Crash of a De Havilland DHC-2 Beaver I in Hesquiat Lake: 2 killed

Date & Time: Aug 16, 2013 at 1023 LT
Type of aircraft:
Operator:
Registration:
C-GPVB
Flight Phase:
Survivors:
Yes
Schedule:
Hesquiat Lake - Gold River
MSN:
871
YOM:
1956
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
17000
Circumstances:
At 1015 Pacific Daylight Time, the de Havilland DHC-2 (Beaver) floatplane (registration CGPVB, serial number 871), operated by Air Nootka Ltd., departed Hesquiat Lake, British Columbia, with the pilot and 5 passengers for Air Nootka Ltd.’s water aerodrome base near Gold River, British Columbia. Visibility at Hesquiat Lake was about 2 ½ nautical miles in rain, and the cloud ceiling was about 400 feet above lake and sea level. Approximately 3 nautical miles west of the lake, while over Hesquiat Peninsula, the aircraft struck a tree top at about 800 feet above sea level and crashed. Shortly after the aircraft came to rest, a post-crash fire developed. All 6 persons on board survived the impact, but the pilot and 1 passenger died shortly after. A brief 406 megahertz emergency locator transmitter signal was transmitted, and a search and rescue helicopter recovered the survivors at about 1600.
Probable cause:
Findings as to causes and contributing factors:
1. The pilot flew just above the tree tops into instrument meteorological conditions and rising terrain, and the aircraft struck a tree that was significantly taller than the others.
2. The pilot and 1 passenger did not exit the aircraft before it was consumed in the postimpact fire.
3. Air Nootka did not have effective methods to monitor its pilots’ in-flight decision making and associated practices. As a result, Air Nootka had no way to detect and correct unsafe behavior or poor decision making such as occurred on this flight.
Findings as to risk:
1. If aircraft are not fitted with technology to reduce fuel leakage or to eliminate ignition sources, the risk of post-impact fire is increased.
2. If aircraft are not equipped with shoulder harnesses for all seating positions then there is an increased risk of injuries.
3. If aircraft are not equipped with some alternate means of escape such as push-out windows, then there is a risk that post-crash structural deformation will jam doors shut and restrict exit for the occupants.
4. If companies operating under self-dispatch do not monitor their operations, they risk not being able to identify unsafe practices that are a hazard to flight crew and passengers.
5. If flight data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.
Final Report:

Crash of a Cessna 404 Titan II near Merugwayi

Date & Time: Jul 30, 2013
Type of aircraft:
Operator:
Registration:
5Y-DOC
Flight Phase:
Survivors:
Yes
Schedule:
Merugwayi - Arusha
MSN:
404-0433
YOM:
1979
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from a remote airstrip in Merugwayi, while flying in bad weather conditions, the twin engine aircraft crashed in a wilderness located in Kapingiro, near Merugwayi. All seven occupants were injured, the copilot aged 23 seriously. The aircraft was damaged beyond repair. Among passengers were several doctors who provided medical services to locals leaving in the remote district.

Crash of a De Havilland DHC-2 Beaver in Thorne Bay

Date & Time: Jul 24, 2013 at 1140 LT
Type of aircraft:
Operator:
Registration:
N4787C
Flight Phase:
Survivors:
Yes
Schedule:
Ketchikan – Shipley Bay
MSN:
1330
YOM:
1959
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19500
Captain / Total hours on type:
600.00
Aircraft flight hours:
33326
Circumstances:
The pilot reported that, while the float-equipped airplane was in cruise flight about 1,200 ft above ground level, the engine made a loud noise and lost partial power, so he maneuvered the airplane to land on a nearby lake. During the approach, the engine lost total power, and the airplane descended into an area of trees before reaching the lake, which resulted in substantial damage to the wings, fuselage, and empennage. The operator reported that the engine had been overhauled (zero-timed) 31 hours before the accident. A postaccident engine examination revealed metal fragments and heavy gouging damage to the rotating components within the crankcase. The bottom portion (crankshaft end) of the n°1 linkrod and its respective bushing were missing from the n°1 linkpin; the oil sump contained metal debris consistent with heavily damaged remnants of these (and other) components. The n°2 cylinder barrel and linkrod and the n°3 linkrod showed deformation to the left (in the direction of engine rotation). Based on the damage observed in the engine, it is likely that the event that initiated the engine failure involved either the the n°1 linkrod bushing or the bottom portion of the n°1 linkrod; however, the extensive damage to these components precluded determination of the failure mode.
Probable cause:
The failure of the n°1 linkrod bushing or the bottom portion of the linkrod, which resulted in a total loss of engine power.
Final Report:

Crash of a Britten-Norman BN-2A-21 Islander on Perico Island

Date & Time: Jul 19, 2013 at 1234 LT
Type of aircraft:
Operator:
Registration:
HP-1338MF
Survivors:
Yes
Schedule:
Isla del Rey - Panama City
MSN:
818
YOM:
1977
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Few minutes after he departed Isla del Rey Airport, while overflying the bay of Panama City, the pilot informed ATC about engine problems. Unable to reach Panama City-Marcos A. Gelabert Airport, the pilot reduced his altitude and elected to make an emergency landing on the Perico Island, some 10 km south of Panama City Airport. After touchdown, the aircraft rolled for few dozen metres before coming to rest against a container. All eight occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-3T Turbo Otter in Soldotna: 10 killed

Date & Time: Jul 7, 2013 at 1120 LT
Type of aircraft:
Operator:
Registration:
N93PC
Flight Phase:
Survivors:
No
Schedule:
Soldotna - Bear Mountain Lodge
MSN:
280
YOM:
1958
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
7765
Captain / Total hours on type:
155.00
Aircraft flight hours:
22831
Circumstances:
Before picking up the nine passengers, the pilot loaded the accident airplane at the operator's base in Nikiski with cargo (food and supplies for the lodge). The operator of the lodge where the passengers were headed estimated the cargo weighed about 300 pounds (lbs) and that the passengers' baggage weighed about 80 lbs. Estimates of the passengers' weights were provided to the lodge operator in preparation for the trip, which totaled 1,350 lbs. The load manifest listed each of these weight estimates for a total weight of 1,730 lbs and did not contain any balance data. The cargo was not weighed, and the pilot did not document any weight and balance calculations nor was he required to do so. The airplane operator did not keep fueling records for each flight. A witness who was present during the fueling operations at the operator's base reported that he saw the pilot top off the front tank then begin fueling the center tank. The first leg of the trip from the operator's base to pick up the passengers was completed uneventfully. According to witnesses at Soldotna Airport, after loading the passengers and their baggage, the pilot taxied for departure. There were no witnesses to the accident. The airplane impacted the ground about 2,320 feet from the threshold of the departure runway and about 154 feet right of the runway centerline. An extensive postcrash fire consumed most of the airplane's cockpit and cabin area, including an unknown quantity of the baggage and cargo. Impact signatures were consistent with a nose- and right-wing-low attitude at impact. The entire airplane was accounted for at the wreckage site. Disassembly and examination of the engine and propeller revealed that both were operating during impact. Examination of the structure and flight control systems found no preimpact malfunctions or failures that would have precluded normal operation. The pilot was properly certificated and qualified in accordance with applicable federal regulations. Toxicological testing of specimens from the pilot was negative for any carbon monoxide, alcohol, or drugs. The airplane was not equipped, and was not required to be equipped, with any type of crashresistant recorder. A video recovered from a passenger's smartphone showed the accident sequence looking out of the row 4 left seat window; the left wing and flaps are in view for most of the sequence and the flap position does not change. The investigation found that the flaps were set to the full-down (or landing) position during takeoff, contrary to recommended procedures in the airplane flight manual (AFM). The recovered video was used to estimate the airplane speed, altitude, and orientation for the portion of the flight where ground references were visible, about 22.5 seconds after the start of the takeoff roll. For the first 12 seconds, the airplane accelerated linearly from the beginning of the takeoff roll through liftoff. The pitch angle decreased slightly in the first 8 seconds as the tail lifted, remained essentially constant for about 4 seconds, and began to slightly increase as the airplane lifted off. Beginning about 14 seconds after the start of the takeoff roll, the speed began decreasing and the pitch angle began increasing. The pitch angle increased at a constant rate (about 2.8 degrees/second), reaching a maximum value of about 30 degrees, and the ground speed decreased from its maximum of about 68 mph to about 44 mph at the end of the analyzed time. The ground references disappeared from the video frame as the airplane experienced a sharp right roll before impacting the ground several seconds later. The low speed, rapid right roll, and pitch down of the airplane is consistent with an aerodynamic stall. The constant pitch rate before the stall is consistent with an aft center of gravity (CG) condition of sufficient magnitude that the elevator pitch down authority was insufficient to overcome the pitching moment generated by the aft CG. Additionally, the flaps setting at the full-down (or landing) position, contrary to procedures contained in the AFM, would have exacerbated the nose-up pitching moment due to the increased downwash on the tail and aft shift of the center of pressure; the additional aerodynamic drag from the fully extended flaps would have altered the airplane's acceleration. Using the data available, the airplane was within weight and balance limitations for the first leg of the trip. However, the cargo loaded was about 2.4 times the weight indicated on the load manifest. Further, the total weight of cargo and baggage in the cargo area, as estimated during the investigation, exceeded the installed cargo net's load limit of 750 lbs by more than 50 lbs. Although the loaded cargo actual weight was higher than indicated on the load manifest, the flight from Nikiski to Soldotna was completed without any concerns noted by the pilot, indicating that even with the higher cargo load, the airplane was within the normal CG range for that leg of the flight. Thus, based on the investigation's best estimate and a calculation of the airplane's weight and balance using the recovered passenger weights, weights and location of the luggage recovered on scene, weight of the cargo recovered on scene, and weights accounting for the liquid cargo destroyed in the postimpact fire, once the passengers were loaded, the airplane weight would have exceeded the maximum gross weight of 8,000 lbs by about 21 lbs and the CG would have been at least 5.5 inches aft of the 152.2-inch limit (a more definitive calculation could not be performed because the exact location of the cargo was not known). Additionally, the kinematics study of the accident airplane's weight and motion during initial climb and up to the point of stall found that with the pilot applying full pitch-down control input, the CG required to produce the motion observed in the video was likely just past 161 inches. Thus, the only way for the airplane motion to match the motion observed in the video was for the CG to be considerably aft of the 152.2-inch limit, which provides additional support to the results from the weight and balance study. Based on the video study, the weight and balance study constructed from available weight and balance information, and the kinematics study, the airplane exceeded the aft CG limit at takeoff, which resulted in an uncontrollable nose-up pitch leading to an aerodynamic stall. The CG was so far aft of the limit that the airplane likely would have stalled even with the flaps in the correct position. Neither 14 CFR Part 135 nor the operator's operations specifications (OpSpec) require that the aircraft weight and balance be physically documented for any flights. However, according to Section A096 of the OpSpec, when determining aircraft weight and balance, the operator should use either the actual measured weights for all passengers, baggage, and cargo or the solicited weights for passengers plus 10 lbs and actual measured weights for baggage and cargo. The operator did not comply with federal regulations that require adherence to the weighing requirements or the takeoff weight limitations in the AFM. Additionally, although the inaccurate estimate of 300 lbs for the cargo resulted in a calculated CG that was within limits for both legs of the flight, the actual weight of the cargo was significantly higher. Once loaded in Soldotna, the combination of the passengers, their baggage, and the actual cargo weight and its location resulted in the CG for the accident flight being significantly aft of the limit. With the CG so far aft, even with full nose-down input from the pilot, the nose continued to pitch up until the airplane stalled. For each flight in multiengine operations, 14 CFR 135.63(c) requires the preparation of a load manifest that includes, among other items the number of passengers, total weight of the loaded aircraft, the maximum allowable takeoff weight, and the CG location of the loaded aircraft; one copy of the load manifest should be carried in the airplane and the operator is required to keep the records for at least 30 days. Single-engine operations are excluded from this requirement. The NTSB attempted to address this exclusion with the issuance of Safety Recommendations A-89-135 and A-99-61, which asked the Federal Aviation Administration (FAA) to amend the record-keeping requirements of 14 [CFR] 135.63(c) to apply to single-engine as well as multiengine aircraft. The FAA did not take the recommended action in either instance, and the NTSB classified Safety Recommendations A-89-135 and A-99-61 "Closed—Unacceptable Action" in 1990 and 2014, respectively.
Probable cause:
The operator's failure to determine the actual cargo weight, leading to the loading and operation of the airplane outside of the weight and center of gravity limits contained in the airplane flight manual, which resulted in an aerodynamic stall. Contributing to the accident was the Federal Aviation Administration's failure to require weight and balance documentation for each flight in 14 Code of Federal Regulations Part 135 single-engine operations.
Final Report:

Crash of a PZL-Mielec AN-2 near Nekrasovka

Date & Time: Jun 28, 2013 at 1100 LT
Type of aircraft:
Operator:
Registration:
RF-00408
Flight Phase:
Survivors:
Yes
Schedule:
Khabarovsk - Samarga
MSN:
1G98-04
YOM:
1968
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft departed Khabarovsk on a charter flight to Samarga, carrying two pilots and seven fishermen flying to a fish camp. En route, the crew encountered engine problems and elected to return to Khabarovsk. Unable to maintain a safe altitude, the crew attempted to carry out an emergency landing when the airplane impacted trees and crashed in a wooded area, coming to rest in a small river. All nine occupants were injured, five of them seriously. The aircraft was damaged beyond repair.

Crash of a De Havilland DHC-2 Beaver I near Petersburg: 1 killed

Date & Time: Jun 4, 2013 at 1531 LT
Type of aircraft:
Operator:
Registration:
N616W
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Petersburg - Petersburg
MSN:
1290
YOM:
1958
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4841
Captain / Total hours on type:
1465.00
Aircraft flight hours:
34909
Circumstances:
The pilot reported that the accident flight was his fourth flight and the third tour flight of the day in a float-equipped airplane. The weather had deteriorated throughout the day with lowering ceilings, light rain, and fog on the mountain ridges. The pilot said that when approaching a mountain pass, he initiated a climb by adding a “little bit” of flap (about 1 pump of the flap handle actuator) but did not adjust the engine power from the cruise power setting. He noted his airspeed at 80 knots, with a 200-feet-per-minute climb on the vertical speed indicator. He was having difficulty seeing over the cowling due to the nose-high attitude, when he suddenly noticed trees in his flight path. He initiated an immediate left turn; the airplane stalled, and began to drop, impacting the mountainous, tree-covered terrain. A passenger reported that the weather conditions at the time of the accident consisted of tufts of low clouds, and good visibility. They did not enter the clouds at any time during the flight. He reported that the airplane made a left turn, stalled, and then made a sharp left turn right before impact. The airplane seemed to be operating fine, and he heard no unusual sounds, other than the engine speed seemed to increase significantly right before impact. The pilot reported that there were no preaccident mechanical anomalies that would have precluded normal operation, and the postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.
Probable cause:
The pilot’s failure to maintain adequate altitude above the trees, and his subsequent failure to maintain adequate airspeed while maneuvering to avoid the trees, which resulted in an
inadvertent aerodynamic stall/spin and an uncontrolled descent.
Final Report:

Crash of a Dornier DO228-202K in Simikot

Date & Time: Jun 1, 2013 at 0714 LT
Type of aircraft:
Operator:
Registration:
9N-AHB
Survivors:
Yes
Schedule:
Nepalgunj - Simikot
MSN:
8169
YOM:
1989
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft was completing a charter flight from Nepalgunj to Simikot, carrying two pilots and five passengers. On approach to Simikot Airport, ground fog and low visibility forced the crew to initiate a go-around procedure. A second and a third attempt to land were abandoned few minutes later. During the fourth attempt to land, without sufficient visual contact with the ground, the crew continued the approach, passed through the clouds when the aircraft landed hard short of runway 28. Upon impact, the undercarriage were torn off and the aircraft slid for few dozen metres, veered to the right and came to rest on the right side of the runway with its left wing broken in two. All seven occupants escaped uninjured and the aircraft was damaged beyond repair.

Crash of an Embraer EMB-820C Carajá in Almeirim: 10 killed

Date & Time: Mar 12, 2013 at 2030 LT
Operator:
Registration:
PT-VAQ
Survivors:
No
Schedule:
Belém - Almeirim
MSN:
820-140
YOM:
1986
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
1300
Captain / Total hours on type:
70.00
Circumstances:
The twin engine aircraft departed Belém-Val de Cans-Júlio Cezar Ribeiro Airport at 1907LT on a flight to Almeirim, carrying one pilot and nine employees of a company taking part to the construction of a hydro-electric station in the area. Following an eventful flight at FL85, the pilot started the descent to Almeirim and contacted ground at 2023LT. On final approach by night, the aircraft descended too low, impacted ground and crashed 5 km short of runway, bursting into flames. The aircraft was destroyed and all 10 occupants were killed.
Probable cause:
The following findings were identified:
- The pilot took the risks inherent to that flight when he accepted to be the only crewmember on a night-time flight with an aircraft in which he lacked enough experience. It is therefore considered that the pilot was complacent when he accepted to fly the aircraft under those circumstances, taking the risks associated with the operation.
- The fact that the pilot made a phone call to his father, to tell that he was feeling insecure for conducting the flight, may be considered an indication that he was not confident, and this condition may have influenced negatively his operational performance during the descent procedure.
- It is possible that the motivation of the pilot in making a fast progress in his career contributed to his acceptance of the challenge to operate the flight, even if he was not feeling fully confident.
- It is possible that the characteristics related to the type of flight, regions, time of the day, in addition to the fact that the pilot was flying the aircraft alone for the first time, contributed to an unclear perception of the relevant elements around him, leading him to a mistaken comprehension, which resulted in the deterioration of his ability to foresee the events.
- The operational progress of the pilot in the company was expedited and, therefore, it is possible that for this reason he did not gather the necessary experience for conducting that type of flight.
- It is possible that the way the work was organized within the company, with designation of pilots not readapted in the aircraft for night-time flights without artificial horizon, and for takeoffs with an aircraft weight above the one prescribed in the manual contributed to the event that resulted in the accident.
- It is possible that the prioritization of the financial sector, in detriment of operational safety, contributed to the designation of a single pilot with short experience for transporting nine passengers.
- It is probable that the pilot, during the preparation of the aircraft for landing, allowed the its speed and power to drop to a value below the minima required for maintenance of level flight on the downwind leg.
- It is possible that the location of the runway in an isolated area of the Amazonian jungle region, without visual references in a night-time flight, contributed to the pilot’s difficulty maintaining a sustained flight.
- It is possible that the training done by the pilot in a shortened manner deprived him from the knowledge and other technical abilities necessary for flying the aircraft.
- The decisions of the company operation sector to designate a short-experienced pilot without a copilot for a night flight destined for an aerodrome located in a jungle region without visual reference with the terrain increased the risk of the operation. Therefore, the risk management process was probably inappropriate.
- It was the first time the pilot was flying the aircraft on a night-time flight without a copilot. Since he had only little experience in the aircraft, it is possible that his operational performance was hindered in the management of tasks, weakening his situational awareness.
- It was not possible to determine whether the company chose to dispense with the copilot on account of the need to transport a ninth passenger and, thus, did not consider in a conservative manner the prescription contained in the aircraft airworthiness certificate by designating just one pilot for the flight.
Final Report:

Crash of a Beechcraft B200 Super King Air in Pias: 9 killed

Date & Time: Mar 6, 2013 at 0741 LT
Operator:
Registration:
OB-1992-P
Survivors:
No
Schedule:
Lima - Pias
MSN:
BB-1682
YOM:
1999
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
4509
Captain / Total hours on type:
312.00
Copilot / Total flying hours:
994
Copilot / Total hours on type:
425
Aircraft flight hours:
3859
Aircraft flight cycles:
4318
Circumstances:
The twin engine aircraft departed Lima-Jorge Chávez Airport at 0625LT on a charter flight to Pias, carrying two pilots and seven employees of the Peruvian company MARSA (Minera Aurífera Retamas) en route to Pias gold mine. On approach to Pias Airport, the crew encountered limited visibility due to foggy conditions. Heading 320° on approach, the crew descended too low when the aircraft collided with power cables, stalled and crashed on the slope of a mountain located 4,5 km from the airport, bursting into flames. The aircraft was destroyed by impact forces and a post crash fire and all 9 occupants were killed.
Probable cause:
Loss of control following the collision with high power cables after the crew lost visual references during an approach completed in poor weather conditions. The following contributing factors were identified:
- Inadequate meteorological information provided by the Pias Airport flight coordinator that did not reflect the actual weather condition in the area,
- Lack of a procedure card to carry out the descent, approach, landing and takeoff at Pias Airport, considering the visual and operational meteorological limitations in the area,
- The copilot training was limited and did not allow the crew to develop skills for an effective CRM in normal and emergency procedures.
Final Report: