Charter/Taxi (Non Scheduled Revenue Flight)

Flight Type:

Survivors:

Site:

City

Schedule:

Nassau - Freeport

MSN:

258

YOM:

1979

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

13800

Copilot / Total flying hours:

996

Aircraft flight hours:

12046

Aircraft flight cycles:

10534

Circumstances:

The aircraft crashed into a garbage and metal recycling plant after striking a towering crane in the Grand Bahama Shipyard, while attempting a second landing approach to runway 06 at Freeport International Airport (MYGF), Freeport, Grand Bahama, Bahamas. The aircraft made an initial ILS instrument approach to Runway 06 at the Freeport International Airport but due to poor visibility and rain at the decision height, the crew executed a go around procedure. The crew requested to hold at the published holding point at 2,000 feet while they waited for the weather to improve. Once cleared for the second ILS approach, the crew proceeded inbound from the holding location to intercept the localizer of the ILS system associated with the instrument approach. During the approach, the crew periodically reported their position to ATC, as the approach was not in a radar environment. The crew was given current weather conditions and advised that the conditions were again deteriorating. The crew continued their approach and descended visually while attempting to find the runway, until the aircraft struck the crane positioned at Dock #2 of the Shipyard at approximately 220 feet above sea level, some 3.2 nautical miles (nm) from the runway threshold. A fireball lasting approximately 3 seconds was observed as a result of the contact between the aircraft and the crane. The right outboard wing, right landing gear and right wingtip fuel tank, separated from the aircraft on impact. This resulted in the aircraft travelling out of control, some 1,578 feet (526 yards) before crashing inverted into a pile of garbage and other debris in the City Services Garbage and Metal Recycling Plant adjacent to the Grand Bahama Shipyard. Both crew and 7 passengers were fatally injured. No person on the ground was injured. The crane in the shipyard that was struck received minimal damages while the generator unit and other equipment in the recycling plant received extensive damages.

Probable cause:

The Air Accident Investigation & Prevention Unit (AAIPU) determines that the probable cause(s) of this accident were:
- The poor decision making of the crew in initiating and continuing a descent in IMC below the authorized altitude, without visual contact with the runway environment.
Contributing Factors includes:
- Improper planning of the approach,
- Failure of the crew to follow the approved ILS approach while in IMC conditions,
- Insufficient horizontal or vertical situational awareness,
- Poor decision making,
- Deliberate actions of the crew by disabling the terrain alert warning system,
- Inadequate CRM practice.

Final Report:

Crash of a Dassault Falcon 50EX in Moscow-Vnukovo: 4 killed

Date & Time: Oct 20, 2014 at 2357 LT

Type of aircraft:

Dassault Falcon 50

Operator:

Registration:

F-GLSA

Flight Phase:

Takeoff (climb)

Flight Type:

Survivors:

Site:

Schedule:

Moscow - Paris

MSN:

348

YOM:

2006

Flight number:

LEA074P

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

6624

Captain / Total hours on type:

1266.00

Copilot / Total flying hours:

1478

Copilot / Total hours on type:

246

Aircraft flight hours:

2197

Aircraft flight cycles:

1186

Circumstances:

During the takeoff run on runway 06 at Moscow-Vnukovo Airport, the three engine aircraft hit a snowplow with its left wing. The aircraft went out of control, rolled over and came to rest upside down in flames. All four occupants were killed, three crew members and Mr. Christophe de Margerie, CEO of the French Oil Group Total, who was returning to France following a meeting with the Russian Prime Minister Dmitry Medvedev. At the time of the accident, the RVR on runway 06 was estimated at 350 meters due to foggy conditions. The pilot of the snow-clearing vehicle was slightly injured.

Probable cause:

The accident occurred at nighttime under foggy conditions while it was taking off after cleared by the controller due to collision with the snowplow that executed runway incursion and stopped on the runway. Most probably, the accident was caused by the combination of the following contributing factors:
- lack of guidance on loss of control over an airdrome vehicle and/or situational awareness on the airfield in pertinent documents defining the duties of airdrome service personnel (airdrome shift supervisor and vehicle drivers);
- insufficient efficiency of risk mitigation measures to prevent runway incursions in terms of airdrome peculiarilies that is two intersecling runways;
- lack of proper supervision from the airdrome service shift supervisor, alcohol detected in his organism, over the airfield operations: no report to the ATM or request to the snowplow driver as he lost visual contact with the snowplow;
- violation by the airdrome service shift supervisor of the procedure for airdrome vehicles operations, their entering the runway (RWY 2) out of operation (closed for takeoff and landing operations) without requesting and receiving clearance from the ground controller;
- violations by the medical personnel of Vnukovo AP of vehicle driver medical check requirements by performing formally (only exterior assessment) the mandatory medical check of drivers after the duty, which significantly increased the risk of drivers consuning alcohol during the duty. The measures and controls applied at Vnukovo Airport to mitigate the risk of airdrome drivers doing their duties under the influence of alcohol were not effective enough;
- no possibility for the snowplow drivers engaged in airfield operations (due to lack of pertinent equipment on the airdrome vehicles) to continuously listen to the radio exchange at the Departure Control frequency, which does not comply with the Interaction Procedure of the Airdrome Service with Vnukovo ATC Center.
- loss of situational awareness by the snowplow driver, alcohol detected in his organism, while perfonning airfield operations that led to runway incursion and stop on the runway in use.
His failure to contact the airdrome service shift supervisor or ATC controllers after situational awareness was lost;
- ineffective procedures that resulted in insufficiently trained personnel using the airfield surveillance and control subsystem A3000 of A-SMGCS at the Vnukovo ATC Center, for air traffic management;
- no recommendation in the SOP of ATM personnel of Vnukovo ATC Center on how to set up the airfield surveillance and control subsystem A3000, including activation and deactivation of the Reserved Lines and alerts (as a result, all alerts were de-activated at the departure controller and ground controller's working positions) as well as how to operate the system including attention allocation techniques during aircraft takeoff and actions to deal with the subsystem messages and alerts;
- the porting of the screen second input of the A3000 A-SMGCS at the ATC shift supervisor WP for the display of the weather information that is not envisaged by the operational manual of the airfield surveillance and control subsystem. When weather information is selected to be displayed the radar data and the light alerts (which were present during the accident takeoff) become un available for the specialist that occupies the ATC shift supervisor's working position;
- the ATC shift supervisor's decision to join the sectors at working positions of Ground and Departure Control without considering the actual level of personnel training and possibilities for them to use the information of the airfield surveillance and control system (the criteria for joining of sectors are not defined in the Job Description of ATC shift supervisor, in particular it does not take into account the technical impossibility to change settings of the airfield surveillance and control system);
- failure by the ground controller to comply with the SOPs, by not taking actions to prevent the incursion of RWY 2 that was closed for takeoff and landing operations by the vehicles though having radar information and alert on the screen of the airfield surveillance and control system;
- failure by the out of staff instructor controller and trainee controller (providing ATM under the supervision of the instructor controller) to detect two runway incursions by the snowplow on the runway in use, including after the aircrew had been cleared to take off (as the clearance was given, the runway was clear), provided there was pertinent radar information on the screen of the airfield surveillance and control subsystem and as a result failure to inform the crew about the obstacle on the runway;
- lack of recommendations at the time of the accident in the Operator's (Unijet) FOM for flight crews on actions when external threats appear (e.g. foreign objects on the runway) during the takeoff;
- the crew failing to take measures to reject takeoff as soon as the Captain mentioned «the car crossing the road». No decision to abort takeoff might have been caused by probable nonoptimal psycho-emotional status of the crew (the long wait for the departure at an unfamiliar airport and their desire to fly home as soon as possible), which might have made it difficult for them to assess the actual threat level as they noticed the snowplow after they had started the takeoff run;
- the design peculiarity of the Falcon 50EX aircraft (the nose wheel steering can only be controlled from the LH seat) resulting in necessity to transfer aircraft control at a high workload phase of the takeoff roll when the FO (seated right) performs the takeoff.

Final Report:

Crash of a BAe 3101 Jetstream 31 in Punta Cana

Date & Time: Oct 12, 2014 at 2025 LT

Type of aircraft:

BAe Jetstream 31

Operator:

Registration:

HI816

Flight Phase:

Flight Type:

Survivors:

Site:

Piper PA-31-350 Navajo Chieftain

Schedule:

San Juan - Punta Cana

MSN:

694

YOM:

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

3850

Captain / Total hours on type:

3000.00

Aircraft flight hours:

29780

Circumstances:

The twin engine aircraft departed San Juan-Luis Muñoz Marín (Isla Verde) Airport, Puerto Rico, on a charter flight to Punta Cana, carrying two pilots, one flight attendant and 10 crew members from Air Europa positioning to Punta Cana. Following an uneventful flight, the crew completed the approach and landing on runway 08. After a roll of about 1,500 feet, the aircraft deviated to the left, made a 45° turn, veered off runway and came to rest in a wooded area, bursting into flames. All 13 occupants evacuated safely, among them two passengers were slightly injured. The aircraft was destroyed.

Probable cause:

The accident was the consequence of the combination of human and technical factor. During the approach to land, the crew observed a fluctuation in oil pressure in the instrument panel of the #2 (right) engine. After landing, the crew activated the thrust reversers on both engines without waiting for the Beta light, an essential indication to ensure a proper operation of those system. This configuration caused the aircraft to turn sharply to the left at an angle of 45° because the thrust reverser system activated on the left engine only. The fluctuation in the oil pressure observed by the crew on final approach and the malfunction of the right engine was the consequence of an oil leak in flight.

Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Araracuara: 10 killed

Date & Time: Sep 6, 2014 at 1505 LT

Type of aircraft:

Operator:

Registration:

HK-4755

Flight Phase:

Takeoff (climb)

Flight Type:

Survivors:

Site:

PAC 750XL - Pacific Aerospace Corporation

Schedule:

Araracuara – Florencia

MSN:

31-7952044

YOM:

1979

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

792

Captain / Total hours on type:

523.00

Copilot / Total flying hours:

211

Aircraft flight hours:

14601

Circumstances:

The twin engine aircraft departed Araracuara Airport runway 09 at 1503LT on a charter flight to Florencia, carrying eight passengers and two pilots. During initial climb, the right engine failed. The crew lost control of the airplane that stalled and crashed in a wooded area. The wreckage was found 8,2 km from the airport. The airplane disintegrated on impact and all 10 occupants were killed, among them a Swiss citizen.

Probable cause:

Loss of control during initial climb following the failure of the right engine for undetermined reasons.
The following contributing factors were identified:
- The crew failed to follow the published procedures when the right engine failed,
- The aircraft was likely operated with a total weight above MTOW,
- A poor risk assessment while performing an operation outside of the aircraft's performance limits.

Final Report:

Crash of a PAC-750XTOL in Golgubip

Date & Time: Jul 19, 2014 at 1143 LT

Type of aircraft:

Operator:

Registration:

P2-RNB

Flight Phase:

Flight Type:

Survivors:

Site:

De Havilland DHC-2 Beaver

Schedule:

Kiunga – Golgubip

MSN:

190

YOM:

2013

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

2930

Captain / Total hours on type:

1900.00

Aircraft flight hours:

143

Circumstances:

A Pacific Aerospace PAC P-750 XTOL single engine aircraft was chartered to transport store goods and six passengers from Kiunga to Golgubip. Although Golgubip is in mountainous terrain and the weather in the area is often poor, the pilot was tasked to fly there without ever having been to Golgubip before. The terrain to the north north east of Golgubip rises gradually behind the airstrip. Visual illusions which may affect the pilot’s perception of height and distance can be associated with airstrips situated in terrain of this kind. On arrival at Golgubip, the pilot orbited and positioned the aircraft for landing. During the final approach he decided to discontinue the approach and to initiate a go-around procedure. The aircraft impacted terrain approximately 500 metres northwest of the airstrip and was substantially damaged. The six passengers were unhurt while the pilot sustained serious injuries. The pilot was treated in Golgubip following the accident, and was airlifted the next day to Tabubil, where he was admitted to hospital. It was later reported that the GPWS alarm sounded on approach until the final impact.

Probable cause:

Loss of control on final approach, maybe following visual illusions.

Final Report:

Crash of a De Havilland DHC-2 Beaver near Kennedy Lake

Date & Time: Jun 25, 2014 at 1425 LT

Type of aircraft:

Operator:

Registration:

C-FHVT

Flight Phase:

Flight Type:

Survivors:

Cessna 207 Skywagon/Stationair

Site:

Plain, Valley

Schedule:

Sudbury - Kennedy Lake

MSN:

284

YOM:

1952

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

3500

Captain / Total hours on type:

1000.00

Circumstances:

The Sudbury Aviation Limited float-equipped de Havilland DHC-2 Beaver aircraft (registration C-FHVT, serial number 284) was on approach to Kennedy Lake, Ontario, with the pilot and 2 passengers on board, when the aircraft rolled to the left prior to the flare. The pilot attempted to regain control of the aircraft by applying full right rudder and right aileron. The attempt was unsuccessful and the aircraft struck rising tree-covered terrain above the shoreline. The aircraft came to a stop on its right side and on a slope. The pilot and the passenger in the rear seat received minor injuries. The passenger in the right front seat was not injured. All were able to walk to the company fishing camp on the lake. There was no fire and the 406 megahertz emergency locator transmitter (ELT) was manually activated by one of the passengers. One of the operator's other aircraft, a Cessna 185, flew to the lake after C-FHVT became overdue. A search and rescue aircraft, responding to the ELT, also located the accident site. Radio contact between the Cessna 185 and the search and rescue aircraft confirmed that their assistance would not be required. The accident occurred at 1425 Eastern Daylight Time.

Probable cause:

Prior to touchdown in a northerly direction, the aircraft encountered a gusty westerly crosswind and the associated turbulence. This initiated an un-commanded yaw and left wing drop indicating an aerodynamic stall. The pilot was unsuccessful in recovering full control of the aircraft and it impacted rising terrain on the shore approximately 30 feet above the water surface.

Final Report:

Crash of a Cessna T207A Turbo Stationair 7 in Page: 1 killed

Date & Time: May 10, 2014 at 1545 LT

Type of aircraft:

Operator:

Registration:

N7311U

Flight Phase:

Flight Type:

Survivors:

Site:

Lineas Aéreas Comerciales (LACSA)

Schedule:

Page - Page

MSN:

207A-0395

YOM:

1977

Location:

Page

Arizona

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

6850

Captain / Total hours on type:

48.00

Aircraft flight hours:

14883

Circumstances:

During a local sightseeing flight, the pilot noticed that the engine had lost partial power, and he initiated a turn back toward the airport while troubleshooting the loss of power. Despite the pilot's attempts, the engine would not regain full power and was surging and sputtering randomly. The pilot entered the airport's traffic pattern on the downwind leg, and, while on final approach to the runway, the airplane encountered multiple downdrafts and wind gusts. It is likely that, due to the downdrafts and the partial loss of engine power, the pilot was not able to maintain airplane control. The airplane subsequently landed hard short of the runway surface and nosed over, coming to rest inverted. The reported wind conditions around the time of the accident varied between 20 and 70 degrees right of the runway heading and were 14 knots gusting to greater than 20 knots. In addition, a company pilot who landed about 8 minutes before the accident reported that he encountered strong downdrafts and windshear while on final approach to the runway and that he would not have been able to reach the runway if he had a partial or total loss of engine power. Postaccident examination of the airframe and engine revealed no evidence of any preexisting mechanical malfunctions or failures that would have precluded normal operation. The engine was subsequently installed on a test stand and was successfully run through various power settings for several minutes. The reason for the partial loss of engine power could not be determined.

Probable cause:

The pilot's inability to maintain aircraft control due to a partial loss of engine power and an encounter with downdrafts and gusting crosswinds while on final approach to the runway. The reason for the partial loss of engine power could not be determined because postaccident examination revealed no mechanical malfunction or failure that would have precluded normal operation.

Final Report:

Crash of a BAe 125-700A in Saltillo: 8 killed

Date & Time: Apr 19, 2014 at 1946 LT

Type of aircraft:

BAe 125

Operator:

Registration:

XA-UKR

Flight Phase:

Flight Type:

Survivors:

Site:

City

Schedule:

Cozumel - Saltillo

MSN:

257191

YOM:

1982

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

12984

Captain / Total hours on type:

4470.00

Copilot / Total flying hours:

620

Copilot / Total hours on type:

Aircraft flight hours:

6166

Aircraft flight cycles:

4699

Circumstances:

Following an uneventful flight from Cozumel, the crew initiated an ILS/DME2 approach to Saltillo-Plan de Guadalupe Airport Runway 17. On final, the crew encountered poor visibility due to foggy conditions. Despite he was unable to establish a visual contact with the runway, the crew continued the approach and descended below the MDA when the aircraft collided with power cables and crashed on a building located in an industrial park, 1,448 metres short of runway. The aircraft was destroyed by impact forces and a post crash fire and all eight occupants were killed. The building was also destroyed by fire. At the time of the accident, the horizontal visibility was estimated to be 800 metres with a vertical visibility of 200 feet.

Probable cause:

The accident was the consequence of the decision of the crew to continue the approach below MDA in IMC conditions until the aircraft collided with power cables and impacted ground. The following contributing factors were identified:
- The approach was unstable,
- The decision of the crew to continue the approach below MDA without visual contact with the runway,
- Poor safety culture by the operator,
- The crew failed to comply with procedures related to an ILS/DME2 approach to runway 17,
- Lack of crew resources management,
- The crew failed to respond to the GPWS alarm,
- The crew did not monitor the altitude during the final approach,
- Poor weather conditions with a visibility below minimums,
- Inadequate maintenance controls,
- The crew failed to follow the SOP's.

Final Report:

Crash of a Quest Kodiak 100 in Doyo Baru: 2 killed

Date & Time: Apr 9, 2014 at 0940 LT

Type of aircraft:

Quest Kodiak 100

Operator:

Registration:

PK-SDF

Flight Phase:

Takeoff (climb)

Flight Type:

Survivors:

Site: