Crash of a Piper PA-31-350 Navajo Chieftain in Middlefield

Date & Time: Jan 18, 2023 at 0903 LT
Registration:
N101MA
Survivors:
Yes
Schedule:
Youngstown – Detroit – Minneapolis
MSN:
31-7752186
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9275
Captain / Total hours on type:
750.00
Aircraft flight hours:
17154
Circumstances:
While enroute in instrument meteorological (IMC) conditions, the pilot of the twin-engine, piston-powered airplane declared an emergency following a loss of power to the right engine. The pilot secured the engine and was provided vectors by air traffic control for an instrument approach procedure at the nearest airport, which he successfully completed. The pilot reported that he flew the approach and landing with the wing flaps retracted and visually acquired the runway about 500 ft above the ground. The airplane touched down on the first third of the runway at 120 knots. The pilot knew he would not be able to stop the airplane on the 3,500-ft long runway but committed to the landing rather than risking a single-engine go-around in IMC. After landing, the airplane continued beyond the departure end of the runway and impacted a berm, collapsing the landing gear and resulting in substantial damage to the airplane. Examination of the engine revealed catastrophic damage consistent with detonation and oil starvation. The damage to the No. 5 cylinder was consistent with a subsequent over pressurization of the crankcase, which likely expelled the crankshaft nose seal and the oil supply. Detonation of the cylinder(s) can create excessive crankcase pressures capable of expelling the crankshaft nose seal. The crankshaft nose seal displacement likely created a rapid loss of oil and the resulting oil starvation of the engine. The fractured connecting rod and high-temperature signatures were consistent with oil starvation. No source or anomaly that would result in engine detonation was identified. According to the Pilot’s Operating Handbook (POH) for the accident airplane, during a single engine inoperative approach, the pilot should maintain an airspeed of 116 kts indicated (KIAS) or above until landing is assured. Once landing is assured, the pilot should extend the gear and flaps, slowly retard the power on the operative engine, and land normally. The airplane’s best single-engine rate of climb speed (blue line) was 106 KIAS, and its minimum controllable airspeed with one engine inoperative (Vmca) was 76 KIAS. The maximum speed for full flap extension (40°) was 132 KIAS. The POH also stated that a single-engine go-around should be avoided if at all possible. The pilot’s decision to commit to the landing was reasonable given the circumstances and the guidance provided by the POH; however, it is likely that his decision to conduct the landing without flaps and the airplane’s excessive airspeed at touchdown resulted in the runway overrun.
Probable cause:
A runway overrun during a precautionary landing following a total loss of right engine power due to detonation and subsequent oil starvation. Contributing was the pilot’s failure to lower the flaps and the excessive airspeed at touchdown.
Final Report:

Crash of a Beechcraft B200 Super King Air in Poplar

Date & Time: Jan 18, 2023 at 0818 LT
Operator:
Registration:
N200EJ
Survivors:
Yes
Schedule:
Billings - Poplar
MSN:
BB-1884
YOM:
2004
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4242
Captain / Total hours on type:
2068.00
Copilot / Total flying hours:
10301
Copilot / Total hours on type:
4137
Aircraft flight hours:
4538
Circumstances:
The pilot reported that while on approach for landing, the airplane started to lose altitude quickly. After the co-pilot noticed the high decent rate and the slow airspeed, he advised the pilot to add power. However, the airplane continued to descend and impacted terrain in a right wing and nose low attitude, about 30 yards short of the runway approach threshold, which resulted in substantial damage to the right wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause:
The pilot’s failure to maintain adequate airspeed and descent rate during the landing approach, which resulted in an impact with terrain short of the runway threshold.
Final Report:

Crash of an Embraer EMB-505 Phenom 300 in Provo: 1 killed

Date & Time: Jan 2, 2023 at 1135 LT
Type of aircraft:
Operator:
Registration:
N555NR
Flight Phase:
Survivors:
Yes
Schedule:
Provo - Chino
MSN:
505-00327
YOM:
2015
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
While taking off from Provo Airport runway 13/31, the airplane went out of control and crashed. Both passengers escaped with minor injuries while both pilots were seriously injured. One of them died from injuries sustained. The airplane was destroyed. It was snowing at the time of the accident.

Crash of a Cessna 208B Grand Caravan in Mweya

Date & Time: Dec 31, 2022 at 1315 LT
Type of aircraft:
Operator:
Registration:
5X-GBR
Survivors:
Yes
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Mweya Airstrip located in the Queen Elizabeth National Park, the single engine airplane was unable to stop within the remaining distance. It overran and collided with a house. All five occupants escaped uninjured and the aircraft was damaged beyond repair. It just completed a charter flight with three European citizens and two pilots on board.

Crash of a Piper PA-42-1000 Cheyenne 400LS in Lewistown

Date & Time: Dec 13, 2022 at 1006 LT
Type of aircraft:
Operator:
Registration:
C-GZPU
Survivors:
Yes
Schedule:
Great Falls – Lewistown
MSN:
42-5527011
YOM:
1984
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 08 at Lewistown Airport, the twin engine airplane started to skid then veered off runway to the left. While contact a snow covered terrain, it slid for few dozen metres and came to rest with its left wing severely damaged. All three occupants evacuated safely.

Crash of a Learjet 45 in Batesville

Date & Time: Nov 29, 2022 at 1910 LT
Type of aircraft:
Operator:
Registration:
N988MC
Survivors:
Yes
Schedule:
Waterloo – Batesville
MSN:
45-352
YOM:
2007
Flight number:
DHR003
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3910
Captain / Total hours on type:
1560.00
Copilot / Total flying hours:
505
Copilot / Total hours on type:
263
Aircraft flight hours:
2490
Circumstances:
The two pilots were conducting a business flight with six passengers when the accident occurred. During the night arrival the captain flew a visual approach with excessive airspeed
and the airplane crossed the runway threshold more than 50 knots above approach speed (Vref). The before-landing checklist was not completed, and the flaps were at an incorrect 20° position instead of 40°. The airplane touched down near the midfield point of the 6,022 ft non grooved runway, which was wet due to earlier precipitation. The captain initially applied intermittent braking, then applied continuous braking starting about 2,069 ft from the end of the runway. The captain did not deploy the thrust reversers. The airplane exited the runway above 100 knots ground speed, then continued into a ditch and airport perimeter fence, which resulted in substantial damage to the forward fuselage. Examination of the airplane revealed no mechanical anomalies that would have precluded normal operation. The operator’s flight manual directed that all approaches were to be flown using the stabilized approach concept. For a visual approach, this included establishing and maintaining the proper approach speed and correct landing configuration at least 500 ft above the airport elevation. Neither pilot recognized the requirement to execute a go-around due to the excessive approach speed or the long landing on a wet runway, which resulted in the runway excursion.
Probable cause:
The crew’s failure to execute a go-around during the unstable approach and long landing, which resulted in a runway excursion.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Medellín: 8 killed

Date & Time: Nov 21, 2022 at 1015 LT
Operator:
Registration:
HK-5121
Flight Phase:
Survivors:
No
Site:
Schedule:
Medellín – Pizarro
MSN:
31-7652004
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
The twin engine airplane was chartered by the Grupo San Germán Express to carry a team of six people from Medellín to Pizarro, Chocó. Shortly after takeoff from runway 02 at Medellín-Enrique Olaya Herrera Airport, while in initial climb, the crew encountered engine problems. The airplane went out of control and crashed onto a house located in the district of Belén Rosales, less than 500 metres from the runway end, bursting into flames. The house and the aircraft were destroyed and all 8 occupants were killed.
Crew:
Julián Aladino, pilot,
Sergio Guevara Delgado, copilot.
Passengers:
Jorge Cantillo Martínez,
Dubán Ovalle Quintero,
Anthony Mosquera Blanquiceth,
Pedro Pablo Serna,
Melissa Pérez Cuadros,
Nicolás Jiménez.

Crash of a De Havilland DHC-3 Otter in Pluto Lake

Date & Time: Oct 13, 2022 at 0929 LT
Type of aircraft:
Operator:
Registration:
C-FDDX
Survivors:
Yes
Schedule:
Mistissini - Pluto Lake
MSN:
165
YOM:
1956
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1938
Captain / Total hours on type:
600.00
Aircraft flight hours:
17489
Circumstances:
On 12 October 2022, the True North Airways Inc. de Havilland DHC-3 Otter aircraft on floats (registration C-FDDX, serial number 165) was conducting a visual flight rules flight, with 1 pilot on board, from Mistissini Water Aerodrome (CSE6), Quebec, to Pluto Lake, Quebec, where it would deliver cargo and pick up passengers. At approximately 0929 Eastern Daylight Time, while manoeuvring for landing on Pluto Lake, the aircraft collided with the surface of the water. The pilot sustained serious injuries. The passengers, who had been waiting near the lake for the aircraft’s arrival, transported the pilot to a nearby cabin from where he was later taken to hospital by a search and rescue helicopter. The emergency locator transmitter activated. There was significant damage to the aircraft.
Probable cause:
3.1 Findings as to causes and contributing factors
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
Due to the visual cues of the landing area that were visible to the pilot, the close proximity of the landing site where passengers were waiting, and the natural tendency to continue a plan under changing conditions, the pilot continued the approach despite visibility in the local area being below the minimum required for visual flight rules flight.
Owing to the reduced visibility, the pilot’s workload, while he was manoeuvring for landing, was high and his attention was focused predominantly outside the aircraft in order to keep the landing area in sight. As a result, a reduction in airspeed went unnoticed.
During the aircraft’s turn from base to final, the increased wing loading, combined with the reduced airspeed, resulted in a stall at an altitude too low to permit recovery.
The pilot was not wearing the shoulder harness while at the controls and operating the aircraft because he found it uncomfortable and other aircraft he flew were not equipped with one. As a result, during impact with the water, the pilot received serious injuries.

3.2 Findings as to risk
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
If aircraft stall warning systems do not provide multiple types of alerts warning the pilot of an impending stall, there is an increased risk that a visual stall warning alone will not be salient enough and go undetected when the pilot’s attention is focused outside the aircraft or during periods of high workload.
If aircraft operators do not ensure that their contact information on file with the Canadian Beacon Registry is accurate, there is a risk that search and rescue operations may be delayed.
If companies do not employ robust flight-following procedures, there is a risk that, after an accident, potentially life-saving search and rescue services will be delayed.

3.3 Other findings
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
The occurrence aircraft was carrying dangerous goods on board, even though the operator was not authorized to do so on its DHC-3 Otter aircraft.
For unknown reasons, the pilot encountered difficulty inflating his personal flotation device, and because of his proximity to the shore, he removed it to make it easier to swim.
Final Report:

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

Date & Time: Oct 3, 2022 at 1338 LT
Type of aircraft:
Operator:
Registration:
VH-WQA
Flight Phase:
Survivors:
Yes
Schedule:
Saibai Island - Horn Island
MSN:
494
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2400
Captain / Total hours on type:
250.00
Aircraft flight hours:
14081
Circumstances:
On the afternoon of 3 October 2022, a Pilatus Britten-Norman Islander BN2A-21, registered VHWQA and operated by Torres Strait Air, was conducting a non-scheduled passenger air transport flight from Saibai Island Airport, Queensland (QLD) to Horn Island Airport, QLD. There was 1 pilot and 6 passengers (students) on board. About 19 km NE of Moa Island both engines began to surge. The pilot diverted towards Kubin Airport on Moa Island. As the aircraft passed to the south of the township of Saint Pauls, the pilot determined there was insufficient altitude remaining to reach the airport. As a result, the pilot conducted a forced landing on a road 7 km ENE of Kubin Airport. There were no reported injuries to the pilot or the passengers. The aircraft was substantially damaged.
Probable cause:
The ATSB found that the dual engine speed fluctuations and associated power loss was probably the result of fuel starvation. The mechanism was not conclusively determined, however it was identified that the pilot did not operate the aircraft's fuel system in accordance with the aircraft flight manual, and that the configuration and location of the aircraft’s fuel controls and tank quantity gauges were probably not conducive to rapid and accurate interpretation. The aircraft manufacturer released a service letter in June 2022 that detailed an optional modification to centralize the fuel system controls and gauges, however this modification was not fitted to VH-WQA. The ATSB considered that these factors increased the risk of inadvertent fuel tank selection.
Final Report:

Crash of a Cessna 208B Grand Caravan in Porto Trombetas: 1 killed

Date & Time: Sep 10, 2022
Type of aircraft:
Operator:
Registration:
PT-MES
Flight Phase:
Survivors:
Yes
Schedule:
Porto Trombetas - Ayaramã
MSN:
208B-0507
YOM:
1996
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
After takeoff from Porto Trombetas Airport, the pilot encountered engine problems and attempted an emergency landing. The airplane crashed in a wooded area and was destroyed. The pilot was killed and all four passengers were injured. They were en route to Ayaramã to provide dental assistance to locals. On board were one dentist, one assistant, one nurse and one employee of the Brazilian Institute for Geography and Statistics.