Crash of a BAe 125-800B in Minsk: 5 killed

Date & Time: Oct 26, 2009 at 2134 LT
Type of aircraft:
Operator:
Registration:
RA-02807
Survivors:
No
Schedule:
Moscow - Minsk
MSN:
258076
YOM:
1986
Flight number:
RLS9607
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
11926
Captain / Total hours on type:
811.00
Copilot / Total flying hours:
2356
Copilot / Total hours on type:
811
Aircraft flight hours:
12751
Aircraft flight cycles:
7979
Circumstances:
Following an uneventful flight from Moscow-Vnukovo Airport, the crew started a night approach to Minsk-2 Airport runway 31. On approach, the crew encountered poor visibility due to marginal weather. The 'Pull Up' alarm sounded and the captain initiated a go-around procedure. Few minutes later, the crew attempted a second approach to land. At an altitude of about 550 metres, the crew realized he was on the wrong ILS frequency and corrected it. On final, the EGPWS alarm sounded for 35 seconds but the captain decided to continue the approach until the aircraft impacted trees and crashed in a wooded area located 3 km short of runway, bursting into flames. The aircraft was destroyed by a post crash fire and all five occupants were killed.
Probable cause:
The cause of the crash of BAe-125-800B RA-02807 during the ILS approach procedure at night, in weather conditions that met ICAO CAT I, was the failure to take timely action by the crew to carry out a missed approach, or divert to an alternate, when the ground could not be seen while descending below decision height during a transition to visual flight, and the lack of a proper response and action required when the TAWS alarm repeatedly sounded, which led to the collision of the aircraft with obstacles (forest) and land in a controlled flight (CFIT), its destruction and death of people on board.

Contributing factors were:
- Deficiencies in the type of retraining and training of the flight crew, especially in the use of automatic flight modes, and flight director;
- Erroneous actions of the captain, which led to an execution of the approach with the wrong ILS frequency set on the left set;
- Lack of preparation of the commander of the plane for an approach in weather conditions that meet CAT I ICAO.
Values of meteorological conditions in the flight log were in most cases were falsified;
- Poor communication and crew resource management (CRM) of the flightcrew;
- Poor control of the level of training of the crew by the airline's management and lack of organization in the airline's flight operations;
- Psychological characteristics of the pilots, unrecorded in the formation of the crew and, possibly, reduced efficiency of the captain in a stressful situation because of chronic ischemic heart disease with coronary artery problems, which was not detected when passing aviation medical checks.
Final Report:

Crash of a Cessna 208 Caravan I in Sheffield

Date & Time: Sep 15, 2009 at 1435 LT
Type of aircraft:
Operator:
Registration:
N336DN
Flight Phase:
Survivors:
Yes
Schedule:
Farmingdale - Saratoga Springs
MSN:
208-0001
YOM:
1985
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3100
Captain / Total hours on type:
25.00
Aircraft flight hours:
10182
Circumstances:
The pilot and the five passengers, who were employees of an industrial services company, were returning from a job site with hazardous materials used for blasting operations. The airplane was in a climb, at an altitude of 8,500 feet, when it experienced a catastrophic engine failure. The pilot declared an emergency and subsequently performed a forced landing to a field. During the landing, the airplane's right wing struck a tree and separated. All occupants exited the airplane without injury; however, the airplane became fully engulfed in fire, which consumed the majority of the airplane. The airplane was equipped with a turbine engine that, at the time of the accident, had been operated for about 7,620 hours since new and 65 hours since it was overhauled about 19 months prior to the accident. Impact damage was observed to the interior of the engine exhaust duct. In addition, the exhaust duct contained portions of a fractured power turbine blade. Additional examination of the engine revealed damage consistent with a distressed 1st stage sun gear, and associated compressor turbine and power turbine damage. Examination of the sun gear teeth output splines revealed that they were too damaged to determine the cause of their deterioration. It was noted that the sun gear found on the accident engine was previously removed from another engine due to "spalled gear teeth" about 7 years prior to the accident. The condition of the sun gear when installed on the accident engine could not be determined.
Probable cause:
A total loss of engine power due to a failure of the 1st stage sun gear output splines for unknown reasons, which resulted in a power turbine overspeed condition, with subsequent blade distress/release.
Final Report:

Crash of a Britten-Norman BN-2A-6 Islander off Caracas

Date & Time: Aug 16, 2009 at 1806 LT
Type of aircraft:
Registration:
YV212T
Survivors:
Yes
Schedule:
Los Roques – Caracas
MSN:
171
YOM:
1970
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
10187
Circumstances:
The twin engine airplane departed Los Roques on a charter flight to Caracas with nine passengers and one pilot on board. While approaching Caracas-Maiquetía-Simón Bolívar Airport, at a distance of about 13 km, the pilot was cleared to descend to 1,500 feet where he completed two circuits. After being cleared to descend to 1,000 feet, he flew two other circuits as he was n°7 on approach. While descending at an altitude of 600 feet, both engines failed simultaneously. The pilot ditched the aircraft some 4 km off the airport. All 10 occupants were rescued, among them three were injured. The aircraft was damaged beyond repair.
Probable cause:
Double engine failure on approach caused by a fuel exhaustion. Poor flight preparation and planning on part of the pilot who miscalculated the fuel consumption for the required trip.
Final Report:

Crash of a Noorduyn Norseman IV in Akiachak

Date & Time: Jul 11, 2009 at 1300 LT
Type of aircraft:
Operator:
Registration:
N225BL
Survivors:
Yes
Schedule:
Bethel – Tuluksak
MSN:
542
YOM:
1944
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8500
Captain / Total hours on type:
100.00
Aircraft flight hours:
15729
Circumstances:
The airline transport pilot was on a Title 14, CFR Part 135 passenger flight. The pilot said during cruise flight he heard a loud bang, and the engine started running rough. He said he diverted to the nearest airport, but the engine quit completely, and he was unable to reach the runway. The airplane subsequently collided with terrain, sustaining substantial damage to both wings and the fuselage. An examination of the engine revealed that a locking screw had backed out of one of the anti-vibration counterweights on the crankshaft, scoring the interior back surface of the engine case. The unsecured counterweight then moved from its position in the crankshaft, and was likely struck by the engine's master rod, which shattered the weight, and liberated it from its normal location. The liberated counterweight was struck by internal moving parts, creating several component failures, and ultimately an engine seizure.
Probable cause:
The loss of engine power due to the failure of a crankshaft component, resulting in an off airport landing.
Final Report:

Crash of a Let L-410UVP-E in Capurganá

Date & Time: Jun 26, 2009 at 1726 LT
Type of aircraft:
Operator:
Registration:
HK-4094
Survivors:
Yes
Schedule:
Medellín – Capurganá
MSN:
86 17 07
YOM:
1986
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16100
Captain / Total hours on type:
244.00
Copilot / Total flying hours:
1030
Copilot / Total hours on type:
556
Aircraft flight hours:
11771
Circumstances:
The twin engine aircraft departed Medellín-Enrique Olaya Herrera Airport at 1610LT on a charter flight to Capurganá, carrying 16 passengers and two pilots. After landing on runway 03 at Capurganá-Narcisa Navas Airport, the aircraft deviated to the left. It veered off runway, rolled through a grassy area then collided with a perimeter fence and came to rest against a tree. All 18 occupants were rescued, among them three were injured, the captain seriously. The aircraft was destroyed.
Probable cause:
Loss of control after touchdown following the execution of an unstabilized approach. The following contributing factors were identified:
- Low situational awareness on part of the crew during the approach and landing procedures,
- Pilot fatigue,
- Absence of sterile cockpit,
- Total ignorance of the crew regarding the landing distance needed.
Final Report:

Crash of a Cessna 207 Skywagon in Crooked Creek

Date & Time: Jun 16, 2009 at 1620 LT
Operator:
Registration:
N1623U
Survivors:
Yes
Schedule:
Aniak – Sleetmute – Crooked Creek
MSN:
207-0223
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1388
Captain / Total hours on type:
486.00
Aircraft flight hours:
9089
Circumstances:
The commercial pilot was on a Title 14, CFR Part 91, other work use flight when the accident occurred. As he approached his destination airport, he said he saw a large rain squall moving over the airport, and he elected to remain south of the airport to allow time for it to move. He reported that while maneuvering the airplane at 1,000 feet msl, all engine power was lost. Unable to restore engine power, the pilot selected a marshy tree-covered area as a forced landing site. The airplane sustained substantial damage to the fuselage during the forced landing. The NTSB discovered no mechanical problems with the engine during a postaccident teardown and examination.
Probable cause:
A total loss of engine power for an undetermined reason.
Final Report:

Crash of a Douglas DC-10-30ER in Baltimore

Date & Time: May 6, 2009 at 1302 LT
Type of aircraft:
Operator:
Registration:
N139WA
Survivors:
Yes
Schedule:
Leipzig – Baltimore
MSN:
46583/292
YOM:
1979
Flight number:
WOA8535
Crew on board:
12
Crew fatalities:
Pax on board:
168
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6500
Captain / Total hours on type:
193.00
Copilot / Total flying hours:
6300
Copilot / Total hours on type:
373
Aircraft flight hours:
107814
Circumstances:
The flight was conducting a straight-in approach during visual meteorological conditions. The approach was backed up by an ILS and was stable at 500 feet above touchdown. The initial touchdown was firm and main landing gear rebounded, possibly bouncing slightly off the runway. Control column input and possibly momentum from the touchdown resulted in a rapid pitch down and hard nose gear impact with the runway. Wing spoilers likely did not deploy due to the main gear bounce and/or throttle position. Following the nose gear impact, the airplane pitched up as expected and the column was held in a slightly forward position. Airspeed rapidly decayed, and engine power began to increase as the airplane pitch reversed to a downward motion for a second time. One of the crew, likely the FO, called “flare flare” and the column recorded a rapid nose up input, followed by a rapid nose down input, and the nose gear again struck the runway very hard, likely causing the majority of the damage at that point. Following the second nose gear impact, column inputs stabilized at a slightly nose up command, power was set on all three engines, and the go-around was successfully executed. A slight lag in the power increase on engine number 3 may have contributed to the nose down motion leading to the second nose gear impact, although the large forward (airplane nose down) column movement appears to be a much more significant contributor. It is unclear why the engine was slower to increase. Throttle lever angle was not recorded, but the engine operated as expected for all other phases of the flight, including after the impact, therefore it is possible the pilot did not advance the number 3 throttle concurrently with the others. The captain’s flight and duty schedule complied with Federal Aviation regulations, but he experienced a demanding 10-day trip schedule prior to the incident involving multiple time zone crossings and several long duty periods, and reported difficulties sleeping prior to the accident leg. The captain was likely further affected by a digestive system upset during the accident flight. It is likely that the captain’s performance was degraded by fatigue and some degree of physical discomfort brought on by a short-term illness. The captain had recently completed upgrade training to DC-10, having previously been flying as an MD-11 first officer. The training program was fragmented over approximately ten months, and while in accordance with FAA regulations, may have adversely affected his consolidation of skills and experience.
Probable cause:
The captain’s inappropriate control inputs following a firm landing, resulting in two hard nose-gear impacts before executing a go-around. Contributing to the inappropriate control inputs was the captain’s fatigue and physical discomfort; and a possible lack of practical consolidation of skills and experience due to a protracted and fragmented training period.
Final Report:

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

Date & Time: Apr 17, 2009 at 1545 LT
Type of aircraft:
Operator:
Registration:
YV1181
Flight Phase:
Survivors:
Yes
Schedule:
Canaima – Ciudad Bolívar
MSN:
208B-0695
YOM:
1998
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3404
Captain / Total hours on type:
1021.00
Copilot / Total flying hours:
269
Copilot / Total hours on type:
59
Aircraft flight hours:
15753
Circumstances:
After takeoff from runway 36 at Canaima Airport, while in initial climb, the single engine aircraft encountered difficulties to gain height. It collided with power lines and crashed in bushes located 80 metres past the runway end. A young boy aged 6 was killed while all other occupants were injured, seven seriously. The aircraft was destroyed.
Probable cause:
The accident occurred as a result of the inability of the aircraft to take off, affected by the tailwind and water puddles that covered part of the runway, which did not allow speed to build up, crashing into the ground. It is considered that the most likely cause of the accident was mismanagement by the crew, in the sense of failing to make adequate planning and analysis, coupled with overconfidence and lack of identification of hazardous conditions at that time of takeoff. Based on our [JIAAC] investigations, we can infer that there were several contributing causes for the occurrence of this accident. In this order, we can state the following:
- Adverse weather and tailwind conditions associated with the phenomenon.
- Incorrect management by the crew to use only the last third of the runway with the meteorological conditions prevailing at that time.
- Failure of the aerodrome administration to identify and correct poor drainage of the runway.
- Failure of the Autoridad Aeronáutica to monitor safety.
- Rejection by the crew of the concatenated form in which the factors involved in this event developed.
After all the analysis to different causes involved in this accident, we can point to as the main Causal Factor: Human Factor, due to the mismanagement by the flight crew upon takeoff in these conditions. Physical and Material factors included everything related to the prevailing weather conditions, road conditions and lack of services at the aerodrome by the authorities; all of them are considered Contributing Factors.
Final Report:

Crash of a Pilatus PC-6/B2-H4 Turbo Porter near Mulia: 11 killed

Date & Time: Apr 17, 2009 at 1015 LT
Operator:
Registration:
PK-LTJ
Flight Phase:
Survivors:
No
Site:
Schedule:
Ilaga - Mulia
MSN:
959
YOM:
2008
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
11
Captain / Total flying hours:
2664
Captain / Total hours on type:
1412.00
Aircraft flight hours:
542
Circumstances:
On the morning of 17 April 2009, a Pilatus PC-6/B2-H4 Turbo Porter aircraft, registered PK-LTJ, operated by PT. Mimika Air, charter flight from Ilaga to Mulia in the Puncak Jaya District of Papua. The Mimika Local Government owned the aircraft. There were 11 people on board; one pilot, one observer, and nine passengers comprised of eight adults and one infant. The aircraft was also carrying National Government election boxes. The flight in accordance with the visual flight rules was estimated to take 18 minutes. There was no record of communication with the aircraft during the flight. Two minutes after the estimated time of arrival, when the Porter had not arrived, a search was commenced. On 18 April, search aircraft located the wreckage of the Porter at an elevation of about 12,000 feet on Mt Gergaji. The location was on the direct track between Ilaga and Mulia. The aircraft impacted the ground in an inverted attitude, and was destroyed by the impact forces and the post-impact fire. All occupants were fatally injured. The weather in the valleys along the route was mostly clear, with cloud on the mountains. The route flown by the pilot was the direct track, which passed over a mountain range, with a high peak adjacent to, and west of the track at about the midway point, at 13,700 feet. The investigation determined that it was likely that the pilot had flown the aircraft into cloud and lost control of the aircraft in instrument meteorological conditions. The impact signature was consistent with uncontrolled flight at the time of impact. This probably resulted from the pilot becoming spatially disoriented after entering cloud.
Probable cause:
The pilot may not have had adequate knowledge of the route and weather conditions, and may have been relying on Global Positioning System navigation, and was attempting to climb on the direct track over Mt Gergaji. It was likely that the pilot became spatially disoriented after entering cloud while operating under visual flight procedures, leading to a loss of control and uncontrolled impact with terrain.
Final Report:

Crash of a Britten-Norman BN-2A-26 Islander near Tuguegarao: 7 killed

Date & Time: Apr 2, 2009
Type of aircraft:
Operator:
Registration:
RP-C764
Flight Phase:
Survivors:
No
Site:
Schedule:
Tuguegarao – Maconacon
MSN:
318
YOM:
1973
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The twin engine aircraft departed Tuguegarao Airport at 0855LT on a charter flight to Maconacon, carrying five passengers and two pilots. Weather conditions at departure were considered as good. As the airplane failed to arrive at destination, SAR operations were initiated. The wreckage was found 13 days later in a wooded and hilly terrain located about 30 km southeast of Tuguegarao. The aircraft was destroyed and all 7 occupants were killed. It is believed that weather conditions deteriorated en route and that the mountain was shrouded in clouds.