Crash of a Learjet 35A in Buenos Aires

Date & Time: Mar 7, 2019 at 1930 LT
Type of aircraft:
Operator:
Registration:
LV-BNR
Survivors:
Yes
Schedule:
Rosario – Buenos Aires
MSN:
35-373
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Rosario-Islas Malvinas Airport at 1900LT on a charter flight to Buenos Aires, carrying two passengers and two pilots. On approach to Buenos Aires-Aeroparque-Jorge Newbury Airport by night, the crew encountered poor weather conditions with thunderstorm activity, heavy rain falls and strong winds. The aircraft landed 200 metres past the runway 13 threshold and the crew stated the braking procedure. After a course of about 500 metres, the aircraft deviated to the left and veered off runway. It rolled on a grassy area then contacted the concrete taxiway, causing both main landing gear to be torn off. The aircraft came to rest 860 metres from the runway threshold and was damaged beyond repair. All four occupants evacuated safely.
Probable cause:
Conclusions regarding factors related to the accident:
- At the time of the event, meteorological conditions were poor with a strong storm, rain and gusts of wind.
- Visual cues may have been reduced due to heavy rain falls.
- The aircraft was displaced from the runway center line when it made contact with the ground.
- The aircraft made contact with the left landing gear off the runway due to strong gusts of wind.
- The lateral excursion to the grassy area occurred due to the impossibility of recovering the trajectory of the aircraft, once it was displaced by the action of the wind.
Final Report:

Crash of a Gulfstream G200 in Moscow

Date & Time: Feb 26, 2019 at 1244 LT
Type of aircraft:
Operator:
Registration:
4K-AZ88
Survivors:
Yes
Schedule:
Baku - Moscow
MSN:
189
YOM:
2008
Flight number:
EWS88
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7608
Captain / Total hours on type:
2356.00
Copilot / Total flying hours:
2554
Copilot / Total hours on type:
609
Aircraft flight hours:
4174
Aircraft flight cycles:
1787
Circumstances:
The airplane departed Baku-Bina Airport on a charter flight to Moscow, carrying three passengers and three crew members. Following an uneventful flight, the crew was cleared for an approach to Moscow-Sheremetyevo Airport runway 24C. The aircraft landed at a speed of 150 knots some 250 metres past the runway threshold. After touchdown, the crew started the braking procedure and activated the thrust reversers. After a course of several hundred metres, the aircraft deviated to the left, made an almost 180 turn and veered off runway to the left. While contacting soft ground, the right main gear was torn off and the aircraft came to rest in a snow covered area. All six occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The reason for the accident with the Gulfstream G200 4K-AZ88 was the stowing of the right-engine reverser by the pilot KVS from maximum thrust reversal while maintaining maximum thrust reversal on the left engine, which led to the appearance of a significant turning moment to the left. The aircraft turning to the left in the presence of a cross wind to the right, as well as turbulence of the airflow near the rudder due to the open thrust reversal mechanism of the left engine and possible ice deposition on the outer surfaces of the aircraft, which led to the development of a significant swing moment on the rudder. The development of a significant articulated moment on the rudder, in the absence of power steering in the rudder control system, led to its deviation to the leftmost position despite significant (up to 82 kg or 180 pounds) forces exerted by the crew on the pedals. The deviation of the rudder (pedals) to the left also led to the deviation of the nose wheel to the left. The total moment from the running reverse of the left engine, from the right engine in direct draft mode, and from the rudder and nose wheel deflection to the left, led to the aircraft rolling out of the runway and its damage. Separate braking applied by the crew could not prevent the aircraft from rolling out.

The following contributing factors were identified:
- The crew did not take into account the provisions of the AOM about the possible "destabilizing" effect of the thrust reverse when landing with a cross wind on the runway with a reduced braking coefficient;
- Increased psycho-emotional tension of the crew members due to long dissatisfaction and emotional discussion of instructions and actions of ATC controllers. At the same time, the instructions and actions of the ATC service controllers were in line with established procedures.
Final Report:

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.