Crash of a Mitsubishi MU-2B-25 Marquise in Cobb County

Date & Time: Sep 28, 2011 at 1715 LT
Type of aircraft:
Registration:
N344KL
Survivors:
Yes
Schedule:
Huntsville - Cobb County
MSN:
257
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11100
Captain / Total hours on type:
1500.00
Aircraft flight hours:
6196
Circumstances:
The pilot stated that after landing, the nose landing gear collapsed. Examination of the airplane nose strut down-lock installation revealed that the strut on the right side of the nose landing gear trunnion was installed incorrectly; the strut installed on the right was a left-sided strut. Incorrect installation of the strut could result in the bearing pulling loose from the pin on the right side of the trunnion, which could allow the nose landing gear to collapse. A review of maintenance records revealed recent maintenance activity on the nose gear involving the strut. The design of the strut is common for the left and right. Both struts have the same base part number, and a distinguishing numerical suffix is added for left side and right side strut determination. If correctly installed, the numbers should be oriented facing outboard. The original MU-2 Maintenance Manual did not address the installation or correct orientation of the strut. The manufacturer issued MU-2 Service Bulletin (SB) No. 200B, dated June 24, 1994, to address the orientation and adjustment. Service Bulletin 200B states on page 8 of 10 that the “Part Number may be visible in this (the) area from the out board sides (Inked P/N may be faded out).”
Probable cause:
The improper installation of the nose landing gear strut and subsequent collapse of the nose landing gear during landing.
Final Report:

Crash of a Beechcraft 1900D in Kathmandu: 19 killed

Date & Time: Sep 25, 2011 at 0731 LT
Type of aircraft:
Operator:
Registration:
9N-AEK
Survivors:
No
Schedule:
Kathmandu - Kathmandu
MSN:
UE-295
YOM:
1997
Flight number:
BHA103
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
19
Copilot / Total hours on type:
18
Circumstances:
The aircraft was performing a special flight with tourists above the Himalayan mountains and especially a tour of the Everest in the early morning. While returning to Kathmandu-Tribhuvan Airport, the copilot (PIC) was cleared to descend to 6,000 feet for a landing on runway 02. In marginal weather conditions, he passed below 6,000 feet until the aircraft contacted trees and crashed in hilly and wooded terrain located near the village of Bishanku Narayan, some 6,7 km southeast of the airport. The aircraft was destroyed by impact forces and a post crash fire. A passenger was seriously injured while 18 other occupants were killed. Few hours later, the only survivor died from his injuries. The 16 tourists were respectively 10 Indians, 2 Americans, 1 Japanese and 3 Nepalese.
Probable cause:
The Accident Investigation Commission assigned by Nepal's Ministry of Tourism and Civil Aviation have submitted their report to the Ministry. The investigators said in a media briefing, that human factors, mainly fatigue by the captain of the flight, led to the crash. The aircraft was flown by the first officer and was on approach to Kathmandu at 5,000 feet MSL instead of 6,000 feet MSL as required, when it entered a cloud. While inside the cloud in low visibility the aircraft descended, hit tree tops and broke up. The captain had flown another aircraft the previous day and had been assigned to the accident flight on short notice in the morning of the accident day, but did not have sufficient rest. The commission analyzed that due to the resulting fatigue the captain assigned pilot flying duties to the first officer although she wasn't yet ready to cope with the task in demanding conditions. The newly assigned first officer had only 18 hours experience on the aircraft type. The mountain view round trip had to turn back about midway due to weather conditions. While on a visual approach to Kathmandu at 5,000 instead of 6,000 feet MSL the aircraft entered a cloud and started to descend until impact with tree tops. The crew did not follow standard operating procedures, that amongst other details required the aircraft to fly at or above 6,000 feet MSL in the accident area, the interaction between the crew members did not follow standard operating procedures, for example the captain distracted the first officer with frequent advice instead of explaining the/adhering to procedures. The commission said as result of the investigation they released a safety recommendation requiring all operators to install Terrain Awareness and Warning Systems (TAWS) in addition to eight other safety recommendations regarding pilot training, installation of visual aids, safety audit and fleet policies.

Crash of a Pilatus PC-6/B2-H4 Turbo Porter near Yahatma: 3 killed

Date & Time: Sep 22, 2011 at 1313 LT
Operator:
Registration:
PK-UCE
Flight Phase:
Survivors:
No
Site:
Schedule:
Pagai - Wamena
MSN:
943
YOM:
2004
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
11312
Captain / Total hours on type:
2647.00
Aircraft flight hours:
5774
Aircraft flight cycles:
6662
Circumstances:
On 22 September 2011, a PC 6 Pilatus Porter aircraft, registration PK-UCE was being operated by Yayasan Jasa Aviasi Indonesia (YAJASI) departed from Pagai to Wamena. The aircraft departed at 0403 UTC1 (1303 LT) and estimated to arrive at Wamena was at 0436 UTC. Aircraft cruise at altitude of 10,000 feet and conducted under Visual Flight Rules (VFR) and followed the visual route via North Gap corridor, which one of visual route to Wamena. Prior to enter the North Gap corridor at time 0413 UTC, the pilot sent a message via a system they called AFFIS to the company Flight Following Officer at Sentani Airport, which was the operation base. The pilot also sent a blind transmission message through Wamena Tower radio frequency. This was local procedure, to submit the message consists of position, altitude and destination to make the other aircraft pilots aware each other. As in the intern YAJASI flight following procedure, pilot should send message when the flying passes the North Gap corridor. In this flight, until the normal elapsed time, the pilot did not send any message to their Flight Following Officer at Sentani that the flight has passed the North Gap corridor. Since there was no message nor radio contact from the pilot until the ETA in Wamena, the Flight Following Officer at Sentani informed to the other personnel at the operation base, and alarmed to the other YAJASI aircraft which were flying in that area to start search the PK-UCE. Some other aircrafts which were flying in the vicinity also contacted to search the PKUCE. PK-UCE was found in mountain location adjacent to Pass Valley airstrip. The accident site was at coordinate S 030 54’ 54.4’’, E 1390 02’ 24.3”, the aircraft was hit the trees and the ground where the elevation was about 7500 feet , the propeller blades was not on feather and bent rearward, the left wing was broken and the aircraft stopped on heading about 85°.
Probable cause:
The pilot decided to descend from the cruise altitude 10000 feet to penetrate the area of marginal weather was most likely not as what his perceive. The pilot avoided the cloud to the left of the VFR route guidance and most likely that the space available was less than the requirement stated for the Weather Minimum class F.
Final Report:

Crash of a Yakovlev Yak-42D in Yaroslavl: 44 killed

Date & Time: Sep 7, 2011 at 1600 LT
Type of aircraft:
Operator:
Registration:
RA-42434
Flight Phase:
Survivors:
Yes
Schedule:
Yaroslavl - Minsk
MSN:
4520424305017
YOM:
1993
Flight number:
AEK9633
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
37
Pax fatalities:
Other fatalities:
Total fatalities:
44
Captain / Total flying hours:
6954
Captain / Total hours on type:
1525.00
Copilot / Total flying hours:
13492
Copilot / Total hours on type:
613
Aircraft flight hours:
6490
Aircraft flight cycles:
3112
Circumstances:
The aircraft was chartered by the Lokomotiv Yaroslavl ice hockey team to carry his staff to Minsk to take part to the first game of the Russian 2011-2012 championship. During the takeoff roll from runway 23 at Yaroslavl-Tunoshna Airport, the crew selected flaps down at 20° and the stabilizer in a nose-up position of 8,7°. The aircraft slowly accelerated to 165 km/h due to a residual pressure on the brake pedal. At a speed of 185 km/h and at a distance of 1,350 metres from the runway end, the nose gear lifted off. But the aircraft continued, passed the runway end and rolled for about 400 metres before it took off. Then it collided with various approach lights and the localizer antenna, lost height and eventually crashed on the shore of the Volga River, bursting into flames, 2 minutes after the takeoff roll was initiated. A passenger and the flight engineer were seriously injured while 43 other occupants were killed. Almost a week later, the passenger died from his injuries. Among the passengers were 26 players from the Lokomotiv Yaroslavl ice hockey team, Russian citizens and also Canadian, Czech, Ukrainian, German and Slovak. The Canadian coach Brad McCrimmon, his both assistants, the cameraman, three masseurs, one admin and two doctors were among the victims.
Probable cause:
Erroneous actions on part of the crew, especially by applying brake pedal pressure just before rotation as result of a wrong foot position on the pedal during the takeoff run. This led to braking forces on the main gear requiring additional time for acceleration, a nose down moment preventing the crew to establish a proper rotation and preventing the aircraft to reach a proper pitch angle for becoming airborne, overrun of the runway at high speed with the elevator fully deflected for nose up rotation (producing more than double the elevator forces required to achieve normal takeoff rotation). The aircraft finally achieved a high rate of nose up rotation, became airborne 450 meters past the runway end and rotated up to a supercritical angle of attack still at a large rate of pitch up causing the aircraft to stall at low altitude, to impact obstacles and ground, break up and catch fire killing all but one occupants.
Contributing factors were:
- serious shortcomings in the re-training of the crew members with regards to the Yak-42, which did not take place in full, was spread out over a long period of time and took place while the crew remained in full operation on another aircraft type (Yak-40), which led to a negative transfer of skills, especially a wrong position of the foot on the brake pedal on the Yak-42,
- Lack of supervision of the re-training,
- errors and missed procedures by the crew in preparation and execution of the takeoff,
- inconsistent, uncoordinated actions by the crew in the final stages of the takeoff.
Final Report:

Crash of a Cessna 207 Skywagon near McGrath: 2 killed

Date & Time: Aug 13, 2011 at 1940 LT
Operator:
Registration:
N91099
Flight Phase:
Survivors:
Yes
Site:
Schedule:
McGrath - Anvik - Aniak
MSN:
207-0073
YOM:
1969
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
25000
Captain / Total hours on type:
10000.00
Aircraft flight hours:
31618
Circumstances:
The commercial pilot departed with five passengers on an on-demand air taxi flight between two remote Alaskan villages separated by mountainous terrain. When the airplane did not reach its destination, the operator reported the airplane overdue. After an extensive search, the airplane's wreckage was discovered in an area of steep, tree-covered terrain, about 1,720 feet msl, along the pilot's anticipated flight path. The flight was conducted under visual flight rules, but weather conditions in the area were reported as low ceilings and reduced visibility due to rain, fog, and mist. There is no record that the pilot obtained a weather briefing before departing. According to a passenger who was seated in the front, right seat, next to the pilot, about 20 minutes after departure, as the flight progressed into mountainous terrain, low clouds, rain and fog restricted the visibility. At one point, the pilot told the passenger, in part: "This is getting pretty bad." The pilot then descended and flew the airplane very close to the ground, then climbed the airplane, and then descended again. Moments later, the airplane entered "whiteout conditions," according to the passenger. The next thing the passenger recalled was looking out the front windscreen and, just before impact, seeing the mountainside suddenly appear out of the fog. A postaccident examination did not reveal any evidence of a mechanical malfunction. A weather study identified instrument meteorological conditions in the area at the time of the accident. Given the lack of mechanical deficiencies with the airplane and the passenger's account of the accident, it is likely that the pilot flew into instrument meteorological conditions while en route to his destination, and subsequently collided with mountainous terrain.
Probable cause:
The pilot's decision to continue visual flight rules flight into instrument meteorological conditions, which resulted in an in-flight collision with mountainous terrain.
Final Report:

Crash of a Cessna 207 Skywagon near Port Vila

Date & Time: Aug 1, 2011 at 1700 LT
Operator:
Registration:
YJ-FLY
Flight Phase:
Survivors:
Yes
Schedule:
Whitegrass - Port Vila
MSN:
207-0362
YOM:
1976
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft was performing a taxi flight from Whitegrass Airport located on Tannu Island, to Port Vila, with six passengers and a pilot on board. While approaching Efate Island, the pilot encountered poor weather conditions with heavy rain falls and attempted an emergency landing in the garden of the Lagon Resort, south of Port Vila. On touchdown, the airplane lost its nose gear and left main gear, cartwheeled and came to rest, broken in two. All occupants were slightly injured and the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-2 Beaver near Buss Lakes: 5 killed

Date & Time: Jun 30, 2011 at 1111 LT
Type of aircraft:
Registration:
C-GUJX
Flight Phase:
Survivors:
No
Schedule:
Buss Lakes - Southend
MSN:
1132
YOM:
1958
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
4023
Captain / Total hours on type:
3664.00
Aircraft flight hours:
12746
Circumstances:
The Lawrence Bay Airways Ltd. float-equipped de Havilland DHC-2 (registration C-GUJX, serial number 1132) departed from a lake adjacent to a remote fishing cabin near Buss Lakes for a day visual flight rules flight to Southend, Saskatchewan, about 37 nautical miles (nm) southeast. There were 4 passengers and 1 pilot onboard. The aircraft crashed along the shoreline of another lake located about 2 nm southeast of its point of departure. The impact was severe and the 5 occupants were killed on impact. The emergency locator transmitter activated, and the aircraft was found partially submerged in shallow water with the right wing tip resting on the shore. There was no post-crash fire. The accident occurred during daylight hours at about 1111 Central Standard Time.
Probable cause:
Findings as to Causes and Contributing Factors:
While manoeuvring at low level, the aircraft's critical angle of attack was likely exceeded and the aircraft stalled. The stall occurred at an altitude from which recovery was not possible.
Other Findings:
The separation of the propeller blade tip likely resulted from impact forces.
The investigation could not determine whether the fuel pressure warning light was illuminated prior to the accident.
Final Report:

Crash of an Embraer EMB-500 Phenom 100 in Sedona

Date & Time: May 25, 2011 at 1550 LT
Type of aircraft:
Operator:
Registration:
N224MD
Survivors:
Yes
Schedule:
San Jose - Sedona
MSN:
500-00057
YOM:
2009
Flight number:
RSP240
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
23970
Captain / Total hours on type:
570.00
Copilot / Total flying hours:
1886
Copilot / Total hours on type:
74
Aircraft flight hours:
1052
Circumstances:
Following an uneventful flight, the flight crew briefed the arrival to the destination airport and set the calculated landing speeds. The captain and the first officer reported that during final approach, it felt like the airplane was “pushed up” as the wind shifted to a tailwind or updraft before landing near the runway number markings. Upon touchdown, the captain applied the brakes and thought that the initial braking was effective; however, he noticed the airplane was not slowing down. The captain applied maximum braking, and the airplane began to veer to the right; he was able to correct back to the runway centerline, but the airplane subsequently exited the departure end of the runway and traveled down a steep embankment. A pilot-rated passenger reported that throughout the approach to landing, he thought the airplane was high and thought that the excessive altitude continued through and into the base-to-final turn. He added that the bank angle of this turn seemed greater than 45 degrees. Recorded communication from the cockpit voice and data recorder (CVDR) revealed that during the approach to landing, the flight crew performed the landing checks, and the captain noted difficulty judging the approach. About 1 minute later, the recording revealed that the ground warning proximity system reported “five hundred” followed by a “sink rate, pull up” alert about 16 seconds later. Data from the CVDR revealed that about 23 seconds before weight-on-wheels was recorded, the airplane was at an indicated airspeed of about 124 knots and descending. The data showed that this approximate airspeed was maintained until about 3 seconds before weight-on-wheels. The recorded data further showed that the approach speed was set to 120 knots, and the landing reference speed (vREF) was set to 97 knots. Using the reported airplane configuration and the 3.5-knot headwind that was reported at the time of the approach and landing, calculations indicate that the vREF speed should have been about 101 knots indicated airspeed, which would have required a landing distance of about 3,112 feet. Utilizing the same airplane configuration and wind condition with the flight’s reported 124 knot indicated airspeed just before touchdown, the landing distance was calculated to be about 5,624 feet. The intended runway for landing was 5,132-feet long with a 1.9 percent downward slope gradient, and a 123-foot long overrun area. A postaccident examination of the airplane, including the braking system, revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The pilot misjudged the airplane’s speed during the final approach, which resulted in runway overrun.
Probable cause:
The pilots’ unstabilized approach and excessive airspeed during approach, which resulted in an insufficient landing distance to stop the airplane before overrunning the runway.
Final Report:

Crash of a Cessna T207A Turbo Stationair 8 in Monument Valley

Date & Time: May 23, 2011 at 1520 LT
Operator:
Registration:
N803AN
Survivors:
Yes
Schedule:
Grand Canyon - Monument Valley
MSN:
207-0570
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
965
Captain / Total hours on type:
140.00
Aircraft flight hours:
13417
Circumstances:
According to the airplane's operator, the airplane was part of a flight of four airplanes that were taking an organized tour group of revenue passengers on a sightseeing tour of southern Utah. While operating in a high density altitude environment, the pilot was flying into an airport that had a 1,000-foot cliff about 400 feet from the end of the runway he was landing on. Because of the presence of the cliff, the Airguide Publications Airport Manual stated that all landings should be made on the runway that was headed toward the cliff and that all takeoffs should be made on the runway that was headed away from the cliff. The manual also stated that a go-around during landing was not possible. During his approach, the pilot encountered a variable wind and downdrafts. During the landing flare, the airplane dropped onto the runway hard and bounced back into the air. The pilot then immediately initiated a go-around and began a turn away from the runway heading. While in the turn, he was most likely unable to maintain sufficient airspeed, and the airplane entered a stall/mush condition and descended into the ground. A 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 decision to initiate a go-around after a bounced landing at an airport where go-arounds were not advised and his failure to maintain adequate airspeed during the go-around.
Final Report:

Crash of a Cessna 340A near Lobatera: 6 killed

Date & Time: Feb 22, 2011 at 1510 LT
Type of aircraft:
Registration:
YV2402
Flight Phase:
Survivors:
No
Site:
Schedule:
Valera – El Vigía – San Antonio del Táchira
MSN:
340A-1502
YOM:
1982
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The twin engine aircraft departed Valera Airport on a charter flight to San Antonio del Táchira with an intermediate stop in El Vigía, carrying five passengers and one pilot. All flight was completed under VFR mode but while descending to San Antonio del Táchira, weather conditions worsened and the pilot switched to IFR mode. Shortly later, control was lost and the aircraft crashed on the slope of Mt Laja, near Lobatera. The wreckage was found about 25 km northeast of San Antonio del Táchira Airport. The aircraft disintegrated on impact and all six occupants were killed.
Probable cause:
The most probable cause for the occurrence of this accident was the loss of situational awareness, caused mainly by the change of flight conditions under visual rules to flight under instrumental flight rules, due to the adverse weather conditions in which the descent phase began, so it is possible to establish the Human Factor as the cause of the accident and the Physical Factor as a contributor.