Later, the pilot reestablished communication with ATC, reported he had lost visual contact with the airport, and requested an instrument approach to the destination airport. The controller then provided a sequence of heading and altitude assignments to vector the airplane onto the approach, but the pilot did not maintain these assignments, and the controller provided several corrections. The pilot expressed his inability to identify the initial approach fix (IAF) and asked the controller for the correct spelling. The radar target then climbed and subsequently entered a descending right turn at 2,500 ft msl and 180 knots ground speed near the IAF, before radar contact with the airplane was lost. Although a review of airplane maintenance records revealed that the airplane was overdue for several required inspections, examination of the wreckage revealed signatures consistent with both engines being at high power at impact, and no evidence of any preimpact mechanical anomalies were found that would have precluded normal operation. Examination of the airplane's panel-mounted GPS, which the pilot was using to navigate the flight, revealed that the navigation and obstruction databases were expired. During a weather briefing before the flight, the pilot was warned of low ceilings and visibility. The weather conditions reported near the destination airport about the time of the accident also included low ceilings and visibilities. The restricted visibility conditions and the high likelihood of inadvertent entry into instrument meteorological conditions were conducive to the development of spatial disorientation. The flight's erratic track, which included altitude and directional changes inconsistent with progress toward the airport, were likely the result of spatial disorientation. After reestablishing contact with ATC and being cleared to conduct an instrument approach to the destination, the airplane's flight track indicated that the pilot was not adequately prepared to execute the controller's instructions. The pilot's subsequent loss of control was likely the result of spatial disorientation due to his increased workload and operational distractions associated with his attempts to configure his navigation radios or reference charts. Postaccident toxicological testing of samples obtained from the pilot revealed the presence of ethanol; however, it could not be determined what percentage was ingested or produced postmortem. The testing also revealed the presence of amphetamine, an opioid painkiller, two sedating antihistamines, and marijuana. Although blood level quantification of these medications and drugs could not be made from the samples provided, their combined effects would have directly impacted the pilot's decision-making and ability to fly the airplane, even if each individual substance was only present in small amounts. Based in the reported weather conditions at the time the pilot reported the airport in sight and canceled his IFR clearance, he likely was not in a position to have seen the destination airport even though he may have been flying between cloud layers or may have momentarily observed the ground. His decision to cancel his IFR clearance so far from the destination, in an area characterized by widespread low ceilings and reduced visibility, increased the pilot's exposure to the hazards those conditions posed to the successful completion of his flight. The pilot showed other lapses in judgment associated with conducting this flight at the operational, aircraft, and the personal level. For example, 1) the pilot did not appear to recognize the significance of widespread low ceilings and visibility along his route of flight and at his destination (nor did he file an alternate airport even though conditions warranted); 2) the accident airplane was being operated beyond mandatory inspection intervals; and 3) toxicological testing showed the pilot had taken a combination of multiple medications and drugs that would have likely been impairing and contraindicated for the safe operation of an airplane. The pilot's decision-making was likely affected by the medications and drugs.
Probable cause:
The pilot's loss of airplane control due to spatial disorientation. Also causal to the accident was the pilot's impairment by the combined effects of multiple medications and drugs.
Final Report:

Crash of an Airbus A321-231 near Hasna: 224 killed

Date & Time: Oct 31, 2015 at 0613 LT
Type of aircraft:
Operator:
Registration:
EI-ETJ
Flight Phase:
Survivors:
No
Site:
Schedule:
Sharm el-Sheikh - Saint Petersburg
MSN:
663
YOM:
1997
Flight number:
KGL9268
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
217
Pax fatalities:
Other fatalities:
Total fatalities:
224
Captain / Total flying hours:
12000
Captain / Total hours on type:
3800.00
Aircraft flight hours:
55772
Aircraft flight cycles:
21175
Circumstances:
The aircraft departed Sharm el-Sheikh at 0549LT bound for Saint Petersburg-Pulkovo Airport and was cleared to climb to FL350. On board were 217 passengers and a crew of seven. Some 23 minutes after takeoff, the aircraft entered a steep descent and reached a descent rate of 6,000 feet per minute with a simultaneous reduction of speed before all radar and radio contact were lost at 0613LT. The aircraft crashed in a desert area located about 50 km southeast of Hasna, in the Sinai. None of the 224 occupants survived the accident. It appears the aircraft crashed in a slightly flat attitude and was destroyed by impact forces and a post crash fire (the central part of the fuselage and wings). Based on the debris scattered on a zone of 16 km2, it is now understood that the engines and the tail have been found few hundred metres from the main wreckage. It is believed the aircraft partially disintegrated in the air but probably during the last phase of the descent and not at high altitude.
Probable cause:
On November 17, 2015, Alexander Bortnikov, Chief of the Russian Secret Services, confirmed to Vladimir Putin that the crash was caused by the detonation of a small 'home made' bomb equivalent to one kilo of TNT that was placed on board the airplane in a beverage can. This was confirmed by the Egyptian Presidency on 24 February 2016.

Crash of a Beechcraft B60 Duke in Bogotá: 9 killed

Date & Time: Oct 18, 2015 at 1619 LT
Type of aircraft:
Operator:
Registration:
HK-3917G
Flight Phase:
Survivors:
No
Site:
Schedule:
Bogotá - Bogotá
MSN:
P-410
YOM:
1977
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
4916
Aircraft flight hours:
1788
Circumstances:
The twin engine aircraft departed Bogotá-El Dorado on a short flight to Bogotá-Guaymaral Airport, carrying three passengers and one pilot. Three minutes after takeoff from runway 13L, while climbing to a height of 200 feet in VFR conditions, the airplane entered a left turn then descended into the ground and crashed into several houses located in the district of Engativá, near the airport, bursting into flames. The aircraft as well as several houses and vehicles were destroyed. All four occupants as well as five people on the ground were killed. Thirteen others were injured, seven seriously.
Probable cause:
The pilot lost control of the airplane following a loss of power on the left engine during initial climb. Investigations were unable to determine the exact cause of this loss of power. The aircraft's speed dropped to 107 knots and the pilot likely did not have time to identify the problem. Operation from a high density altitude airport contributed to the accident.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Ozren: 1 killed

Date & Time: Sep 24, 2015 at 1230 LT
Operator:
Registration:
YU-BSW
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Banja Luka – Tuzla
MSN:
421B-0248
YOM:
1972
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The twin engine aircraft, operated by STS Avijacija (STS Aviation), departed Banja Luka on a charter flight to Tuzla, carrying two passengers and one pilot taking part to a foxes vaccination program. While cruising at low altitude, the airplane entered an area of clouds when it impacted trees and crashed on the slope of a mountain located near the Monastery of Ozren, southeast part of the Serbian Republic of Bosnia, bursting into flames. Both passengers were seriously injured and the pilot was killed.
Probable cause:
The root cause of the accident is the entry of the aircraft into the cloud at a low altitude, in conditions of increased cloudiness, which led to the impact of the aircraft in the ground. The accident is caused by inadequate preparation of the crew for the flight, deviation of the crew from the planned and approved route by location (diversion from the given route) and flight height (flight at a lower altitude than the approved one), as well as not taking timely procedures to return to the given route and flight height, as well as incorrect actions in case of encountering a deteriorated weather situation on the route under VFR flight conditions.
The accident was affected by:
a) The decision of the manager on the manner of execution of the flight,
b) Ignoring information about the meteorological situation and weather forecast,
c) Inadequate preparation of the crew for the execution of the flight at a low altitude and in conditions of fire of the meteorological situation,
d) Non-compliance with VFR rules for minimum flight height and meteorological minimum for airspace class “F” and “G”,
e) Loss of visual contact with the ground.

Crash of a De Havilland DHC-3T Turbo Otter in Iliamna: 3 killed

Date & Time: Sep 15, 2015 at 0606 LT
Type of aircraft:
Operator:
Registration:
N928RK
Flight Phase:
Survivors:
Yes
Schedule:
Iliamna - Swishak River
MSN:
61
YOM:
1954
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
11300
Captain / Total hours on type:
450.00
Aircraft flight hours:
15436
Circumstances:
On September 15, 2015, about 0606 Alaska daylight time, a single-engine, turbine-powered, float-equipped de Havilland DHC-3T (Otter) airplane, N928RK, impacted tundra-covered terrain just after takeoff from East Wind Lake, about 1 mile east of the Iliamna Airport, Iliamna, Alaska. Of the 10 people on board, three passengers died at the scene, the airline transport pilot and four passengers sustained serious injuries, and two passengers sustained minor injuries. The airplane sustained substantial damage. The airplane was registered to and operated by Rainbow King Lodge, Inc., Lemoore, California, as a visual flight rules other work use flight under the provisions of 14 Code of Federal Regulations (CFR) Part 91. Dark night, visual meteorological conditions existed at the departure point at the time of the accident, and no flight plan was filed for the flight. At the time of the accident, the airplane was en route to a remote fishing site on the Swishak River, about 75 miles northwest of Kodiak, Alaska.
Probable cause:
The pilot's decision to depart in dark night, visual meteorological conditions over water, which resulted in his subsequent spatial disorientation and loss of airplane control. Contributing to the accident was the pilot's failure to determine the airplane's actual preflight weight and balance and center of gravity (CG), which led to the airplane being loaded and operated outside of the weight and CG limits and to a subsequent aerodynamic stall.
Final Report:

Crash of a Cessna 550 Citation Bravo in Vienna

Date & Time: Sep 3, 2015 at 1227 LT
Type of aircraft:
Operator:
Registration:
OE-GLG
Survivors:
Yes
Schedule:
Salzburg - Vienna
MSN:
550-0977
YOM:
2001
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5000
Captain / Total hours on type:
1800.00
Copilot / Total flying hours:
1200
Copilot / Total hours on type:
350
Aircraft flight hours:
7525
Aircraft flight cycles:
5807
Circumstances:
Following an uneventful flight from Salzburg, the crew was cleared to descent to Vienna-Schwechat Airport. On approach to runway 34, the crew completed the checklist and lowered the landing gear when he realized the the left main gear remained stuck in its wheel well and that the green light failed to come on on the cockpit panel. The crew agreed to continue. After touchdown on runway 34, the aircraft deviated to the left, veered off runway and came to rest in a grassy area located near taxiway D and taxiway B5 and B6. All five occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The accident was caused by a metallic foreign body between valve seat and ball of the spring loaded ball check valve in the undercarriage servo valve of the left main landing gear caused the check valve not to close as intended and hydraulic fluid was directed directly to the landing gear cylinder without moving the piston rod. Due to the fact that the piston rod of the undercarriage servo valve did not move as intended, the mechanical unlocking hook of the left undercarriage was also not controlled - the landing gear was therefore not deployed.
Contributing factors:
- The possibility to abort the approach, to Go Around and fly a holding to carry out troubleshooting, as described in the operations manual of the aviation company as well as in the "Emergency / Abnormal Procedures" manual of the aircraft manufacturer, was not used.
- The emergency extension system of the landing gear was not used.
Final Report:

Crash of a Cessna S550 Citation II in Charallave

Date & Time: Aug 26, 2015 at 2230 LT
Type of aircraft:
Operator:
Registration:
YV3125
Survivors:
Yes
Schedule:
Oranjestad – Barcelona – Charallave
MSN:
S550-0085
YOM:
1986
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing a charter flight from Oranjestad (Aruba) to Charallave with an intermediate stop in Barcelona. While on a night approach to runway 10, the captain initiated a go-around procedure for unknown reasons. During the second attempt to land, the aircraft landed long and the touchdown point appeared to be half way down the runway 10 which is 2,000 meters long. Unable to stop within the remaining distance, the aircraft overran, went down an embankment and came to rest. All eight occupants evacuated safely while the aircraft was damaged beyond repair. The passengers were members of the pop band 'Los Cadillac's' accompanied by the Venezuelan singer and actor Arán de las Casas.

Crash of a De Havilland DHC-2 Beaver near Les Bergeronnes: 6 killed

Date & Time: Aug 23, 2015 at 1127 LT
Type of aircraft:
Operator:
Registration:
C-FKRJ
Flight Phase:
Survivors:
No
Schedule:
Lac Long - Lac Long
MSN:
1210
YOM:
1958
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
5989
Captain / Total hours on type:
4230.00
Aircraft flight hours:
25223
Circumstances:
The float-equipped de Havilland DHC-2 Mk. 1 Beaver (registration C-FKRJ, serial number 1210), operated by Air Saguenay (1980) inc., was on a visual flight rules sightseeing flight in the region of Tadoussac, Quebec. At 1104 Eastern Daylight Time, the aircraft took off from its base on Lac Long, Quebec, for a 20-minute flight, with 1 pilot and 5 passengers on board. At 1127, on the return trip, approximately 2.5 nautical miles north-northwest of its destination (7 nautical miles north of Tadoussac), the aircraft stalled in a steep turn. The aircraft descended vertically and struck a rocky outcrop. The aircraft was substantially damaged in the collision with the terrain and was destroyed by the post-impact fire. The 6 occupants received fatal injuries. No emergency locator transmitter signal was captured.
Probable cause:
Findings as to causes and contributing factors:
1. The pilot performed manoeuvres with a reduced safety margin at low altitudes. As a result, these flights involved a level of risk that was unnecessary to attain the objectives of sightseeing flights.
2. With no restrictions on manoeuvres and no minimum altitude prescribed by the company prior to flight, the pilot flew according to his own limits and made a steep turn at approximately 110 feet above ground level.
3. When the pilot made a steep left turn, aerodynamic stalling ensued, causing an incipient spin at an altitude insufficient to allow control of the aircraft to be regained prior to vertical collision with the terrain.
4. The absence of an angle-of-attack indicator system and an impending stall warning device deprived the pilot of the last line of defence against loss of control of the aircraft.

Findings as to risk:
1. If lightweight flight data recording systems are not used to closely monitor flight operations, there is a risk that pilots will deviate from established procedures and limits, thereby reducing safety margins.
2. If Transport Canada does not take concrete measures to facilitate the use of lightweight flight data recording systems and flight data monitoring, operators may not be able to proactively identify safety deficiencies before they cause an accident.
3. If pilots do not obtain at least the regulatory rest periods, there is a risk that flights will be conducted when pilots are fatigued.
4. Unless all flights made are recorded in the pilot’s logbook and monitored by the company, it is possible that the pilot will not receive the required rest periods, which increases the risk of flights being conducted when the pilot is fatigued.
5. If flights made are not recorded in the aircraft’s journey logbook, it is possible that inspection and maintenance schedules and component lifetimes will be exceeded, increasing the risk of failure.
6. Unless safety management systems are required, assessed, and monitored by Transport Canada in order to ensure continual improvement, there is an increased risk that companies will not be able to identify and effectively mitigate the hazards involved in their operations.
7. If pilots do not receive stall training that demonstrates the aircraft’s actual behaviour in a steep turn under power, there is a high risk of loss of control.

Other findings:
1. The replacement of the ventral fin with Seafins on C-FKRJ was in compliance with the requirements of Kenmore Air Harbor Inc.’s supplemental type certificate.
2. The control wheel was in the left-hand position (pilot side) at the moment of impact.
3. Angle-of-attack indicator systems have been recognized as contributing to flight safety by improving pilot awareness of the stall margin at all times, thereby allowing pilots to react in order to prevent loss of control of the aircraft.
4. Stall warning systems have been recognized as a means of improving flight safety by providing a clear, unambiguous warning of an impending stall.
Final Report:

Crash of a Beechcraft A100 King Air in Margaree

Date & Time: Aug 16, 2015 at 1616 LT
Type of aircraft:
Operator:
Registration:
C-FDOR
Survivors:
Yes
Schedule:
Halifax – Margaree
MSN:
B-103
YOM:
1972
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1723
Captain / Total hours on type:
298.00
Copilot / Total flying hours:
532
Copilot / Total hours on type:
70
Aircraft flight hours:
14345
Circumstances:
On 16 August 2015, a Maritime Air Charter Limited Beechcraft King Air A100 (registration C-FDOR, serial number B-103) was on a charter flight from Halifax Stanfield International Airport, Nova Scotia, to Margaree Aerodrome, Nova Scotia, with 2 pilots and 2 passengers on board. At approximately 1616 Atlantic Daylight Time, while conducting a visual approach to Runway 01, the aircraft touched down hard about 263 feet beyond the threshold. Almost immediately, the right main landing gear collapsed, then the right propeller and wing contacted the runway. The aircraft slid along the runway for about 1350 feet, then veered right and departed off the side of the runway. It came to rest about 1850 feet beyond the threshold and 22 feet from the runway edge. There were no injuries and there was no post-impact fire. The aircraft was substantially damaged. The occurrence took place during daylight hours. The 406-megahertz emergency locator transmitter did not activate.
Probable cause:
Findings:
Findings as to causes and contributing factors:
1. Neither pilot had considered that landing on a short runway at an unfamiliar aerodrome with known high terrain nearby and joining the circuit directly on a left base were hazards that may create additional risks, all of which would increase the crew’s workload.
2. The presence of the tower resulted in the pilot not flying focusing his attention on monitoring the aircraft’s location, rather than on monitoring the flight or the actions of the pilot flying.
3. The crew’s increased workload, together with the unexpected distraction of the presence of the tower, led to a reduced situational awareness that caused them to omit the Landing Checks checklist.
4. At no time during the final descent was the engine power increased above about 400 foot-pounds of torque.
5. Using only pitch to control the rate of descent prevented the pilot flying from precisely controlling the approach, which would have ensured that the flare occurred at the right point and at the right speed.
6. Neither pilot recognized that the steep rate of descent was indicative of an unstable approach.
7. Advancing the propellers to full would have increased the drag and further increased the rate of descent, exacerbating the already unstable approach.
8. The aircraft crossed the runway threshold with insufficient energy to arrest the rate of descent in the landing flare, resulting in a hard landing that caused the right main landing gear to collapse.
Findings as to risk:
1. If data recordings are not available to an investigation, then the identification and communication of safety deficiencies to advance transportation safety may be precluded.
2. If organizations do not use modern safety management practices, then there is an increased risk that hazards will not be identified and risks will not be mitigated.
3. If passenger seats installed in light aircraft are not equipped with shoulder harnesses, then there is an increased risk of passenger injury or death in the event of an accident.
4. If the experience and proficiency of pilots are not factored into crew selection, then there is a risk of suboptimal crew pairing, resulting in a reduction of safety margins.
5. If pilots do not carry out checklists in accordance with the company’s and manufacturer’s instructions, then there is a risk that a critical item may be missed, which could jeopardize the safety of the flight.
6. If crew resource management is not used and continuously fostered, then there is a risk that pilots will be unprepared to avoid or mitigate crew errors encountered during flight.
7. If organizations do not have a clearly defined go-around policy, then there is a risk that flight crews will continue an unstable approach, increasing the risk of an approach-and-landing accident.
8. If pilots are not prepared to conduct a go-around on every approach, then there is a risk that they may not respond to situations that require a go-around.
9. If operators do not have a stable approach policy, then there is a risk that an unstable approach will be continued to a landing, increasing the risk of an approach-andlanding accident.
10. If an organization’s safety culture does not fully promote the goals of a safety management system, then it is unlikely that it will be effective in reducing risk.
Other findings:
1. There were insufficient forward impact forces to automatically activate the emergency locator transmitter.
Final Report:

Crash of a Pacific Aerospace PAC750XL in Ninia: 1 killed

Date & Time: Aug 12, 2015 at 0748 LT
Operator:
Registration:
PK-KIG
Survivors:
Yes
Schedule:
Wamena – Ninia
MSN:
170
YOM:
2010
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1537
Captain / Total hours on type:
395.00
Aircraft flight hours:
757
Aircraft flight cycles:
1315
Circumstances:
On 12 August 2015, a PAC-750XL aircraft, registered PK-KIG, was being operated by PT. Komala Indonesia on an unscheduled passenger flight from Wamena Airport (WAJW) Papua to Ninia Airstrip , Yahukimo, Papua that was located on radial 127° from Wamena with a distance of approximately 26 Nm. At 0733 LT (2233 UTC), the aircraft departed from Wamena Airport with an estimated time of arrival at Ninia of 2248 UTC. The flight was uneventful until approaching Ninia. On board the aircraft were one pilot, one engineer and 4 passengers. According to the pilot statement, an airspeed indicator malfunction occurred during flight. Video footage taken by a passenger showed that, during the approach at an altitude of approximately 6,500 feet, the airspeed indicators indicated zero and the aural stall warning activated. The aircraft then flew on the left side and parallel to the runway. Thereafter the aircraft climbed, turned left and impacted the ground about 200 meters south-west of the runway. The engineer on board was fatally injured, one passenger had minor injuries and the other occupants, including the pilot, were seriously injured. Two occupants were evacuated to a hospital in Jayapura Airport and four others, including the fatally injured, were evacuated to a hospital in Wamena.
Probable cause:
The following findings were identified:
1. Continuing the flight with both airspeed indicators unserviceable increased the complexity of the flight combined with high-risk aerodrome increased the pilot workload.
2. The improper corrective action at the time of the aural stall warning activating on the final approach, and the aircraft flew to insufficient area for a safe maneuver.
3. The unfamiliarity to the airstrip resulted in inappropriate subsequent escape maneuver and resulted in the aircraft stalling.
4. The pilot was not provided with appropriate training and familiarization to fly into a high-risk airstrip
Final Report: