Crash of a Piper PA-31 Navajo Chieftain in Darwin

Date & Time: Feb 6, 2009 at 0840 LT
Operator:
Registration:
VH-TFX
Flight Phase:
Survivors:
Yes
Schedule:
Darwin – Maningrida
MSN:
31-8152143
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Darwin Airport, while in initial climb, one of the engine failed. The pilot declared an emergency and elected to return but eventually attempted to ditch the aircraft that came to rest in shallow water about 200 metres offshore. All six occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-6 Twin Otter 100 in La Ronge

Date & Time: Feb 4, 2009 at 0915 LT
Operator:
Registration:
C-FCCE
Flight Phase:
Survivors:
Yes
Schedule:
La Ronge – Deschambeault Lake
MSN:
8
YOM:
1966
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14000
Captain / Total hours on type:
11000.00
Copilot / Total flying hours:
625
Copilot / Total hours on type:
425
Circumstances:
The aircraft was taking off from a ski strip east of and parallel to Runway 36 at La Ronge. After the nose ski cleared the snow, the left wing rose and the aircraft veered to the right and the captain, who was the pilot flying, continued the take-off. The right ski, however, was still in contact with the snow. The aircraft became airborne briefly as it cleared a deep gully to the right of the runway. The aircraft remained in a steep right bank and the right wing contacted the snow-covered ground. The aircraft flew through a chain link fence and crashed into trees surrounding the airport. The five passengers and two crewmembers evacuated the aircraft with minor injuries. There was a small fire near the right engine exhaust that was immediately extinguished by the crew.
Probable cause:
Findings as to Causes and Contributing Factors:
1. Contamination on the wings of the aircraft was not fully removed before take-off. It is likely that asymmetric contamination of the wings created a lift differential and a loss of lateral control.
2. Although the operator was not authorized for short take-off and landing (STOL) take-off on this aircraft, the crew conducted a STOL take-off, which reduced the aircraft’s safety margin relative to its stalling speed and minimum control speed.
3. As a result of the loss of lateral control, the slow STOL take-off speed, and the manipulation of the flaps, the aircraft did not remain airborne and veered right, colliding with obstacles beside the ski strip.
Findings as to Risk:
1. The out of phase task requirements regarding the engine vibration isolator assembly, as listed in the operator’s maintenance schedule approval, results in a less than thorough inspection requirement, increasing the likelihood of fatigue cracks remaining undetected.
2. The right engine inboard and top engine mounts had pre-existing fatigue cracks, increasing the risk of catastrophic failure.
Other Findings:
1. The cockpit voice recorder (CVR) contained audio of a previous flight and was not in operation during the occurrence flight. Minimum equipment list (MEL) procedures for logbook entries and placarding were not followed.
2. The Transwest Air Limited safety management system (SMS) did not identify deviations from standard operating procedures.
Final Report:

Crash of a Beechcraft F90-1 King Air in Mamuno

Date & Time: Jan 21, 2009
Type of aircraft:
Operator:
Registration:
A2-AHV
Survivors:
Yes
MSN:
LA-212
YOM:
1983
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Mamuno Airstrip, the pilot decided to initiate a go-around procedure. After the undercarriage were raised, the twin engine aircraft continued to descent and hit the runway surface. It slid for few dozen metres then veered off runway to the left and came to rest in a grassy area. The high engine temperature set the grass on fire and the aircraft was destroyed by fire. There were no injuries among the occupants.

Crash of a Gulfstream G200 in Oradea

Date & Time: Jan 16, 2009 at 1535 LT
Type of aircraft:
Operator:
Registration:
YR-TIG
Survivors:
Yes
Schedule:
Bucharest - Oradea
MSN:
012
YOM:
1999
Flight number:
TIH101
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13000
Captain / Total hours on type:
2000.00
Copilot / Total flying hours:
1600
Copilot / Total hours on type:
465
Circumstances:
Following an uneventful flight from Bucharest-Otopeni Airport, the crew started the approach to Oradea Airport in marginal weather conditions. On final approach, the pilot-in-command established a visual contact with the runway 19 and continued the descent. The aircraft landed 761 metres past the runway threshold. After touchdown, it was unable to stop within the remaining distance, overran and came to rest in a drainage ditch located 420 metres short of runway 01 threshold. All 13 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The contrast between the area covered with snow and the snow-cleared area (the runway) induced the pilots visual sensation about the runway threshold. This caused the crew to miscalculate the touchdown point, causing the aircraft to land too far down the runway.
Final Report:

Crash of a Cessna 550 in Wilmington

Date & Time: Jan 4, 2009 at 0209 LT
Type of aircraft:
Operator:
Registration:
N815MA
Survivors:
Yes
Schedule:
La Isabela - Wilmington
MSN:
550-0406
YOM:
1982
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6914
Captain / Total hours on type:
1400.00
Copilot / Total flying hours:
1717
Aircraft flight hours:
11123
Circumstances:
During a night, northbound, international over water flight that paralleled the east coast of the southeast United States, the airplane encountered headwinds. Upon arrival at the intended destination, the weather was below forecasted conditions, resulting in multiple instrument approach attempts. After the first missed approach, the controller advised the crew that there was an airport 36 miles to the north with "much better" weather, but the crew declined, citing a need to clear customs. During the third missed approach, the left engine lost power, and while the airplane was being vectored for a fourth approach, the right engine lost power. Utilizing the global positioning system, the captain pointed the airplane toward the intersection of the airport's two runways. Approximately 50 feet above the ground, he saw runway lights, and landed. The captain attempted to lower the landing gear prior to the landing, but it would not extend due to a lack of hydraulic pressure from the loss of engine power, and the alternate gear extension would not have been completed in time. The gear up landing resulted in damage to the underside of the fuselage and punctures of the pressure vessel. The captain stated that the airplane arrived in the vicinity of the destination with about 1,000 pounds of fuel on board or 55 minutes of fuel remaining. However, air traffic and cockpit voice recordings revealed that the right engine lost power about 14 minutes after arrival, and the left engine, about 20 minutes after arrival. Federal air regulations require, for an instrument flight rules flight plan, that an airplane carry enough fuel to complete the flight to the first airport of landing, fly from that airport to an alternate, and fly after that for 45 minutes at normal cruising speed. The loss of engine power was due to fuel exhaustion, with no preaccident mechanical anomalies noted to the airplane.
Probable cause:
A loss of engine power due to the crew's inadequate in-flight fuel monitoring.
Final Report:

Crash of a Britten-Norman BN-2A Trislander off Providenciales: 12 killed

Date & Time: Dec 15, 2008 at 1645 LT
Type of aircraft:
Registration:
N650LP
Flight Phase:
Survivors:
No
Schedule:
Santiago de los Caballeros – Mayaguana – New York
MSN:
1029
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
12
Circumstances:
The aircraft was making a charter flight from Santiago de los Caballeros to New York with an intermediate stop at Mayaguana, Bahamas. The flight departed Santiago-Cibao Airport, Dominican Republic, at 1605LT. Thirty-five minutes later, while cruising off the Turks & Caicos Islands, the pilot sent a brief mayday message and the aircraft crashed 25 km off Providenciales. SAR teams and US Coast Guards did not find any trace of the aircraft nor the 12 occupants. A spokesman from the Dominican Pilots Association later reported that the pilot's licence had been suspended in October 2006.

Crash of a Dornier DO228-202 in Cambridge Bay

Date & Time: Dec 13, 2008 at 0143 LT
Type of aircraft:
Operator:
Registration:
C-FYEV
Survivors:
Yes
Schedule:
Resolute Bay - Cambridge Bay
MSN:
8133
YOM:
1987
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13400
Captain / Total hours on type:
802.00
Copilot / Total flying hours:
850
Copilot / Total hours on type:
470
Circumstances:
The Summit Air Charters Dornier 228-202 was on a charter flight from Resolute Bay to Cambridge Bay, Nunavut, under instrument flight rules. While on final approach to Runway 31 True, the aircraft collided with the ground approximately 1.5 nautical miles from the threshold at 0143 mountain standard time. Of the 2 pilots and 12 passengers on board, 2 persons received serious injuries. The aircraft was substantially damaged. The emergency locator transmitter activated, and the crew notified the Cambridge Bay Airport radio operator of the accident via the aircraft radio. Local ground search efforts found the aircraft within 30 minutes, and all occupants were removed from the site within two hours.
Probable cause:
Findings as to Causes and Contributing Factors:
1. An abbreviated visual approach was conducted at night in instrument meteorological conditions, which resulted in the flight crew’s inability to obtain sufficient visual reference to judge their height above the ground.
2. The flight crew did not monitor pressure altimeter readings or reference the minimum altitude requirements in relation to aircraft position on the approach, resulting in controlled flight into terrain.
3. The pilots had not received training and performance checks for the installed global positioning system (GPS) equipment, and were not fully competent in its use. The attempts at adjusting the settings likely distracted the pilots from maintaining the required track and ground clearance during the final approach.
Findings as to Risk:
1. The precision approach path indicator systems (PAPI) at Cambridge Bay had not been inspected in accordance with the Airport Safety Program Manual. Although calibration of the equipment did not have a bearing on this occurrence, there was an increased risk of aircraft misalignment from the proper glide path, especially during night and reduced visibility conditions.
2. The flight crew’s cross-check of barometric altimeter performance was not sufficient to detect which instrument was inaccurate. As a result, reference was made to a defective altimeter, which increased the risk of controlled flight into terrain.
3. Operators’ maintenance organizations normally do not have access to the troubleshooting information contained in Component Maintenance Instruction Manuals for the Intercontinental Dynamics Corporation altimeters. Therefore, aircraft could be dispatched with damaged instruments with the potential for developing a loss of calibration during flight.
4. The flight was conducted during a period in which the crew’s circadian rhythm cycle could result in cognitive and physical performance degradation unless recognized and managed.
Final Report:

Crash of a Rockwell Grand Commander 690B in the El Yunque National Forest: 3 killed

Date & Time: Dec 3, 2008 at 1205 LT
Operator:
Registration:
N318WA
Flight Phase:
Survivors:
No
Site:
Schedule:
Tortola – San Juan
MSN:
690-11444
YOM:
1978
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
9600
Aircraft flight hours:
5286
Circumstances:
The charter flight departed for the destination, where the passengers would connect with another airline flight. The instrument-rated pilot may have felt pressured as the flight departed late. The accident airplane approached the destination airport from the east, descending at 250 knots ground speed from 8,800 feet above mean sea level (msl), on a 270 degree assigned heading, and was instructed to enter the right downwind for runway 10. The airplane's altitude readout was then observed by the approach controller to change to "XXX." The pilot was queried regarding his altitude and he advised that he was descending to 3,200 feet msl. The pilot was asked to confirm that he was in visual flight rules (VFR) conditions and was advised that the minimum vectoring altitude (MVA) for the area was 5,500 feet msl. The pilot responded that “We just ahh,” at which time the controller advised that she missed his transmission and asked him to repeat it. The pilot stated “Ahh roger, could we stay right just a little, we are in and out of some clouds right now.” The controller advised the pilot to “Maintain VFR” and again of the MVA. The controller then made multiple attempts to contact the pilot without result. The wreckage was discovered on the side of a mountain, where the airplane impacted after entering instrument meteorological conditions. Because aircraft operating in VFR flight are not required to comply with minimum instrument altitudes, aircraft receiving VFR radar services are not automatically afforded Minimum Safe Altitude Warning services except by pilot request. The controller's query to the pilot about his altitude and flight conditions was based on her observation of the loss of altitude reporting information. The pilot had not indicated any difficulty in maintaining VFR flight or terrain clearance up to that point. His comment that the aircraft was "in and out of some clouds" was her first indication that the pilot was not operating in visual conditions, and came within seconds of impact with the terrain. The controller was engaged in trying to correct the situation, and despite having been advised of the minimum vectoring altitude, the pilot continued to descend. The airplane was equipped with a terrain avoidance warning system but it could not be determined if it was functional. The pilot owned the charter operation. Documents discovered in the wreckage identified the pilot and airplane as operating for a different company since the pilot did not have the permissions necessary to operate in the United Kingdom Overseas Territories.
Probable cause:
The pilot's continued visual flight into instrument meteorological conditions, which resulted in an in-flight collision with terrain.
Final Report:

Crash of a Falcon 900EX EASy in Brindisi

Date & Time: Nov 28, 2008 at 1900 LT
Type of aircraft:
Operator:
Registration:
I-FLYI
Survivors:
Yes
Schedule:
Athens - Rome
MSN:
204
YOM:
2008
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
100
Circumstances:
The aircraft was on its way from Athens-Elefterios Venizelos Airport to Rome with 3 passengers and 3 crew members on board. While at cruising level over the Adriatic Sea, the crew informed ATC about burn smell on board (possible smoke), declared an emergency and elected to divert to Brindisi-Papola Casale Airport. Upon arrival at Brindisi, weather conditions were poor with rain showers and strong crosswinds. In the meantime, the runway 14/32 (3,330 meters long) was closed to traffic due to works in progress. After landing on runway 23, the aircraft skidded, veered off runway and lost its right main gear before coming to rest. Three occupants were evacuated to local hospital with minor injuries while the aircraft was damaged beyond repair due to severe damages to the right wing and the right part of the fuselage. Brand new, it was delivered this year and completed 100 flying hours only.

Crash of a Beechcraft 200 Super King Air in Recife: 2 killed

Date & Time: Nov 23, 2008 at 1115 LT
Operator:
Registration:
PT-OSR
Survivors:
Yes
Site:
Schedule:
Teresina - Recife
MSN:
BB-784
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
10000
Circumstances:
Following an uneventful flight from Teresina, the crew started the approach to Recife-Guararapes Airport runway 18. On final, both engines failed simultaneously. The aircraft stalled and crashed in a residential area located 5 km from the runway threshold. A passenger and a pilot were killed while eight others occupants were injured. There were no victims on the ground while the aircraft was destroyed.
Probable cause:
Double engine failure caused by a fuel exhaustion. The following contributing factors were identified:
- Poor flight planning,
- The crew failed to add sufficient fuel prior to departure from Teresina Airport,
- The fuel quantity was insufficient for the required distance,
- The crew failed to follow the published procedures,
- Overconfidence from the crew,
- Poor organisational culture on part of the operator,
- Lack of discipline and poor judgment on part of the crew,
- Lack of supervision.
Final Report: