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:

Crash of a De Havilland DHC-3T Turbo Otter near Ella Lake: 9 killed

Date & Time: Jun 25, 2015 at 1215 LT
Type of aircraft:
Operator:
Registration:
N270PA
Flight Phase:
Survivors:
No
Site:
Schedule:
Ketchikan - Ketchikan
MSN:
270
YOM:
1958
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
4070
Captain / Total hours on type:
40.00
Aircraft flight hours:
24439
Circumstances:
The airplane collided with mountainous, tree-covered terrain about 24 miles east-northeast of Ketchikan, Alaska. The commercial pilot and eight passengers sustained fatal injuries, and the airplane was destroyed. The airplane was owned by Pantechnicon Aviation, of Minden, Nevada, and operated by Promech Air, Inc., of Ketchikan. The flight was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as an on-demand sightseeing flight; a company visual flight rules flight plan (by which the company performed its own flight-following) was in effect. Marginal visual flight rules conditions were reported in the area at the time of the accident. The flight departed about 1207 from Rudyerd Bay about 44 miles east-northeast of Ketchikan and was en route to the operator’s base at the Ketchikan Harbor Seaplane Base, Ketchikan. The accident airplane was the third of four Promech-operated float-equipped airplanes that departed at approximate 5-minute intervals from a floating dock in Rudyerd Bay. The accident flight and the two Promech flights that departed before it were carrying cruise-ship passengers who had a 1230 “all aboard” time for their cruise ship that was scheduled to depart at 1300. (The fourth flight had no passengers but was repositioning to Ketchikan for a tour scheduled at 1230; the accident pilot also had his next tour scheduled for 1230.) The sightseeing tour flight, which the cruise ship passengers had purchased from the cruise line as a shore excursion, overflew remote inland fjords; coastal waterways; and mountainous, tree-covered terrain in the Misty Fjords National Monument Wilderness. Promech pilots could choose between two standard tour routes between Rudyerd Bay and Ketchikan, referred to as the “short route” (which is about 52 nautical miles [nm], takes about 25 minutes to complete, and is primarily over land) and the “long route” (which is about 63 nm, takes about 30 minutes to complete, and is primarily over seawater channels). Although the long route was less scenic, it was generally preferred in poor weather conditions because it was primarily over water, which enabled the pilots to fly at lower altitudes (beneath cloud layers) and perform an emergency or precautionary landing, if needed. Route choice was at each pilot’s discretion based on the pilot’s assessment of the weather. The accident pilot and two other Promech pilots (one of whom was repositioning an empty airplane) chose the short route for the return leg, while the pilot of the second Promech flight to depart chose the long route. Information obtained from weather observation sources, weather cameras, and photographs and videos recovered from the portable electronic devices (PEDs) of passengers on board the accident flight and other tour flights in the area provided evidence that the accident flight encountered deteriorating weather conditions. Further, at the time of the accident, the terrain at the accident site was likely obscured by overcast clouds with visibility restricted in rain and mist. Although the accident pilot had climbed the airplane to an altitude that would have provided safe terrain clearance had he followed the typical short route (which required the flight to pass two nearly identical mountains before turning west), the pilot instead deviated from that route and turned the airplane west early (after it passed only the first of the two mountains). The pilot’s route deviation placed the airplane on a collision course with a 1,900-ft mountain, which it struck at an elevation of about 1,600 ft mean sea level. In the final 2 seconds of the flight, the airplane pitched up rapidly before colliding with terrain. The timing of this aggressive pitch-up maneuver strongly supports the scenario that the pilot continued the flight into near-zero visibility conditions, and, as soon as he realized that the flight was on a collision course with the terrain, he pulled aggressively on the elevator flight controls in an ineffective attempt to avoid the terrain. Although Promech’s General Operations Manual specified that both the pilot and the flight scheduler must jointly agree that a flight can be conducted safely before it is launched, no such explicit concurrence occurred between the accident pilot and the flight scheduler (or any member of company management) before the accident flight. As a result, the decision to initiate the accident tour rested solely with the accident pilot, who had less than 2 months’ experience flying air tours in Southeast Alaska and had demonstrated difficulty calibrating his own risk tolerance for conducting tour flights in weather that was marginal or below Federal Aviation Administration (FAA) minimums. Further, evidence from the accident tour flight and the pilot’s previous tour flights support that the pilot’s decisions regarding his tour flights were influenced by schedule pressure; his attempt to emulate the behavior of other, more experienced pilots whose flights he was following; and Promech’s organizational culture, which tacitly endorsed flying in hazardous weather conditions, as evidenced (in part) by the company president/chief executive officer’s own tour flight below FAA minimums on the day of the accident.
Probable cause:
The National Transportation Safety Board determines that the probable cause of this accident was
(1) the pilot’s decision to continue visual flight into an area of instrument meteorological conditions, which resulted in his geographic disorientation and controlled flight into terrain; and
(2) Promech’s company culture, which tacitly endorsed flying in hazardous weather and failed to manage the risks associated with the competitive pressures affecting Ketchikan-area air tour operators; its lack of a formal safety program; and its inadequate operational control of flight releases.
Final Report:

Crash of a Embraer EMB-821 Carajá in Rochedo

Date & Time: May 24, 2015 at 0953 LT
Operator:
Registration:
PT-ENM
Flight Phase:
Survivors:
Yes
Schedule:
Miranda – Campo Grande
MSN:
820-072
YOM:
1978
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8378
Captain / Total hours on type:
470.00
Copilot / Total flying hours:
1006
Copilot / Total hours on type:
4
Circumstances:
The twin engine airplane departed Miranda-Estância Caimam Airfield at 0915LT on a charter flight to Campo Grande, carrying seven passengers and two pilots. About 35 minutes into the flight, while flying 79 km from the destination in good weather conditions, the left engine failed. The crew was unable to feather the propeller and to maintain a safe altitude, so he decided to attempt an emergency landing. The aircraft belly landed in an agriculture area, slid for few dozen metres and came to rest. All nine occupants suffered minor injuries and the aircraft was damaged beyond repair.
Probable cause:
Failure of the left engine in flight due to fuel exhaustion. The following findings were identified:
- The fuel tanks in the left wing were empty while a quantity of 320 litres of fuel was still present in the fuel tanks of the right wing,
- The crew was unable to maintain altitude because he could not feather the left propeller,
- The pilots were misled by a false indication of the fuel gauge coupled to the left wing tank which displayed a certain value while the tank was actually empty. This error was caused by the fuel sensors for the left wing tanks being installed inverted,
- The aircraft was not airworthy at the time of the accident due to several defects,
- The Minimum Equipment List (MEL) was not up to date,
- The Cockpit Voice Recorder (CVR) was unserviceable,
- The automatic propeller feathering system was out of service,
- The fuel sensors for the left wing tanks had been installed inverted,
- Bad contact with the right wing fuel sensor connector plug,
- The pilots failed to follow the published procedures related to an engine failure,
- Poor flight preparation,
- Crew complacency,
- The crew training program by the operator was inadequate,
- Lack of supervision on part of the operator.
Final Report: