Crash of an Embraer EMB-120 Brasília in Somalia

Date & Time: Feb 14, 2019
Type of aircraft:
Operator:
Registration:
5Y-FAU
Survivors:
Yes
MSN:
120-194
YOM:
1990
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The left main gear collapsed after the airplane landed on a gravel airstrip located somewhere in Somalia. There were no injuries among the occupants and the airplane was damaged beyond repair.
Probable cause:
Failure of the left main gear upon landing on a gravel airstrip.

Crash of a Cessna 208 Caravan I near Caracaraí

Date & Time: Feb 9, 2019 at 1040 LT
Type of aircraft:
Operator:
Registration:
PR-RTA
Survivors:
Yes
Schedule:
Manaus - Caracaraí
MSN:
208-0380
YOM:
2004
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine floatplane departed Manaus-Eduardo Gomes Airport on a charter flight to the area of the Xeriuini River near Caracaraí, carrying eight passengers and two pilots bound for a fish camp. Due to the potential presence of obstacles in the river due to low water level, the crew decided to land near the river bank. After landing, the left wing impacted a tree and the aircraft rotated to the left and came to rest against trees on the river bank. All 10 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The following findings were identified:
- Attention,
- Judgment,
- Perception,
- Management planning,
- Decision making processes,
- Organization processes,
- Support systems.
Final Report:

Crash of a Piper PA-46-310P Malibu off Guernsey: 2 killed

Date & Time: Jan 21, 2019 at 2016 LT
Operator:
Registration:
N264DB
Flight Phase:
Survivors:
No
Schedule:
Nantes - Cardiff
MSN:
46-8408037
YOM:
1984
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3500
Captain / Total hours on type:
30.00
Aircraft flight hours:
6636
Circumstances:
The pilot of N264DB flew the aircraft and the passenger from Cardiff Airport to Nantes Airport on 19 January 2019 with a return flight scheduled for 21 January 2019. The pilot arrived at the airport in Nantes at 1246 hrs on 21 January to refuel and prepare the aircraft for the flight. At 1836 hrs the passenger arrived at airport security, and the aircraft taxied out for departure at 1906 hrs with the passenger sitting in one of the rear, forward-facing passenger seats. Figure 1 shows the aircraft on the ground before departure. The pilot’s planned route would take the aircraft on an almost direct track from Nantes to Cardiff, flying overhead Guernsey en route (Figure 2). The Visual Flight Rules (VFR) flight plan indicated a planned cruise altitude of 6,000 ft amsl and distance of 265 nm. The aircraft took off from Runway 03 at Nantes Airport at 1915 hrs, and the pilot asked Air Traffic Control (ATC) for clearance to climb to 5,500 ft. The climb was approved by Nantes Approach Control and the flight plan was activated. The aircraft flew on its planned route towards Cardiff until it was approximately 13 nm south of Guernsey when the pilot requested and was given a descent clearance to remain in Visual Meteorological Conditions (VMC). Figure 3 shows the aircraft’s subsequent track. The last radio contact with the aircraft was with Jersey ATC at 2012 hrs, when the pilot asked for a further descent. The aircraft’s last recorded secondary radar point was at 2016:34 hrs, although two further primary returns were recorded after this. The pilot made no distress call that was recorded by ATC. On February 4, 2019, the wreckage (relatively intact) was found at a depth of 63 meters few km north of the island of Guernsey. On February 6, a dead body was found in the cabin and recovered. It was later confirmed this was the Argentine footballer Emiliano Sala. The pilot's body was not recovered.
Probable cause:
Causal factors
1. The pilot lost control of the aircraft during a manually-flown turn, which was probably initiated to remain in or regain VMC.
2. The aircraft subsequently suffered an in-flight break-up while manoeuvring at an airspeed significantly in excess of its design manoeuvring speed.
3. The pilot was probably affected by CO poisoning.
Contributory factors
1. A loss of control was made more likely because the flight was not conducted in accordance with safety standards applicable to commercial operations. This manifested itself in the flight being operated under VFR at night in poor weather conditions despite the pilot having no training in night flying and a lack of recent practice in instrument flying.
2. In-service inspections of exhaust systems do not eliminate the risk of CO poisoning.
3. There was no CO detector with an active warning in the aircraft which might have alerted the pilot to the presence of CO in time for him to take mitigating action.
Final Report:

Crash of a Dassault Falcon 50 in Greenville: 2 killed

Date & Time: Sep 27, 2018 at 1346 LT
Type of aircraft:
Registration:
N114TD
Survivors:
Yes
Schedule:
St Petersburg - Greenville
MSN:
17
YOM:
1980
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
11650
Copilot / Total flying hours:
5500
Aircraft flight hours:
14002
Circumstances:
The flight crew was operating the business jet on an on-demand air taxi flight with passengers onboard. During landing at the destination airport, the cockpit voice recorder (CVR) recorded the sound of the airplane touching down followed by the pilot's and copilot's comments that the brakes were not operating. Air traffic controllers reported, and airport surveillance video confirmed, that the airplane touched down "normally" and the airplane's thrust reverser deployed but that the airplane continued down the runway without decelerating before overrunning the runway and impacting terrain. Postaccident examination of the airplane's brake system revealed discrepancies of the antiskid system that included a broken solder joint on the left-side inboard transducer and a reversal of the wiring on the right-side outboard transducer. It is likely that these discrepancies resulted in the normal braking system's failure to function during the landing. Before the accident flight, the airplane had been in long-term storage for several years and was in the process of undergoing maintenance to bring the airplane back to a serviceable condition, which in-part required the completion of several inspections, an overhaul of the landing gear, and the resolution of over 100 other unresolved discrepancies. The accident flight and four previous flights were all made with only a portion of this required maintenance having been completed and properly documented in the airplane's maintenance logs. A pilot, who had flown the airplane on four previous flights along with the accident pilot (who was acting as second-in-command during them), identified during those flights that the airplane's normal braking system was not operating when the airplane was traveling faster than 20 knots. He remedied the situation by configuring the airplane to use the emergency, rather than normal, braking system. That pilot reported this discrepancy to the operator's director of maintenance, and it is likely that maintenance personnel from the company subsequently added an "INOP" placard near the switch on the date of the accident. The label on the placard referenced the antiskid system, and the airplane's flight manual described that with the normal brake (or antiskid) system inoperative, the brake selector switch must be positioned to use the emergency braking system. Following the accident, the switch was found positioned with the normal braking system activated, and it is likely that the accident flight crew attempted to utilize the malfunctioning normal braking system during the landing. Additionally, the flight crew failed to properly recognize the failure and configure the airplane to utilize the emergency braking system, or utilize the parking brake, as described in the airplane's flight manual, in order to stop the airplane within the available runway.
Probable cause:
The operator's decision to allow a flight in an airplane with known, unresolved maintenance discrepancies, and the flight crew's failure to properly configure the airplane in a way that would have allowed the emergency or parking brake systems to stop the airplane during landing.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Igiugig

Date & Time: Sep 20, 2018 at 1530 LT
Type of aircraft:
Operator:
Registration:
N121AK
Flight Phase:
Survivors:
Yes
MSN:
121
YOM:
1951
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12496
Captain / Total hours on type:
5000.00
Circumstances:
The pilot of the float-equipped airplane reported that, during the initial climb after a water takeoff, about 200 feet, he turned right, and the engine lost power. He immediately switched fuel tanks and attempted to restart the engine to no avail. The airplane descended and struck trees, and the right wing impacted terrain. The airplane sustained 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. The pilot reported to the Federal Aviation Administration inspector that, during the initial climb and after the engine lost power, he noticed that the center tank, which was selected for takeoff, was empty. He added that passengers stated that the engine did regain power after switching tanks, but the airplane had already struck trees. The pilot reported as a recommendation to more closely follow checklists.
Probable cause:
The pilot's selection of an empty fuel tank for takeoff, which resulted in fuel starvation and the subsequent total loss of engine power.
Final Report:

Crash of a Let L-410UVP off Yirol: 20 killed

Date & Time: Sep 9, 2018 at 0845 LT
Type of aircraft:
Operator:
Registration:
UR-TWO
Survivors:
Yes
Schedule:
Juba - Yirol
MSN:
84 13 28
YOM:
1984
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
20
Circumstances:
On approach to Yiral Airport in poor visibility due to fog, the twin engine aircraft descended too low, impacted the surface of the Yirol Lake and crashed about 2 km north of the airfield. The aircraft was destroyed upon impact and four occupants were rescued while 19 others were killed. A day later, one of the survivor died from his injuries. The three survivors are two children and a Italian doctor. The flight was completed on behalf of the Slaver Company based in Ukraine.
Probable cause:
The committee for the investigations of Slav air let410 aircraft registration UR-TWO has finally concluded that the cause of the accident at Yirol Eastern Lake State Republic of South Sudan was caused by a combination of the following factors:
1. Severely bad weather in the morning of the accident.( Not making a decision to return back to Juba or diverting to the nearest airportRumbek).
2. Pilot incompetency and error in setting the altimeter for Yirol airstrip before the crash. (Causing variations in altitude- flying at false altitude actually below the actual flight level).
3. Replacement of a faulty propeller in Pibor and not informing the safety department of the changes and not being given the release document for operations.
Final Report:

Crash of a Beechcraft A100 King Air in Itapaci

Date & Time: Sep 6, 2018 at 0830 LT
Type of aircraft:
Operator:
Registration:
PT-LJN
Survivors:
Yes
Schedule:
Goiânia – Ceres
MSN:
B-121
YOM:
1972
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane departed Goiânia-Santa Genoveva Airport at 0810LT on a charter flight to Ceres, carrying nine passengers and one pilot. En route, it was decided to change the itinerary and to land in Itapaci where there was no suitable terrain for landing. On final approach, the aircraft impacted ground, lost its undercarriage and veered to the right. It collided with a fence and made a 180 turn before coming to rest. All 10 occupants evacuated safely and the aircraft was damaged beyond repair. On board was the candidate for governor of the state of Goiás and his campaign team.
Probable cause:
The pilot intentionally changed his routing for Itapaci where the landing zone was not approved for flight operations. During the landing, the plane struck the ground before the planned zone and crashed. The pilot violated the rules established by the authority.
Final Report:

Cras of a De Havilland DHC-6 Twin Otter in Mojo: 18 killed

Date & Time: Aug 30, 2018 at 1030 LT
Operator:
Registration:
ET-AIU
Survivors:
No
Schedule:
Dire Dawa – Debre Zeit
MSN:
822
YOM:
1985
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
18
Circumstances:
The twin engine airplane departed Dire Dawa in the morning on a flight to Harar Meda Airbase located in Debre Zeit, carrying 15 Army officers and three civilians on behalf of the Ethiopian Army. While descending to Harar Meda, the airplane crashed in unknown circumstances in a wooded area located in Mojo, some 17 km southeast of the airfield. The aircraft was totally destroyed and all 18 occupants were killed, among them two children. Operated on behalf of the Ethiopian Army with dual registration ET-AIU/808.

Crash of a Pacific Aerospace PAC 750XL near Oksibil: 8 killed

Date & Time: Aug 11, 2018 at 1420 LT
Operator:
Registration:
PK-HVQ
Survivors:
Yes
Site:
Schedule:
Tanah Merah – Oksibil
MSN:
144
YOM:
2009
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
13665
Captain / Total hours on type:
1468.00
Aircraft flight hours:
4574
Aircraft flight cycles:
5227
Circumstances:
On 11 August 2018, a PAC 750XL aircraft registered PK-HVQ was being operated by PT. Marta Buana Abadi (Dimonim Air) on unscheduled passenger flight from Tanah Merah to Oksibil. At the day of the occurrence the meteorological condition at Oksibil was below the requirement of Visual Flight Rule (VFR) weather minima and did not improve. Being aware that some flights had performed flight to Tanah Merah to Oksibil and returned, the pilot decided to fly to Oksibil. At 1342 LT, on daylight condition the PK-HVQ aircraft departed from Tanah Merah to Oksibil, on board the aircraft were one pilot, one observer pilot and 7 passengers. According to the passenger and cargo manifest, the total weight of passenger and the baggage were 473 kg. Prior to the departure, there was no record or report of aircraft system malfunction. At 1411 LT, the PK-HVQ pilot made initial contact to Oksibil Tower controller and reported that the aircraft was maintaining altitude of 7,000 feet over and the estimate time arrival at Oksibil would be 0520 UTC (1420 LT). The Oksibil Tower controller advised the pilot of the latest meteorological condition that the visibility was 1 up to 2 km and most of the area were covered by cloud. At 1416 LT, the pilot reported that the aircraft position was over Oksibil Aiport and the Oksibil Tower controller instructed the pilot to continue the flight to the final runway 11 and to report when the runway had in sight. The Oksibil Tower controller and pilots of other aircraft called the pilot but no reply. On the following day, the aircraft was found on a ridge of mountain about 3.8 Nm north west of Oksibil on bearing 331° with elevation about 6,800 feet. Eight occupants were fatally injured and one occupant was seriously injured.
Probable cause:
The KNKT concluded the contributing factors as follows:
- The VFR weather minimum requirement that was not implemented properly most likely had made the pilot did not have a clear visual to the surrounding area.
- Considering that the Pilot in Command (PIC) had lack knowledge of the terrain surrounding the Oksibil area, and the absence of voice alert from the TAWS when the aircraft flying close to terrain, resulted in the PIC did not have adequate awareness to the surrounding terrain while flying into clouds and continued to fly below the terrain height until the aircraft impacted the terrain.
Final Report:

Crash of a De Havilland DHC-2 Beaver I on Mt Kahiltna: 5 killed

Date & Time: Aug 4, 2018 at 1753 LT
Type of aircraft:
Operator:
Registration:
N323KT
Flight Phase:
Survivors:
No
Site:
Schedule:
Talkeetna - Talkeetna
MSN:
1022
YOM:
1957
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
2550
Captain / Total hours on type:
346.00
Aircraft flight hours:
15495
Circumstances:
The commercial pilot was conducting a 1-hour commercial air tour flight over Denali National Park and Preserve with four passengers on board. About 48 minutes after departure, the Alaska Rescue Coordination Center received an alert from the airplane's emergency locator transmitter. About 7 minutes later, company personnel received a call from the pilot, who reported that the airplane had run "into the side of a mountain." Although a search was initiated almost immediately, due to poor weather conditions in the area, the wreckage was not located until almost 36 hours later in a crevasse on a glacier about 10,920 ft mean sea level. Due to the unique challenges posed by the steepness of terrain, the crevasse, avalanche hazard, and the condition of the airplane, neither the occupants nor the wreckage were recovered from the accident site. A weather model sounding for the area of the accident site estimated broken cloud bases at 700 ft above ground level (agl) with overcast clouds at 1,000 ft agl and cloud tops to 21,000 ft agl and higher clouds above. The freezing level was at 9,866 ft and supported light-to-moderate rime type icing in clouds and precipitation. The on-scene assessment indicated that the right wing impacted snow while the airplane was flying in a wings-level attitude; the right wing had separated from the remainder of the wreckage. Based upon available weather data and forecast models and the impact evidence, it is likely that the pilot entered an area of reduced visibility and was unable to see the terrain before the airplane's right wing impacted the snow. The company's organizational structure was such that one group of management personnel oversaw operations in both Anchorage and Talkeetna. Interviews with company management revealed that they were not always aware of the exact routing a pilot would take for a tour; the route was pilot's discretion based upon the weather at the time of the flight to provide the best tour experience. Regarding risk mitigation, the company did not utilize a formal risk assessment process, but rather relied on conversations between pilots and flight followers. This could lead to an oversight of actual risk associated with a particular flight route and weather conditions. About 8 months after the accident, an assessment flight conducted by the National Park Service determined that during the winter, the hazardous hanging glacier at the accident site calved, releasing an estimated 4,000 to 6,000 tons of ice and debris. There was no evidence of the airplane wreckage near the crash site, in the steep fall line, or on the glacier surface over 3,600 ft below. Although the known circumstances of the accident are consistent with a controlled flight into terrain event, the factual information available was limited because the wreckage was not recovered and no autopsy or toxicology of the pilot could be performed; therefore, whether other circumstances may have contributed to the accident could not be determined.
Probable cause:
Impact with terrain for reasons that could not be determined because the airplane was not recovered due to the inaccessible nature of the accident site.
Final Report: