Charter/Taxi (Non Scheduled Revenue Flight)

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.

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.

The single engine airplane suffered an accident upon landing at Mandeng Airfield. The undercarriage were torn off and the aircraft was severely damaged. There were no casualties.

For unknown reason, the twin engine aircraft landed hard. Impact caused the tail to separate. The aircraft lost its undercarriage then slid for few dozen metres before coming to rest, bursting into flames. All five occupants evacuated safely and the aircraft was destroyed. It seems the aircraft suffered an engine failure shortly before landing.

The approach to the Barneo Ice Station was completed in poor weather conditions. In low visibility, the aircraft landed hard with an acceleration of 2,4 g. This caused the right main gear to partially collapse and the aircraft came to rest in a nose up attitude on the icy runway. All 17 occupants evacuated safely and despite the fact the aircraft was slightly damaged, it was decided to abandon the aircraft that would not be repaired. An insurance claim was submitted 24APR2015 and the engines were removed. The aircraft drifted with the ice floe to the west then floe cracked between 26 and 27JUL2015, causing the aircraft to sank in the Arctic Ocean.

The twin engine airplane departed Laguna del Sauce Airport on a charter flight to San Fernando Airport near Buenos Aires, carrying eight passengers and two pilots. Shortly after a night takeoff from Laguna del Sauce Airport runway 01, the aircraft entered a controlled descent and crashed in shallow water some 2 km northwest of the airport, bursting into flames. The aircraft was destroyed by a post crash fire and all 10 occupants were killed.

The aircraft planned to fly from Avignon Airport, France to Blackpool Airport, with two flight crew and two passengers. The co-pilot performed the external checks; this included checking the fluid level in the hydraulic reservoir, as stated in the ‘Pilot Checklist’. The aircraft was refuelled to 3,000 lb and, after the passengers boarded, it departed for Blackpool. The commander was the pilot flying (PF). The takeoff and cruise to Blackpool were uneventful. Prior to the descent the crew noted ATIS Information ‘Lima’, which stated: Runway 10, wind from 150° at 18 kt, visibility 9 km, FEW clouds at 2,000 ft aal, temperature 11°C, dew point 8°C, QNH 1021 hPa, runway damp over its whole length. The commander planned and briefed for the NDB approach to Runway 10, which was to be flown with the autopilot engaged. Whilst descending through FL120, the left, followed by the right, hydraulic low pressure cautions illuminated. Upon checking the hydraulic pressure gauge, situated to the left of the commander’s control column, the pressure was noted to be ‘cycling up and down’, but for the majority of the time it indicated about 2,800 psi (in the green arc). During this time the hydraulic low pressure cautions went on and off irregularly, with the left caution being on more often than the right. The co-pilot then actioned the ‘HYDRAULIC SYSTEM - HYDRAULIC PUMP FAILURE’ checklist. It stated that if the hydraulic pressure was a minimum of 2,800 psi, the flight could be continued. Just before the aircraft reached the Blackpool NDB, the commander commented “it’s dropping”, but he could not recall what he was referring to. This was followed by the roll fail and speed brk [brake] fail caution messages illuminating. The co-pilot then actioned the applicable checklists. These stated that the Landing Distances Required (LDR) would increase by approximately 65% and 21%, respectively. As the roll fail LDR increase was greater than that of the speed brk fail, the crew used an LDR increase of 65% which the co-pilot equated to 5,950 ft. Runway 10 at Blackpool has an LDA of 6,131 ft, therefore they elected to continue to Blackpool. The roll fail checklist stated that a ‘FLAPS UP’ landing was required. The co-pilot then calculated the VREF of 132 kt, including a 20 kt increment, as stipulated by the ‘FLAPS UP, 10, OR 20 APPROACH AND LANDING’ checklist. The commander then continued with the approach. At about 4 nm on final approach the co-pilot lowered the landing gear, in response to the commander’s request. About 8 seconds later the commander said “just lost it all”; referring to the general state of the aircraft. This was followed almost immediately by the landing gear unsafe aural warning, as the main landing gear was not indicating down and locked. Whilst descending through 1,000 ft, at just over 3 nm from the threshold, the commander asked the co-pilot to action the ‘ALTERNATE GEAR EXTENSION’ checklist. The commander then discontinued the approach by selecting ALT HOLD, increased engine thrust and selected a 500 ft/min rate of climb on the autopilot. However, a few seconds later, before the co-pilot could action the checklist, the main gear indicated down and locked. The commander disconnected the autopilot and continued the approach. The crew did not consider reviewing the ‘HYDRAULIC SYSTEM - HYDRAULIC PUMP FAILURE’ checklist as they had not recognised the symptoms of loss of hydraulic pressure. When ATC issued the aircraft its landing clearance the wind was from 140° at 17 kt. This equated to a headwind component of about 10 kt and a crosswind of about 12 kt. As the aircraft descended through 500 ft (the Minimum Descent Altitude (MDA) for the approach) at 1.5 nm from the threshold, the commander instructed the co-pilot to advise ATC that they had a hydraulic problem and to request the RFFS to be put on standby. There was a slight delay in transmitting this request, due to another aircraft on frequency, but the request was acknowledged by ATC. The aircraft touched down about 1,500 ft from the start of the paved surface at an airspeed of 132 kt and a groundspeed of 124 kt. When the commander applied the toe (power) brakes he felt no significant retardation. During the landing roll no attempt was made to apply the emergency brakes, as required in the event of a power brake failure. The co-pilot asked if he should try to operate the lift dump, but it failed to function, due to the lack of hydraulic pressure. At some point, while the aircraft was on the runway, the co-pilot transmitted a MAYDAY call to ATC. When an overrun appeared likely, the commander shut down the engines. The aircraft subsequently overran the end of the runway at a groundspeed of about 80 kt. The commander later commented that he was in a “state of panic” during the landing roll and was unsure whether or not he had applied the emergency brake. As the aircraft left the paved surface the commander steered the aircraft slightly right to avoid a shallow downslope to the left of runway’s extended centreline. The aircraft continued across the rough, uneven ground, during which the nose gear collapsed and the wing to fuselage attachments were severely damaged (Figure 1). Once it had come to a stop, he shut down the remaining aircraft systems. The passengers and crew, who were uninjured, vacated the aircraft via the entry/exit door and moved upwind to a safe distance. The RRFS arrived shortly thereafter.

On 8 March 2015, the pilot of an Aero Commander 500 aircraft, registered VH-WZV, prepared to conduct a charter flight from Badu Island to Horn Island, Queensland, with five passengers. The aircraft had been refuelled earlier that day at Horn Island, where the pilot conducted fuel drains with no contaminants found. He had operated the aircraft for about 2 hours prior to landing at Badu Island with no abnormal performance or indications. At about 1330 Eastern Standard Time (EST), the pilot started the engines and conducted the standard checks with all indications normal, obtained the relevant clearances from air traffic control, and taxied for a departure from runway 30. As the pilot lined the aircraft up on the runway centreline at the threshold, he performed a pre-take-off safety self-brief and conducted the pre-takeoff checks. He then applied full power, released the brakes and commenced the take-off run. All engine indications were normal during the taxi and commencement of the take-off run. When the airspeed had increased to about 80 kt, the pilot commenced rotation and the nose and main landing gear lifted off the runway. Just as the main landing gear lifted off, the pilot detected a significant loss of power from the left engine. The aircraft yawed to the left, which the pilot counteracted with right rudder. He heard the left engine noise decrease noticeably and the aircraft dropped back onto the runway. The pilot immediately rejected the take-off; reduced the power to idle, and used rudder and brakes to maintain the runway centreline. The pilot initially assessed that there was sufficient runway remaining to stop on but, due to the wet runway surface, the aircraft did not decelerate as quickly as expected and he anticipated that the aircraft would overrun the runway. As there was a steep slope and trees beyond the end of the runway, he steered the aircraft to the right towards more open and level ground. The aircraft departed the runway to the right, collided with a fence and a bush resulting in substantial damage. The pilot and passengers were not injured.

The single engine aircraft was approaching Shatyrkul in foggy conditions when it crashed in a snow covered field located 1,2 km south of the landing zone area, some 20 km north of Shatyrkul. SAR arrived on scene at 1701LT. A female passenger was seriously injured and was evacuated to a local hospital while six other occupants were killed. The four passengers were employees of the Kazakhmys Mining Company. At the time of the accident, the visibility was poor due to fog.

On or about 1000H January 17, 2015, the Holy Father “Pope Francis” visited the typhoon-devastated province of Leyte and utilized an Airbus 320 aircraft for Tacloban airport, and Bombardier Global 5000 RP-C9363 aircraft was part of the Papal entourage with passengers on board. The weather condition was worsening and the visit of the Pope had to cut short due to approaching tropical storm code named “AMANG”, with strong winds of up to 130km/h(80mph) according to PAGASA and moderate rain as signal n°2 was already forecasted at the province of Leyte. At 1304H, the Global 5000 RP-C9363 was given start up clearance by tower controller and subsequently a taxi clearance at 1308H to exit via south taxiway next to the departing Airbus320 PAL8010. At 1306H, the First Airbus 320 PAL8010 aircraft carrying the Papal entourage took-off utilizing RWY 36 with prevailing wind condition of 290̊/18 knots crosswind and temperature of 24°. At 1311H, RP-C 9363 was not allowed to move from present position to proceed to the active runway via south taxiway by the military ground marshaller. At 1322H, the 2nd Airbus 320 PAL8191 took-off with prevailing wind conditions of 290°/23 kts crosswind. The separation time between the Global 5000 to the first and second aircraft were 29 minutes and 13 minutes respectively. At 1335H, finally RP-C9363 Global 5000 was cleared for take-off at runway 36 bound for Ninoy Aquino International Airport (RPLL) with two (2) pilots and 14 passengers on board. The wind condition at that time was 300°/18 kts with gustiness and temperature of 24°. The aircrew performed rolling take-off and the acceleration was normal, the pilot nonflying (NPF) called for air speed alive, 80 knots, V1 and Rotate. Before approaching south taxiway abeam the terminal building, the aircraft started to veer to the left side of the runway centerline. The aircraft continued to roll veering to the left side of the runway and the left hand main landing gear was already out of the runway after the north taxiway. The aircraft underwent runway excursion and sustained substantial damage after simultaneous collision with the concrete bases of runway edge lights and to the concrete culvert before it came to a complete stop at approximately 1500 meters from the take-off point. Immediate evacuation was performed to all passengers. The crash and fire rescue personnel arrived at the area and assisted the passengers and aircrew.