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

Date & Time: Jan 7, 2018 at 1645 LT
Type of aircraft:
Operator:
Registration:
5Y-FDC
Flight Phase:
Survivors:
Yes
Schedule:
Akobo – Juba
MSN:
208B-1280
YOM:
2007
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
In unclear circumstances, the single engine aircraft crashed while taking off from Akobo Airstrip. It struck a house and several cows before coming to rest, bursting into flames. One person on the ground was killed while all 11 occupants escaped uninjured. The aircraft was totally destroyed by a post crash fire.

Crash of a Cessna (DMI) Falcon 402 on Bazaruto Island

Date & Time: Jan 2, 2018 at 1145 LT
Type of aircraft:
Operator:
Registration:
ZU-MDI
Flight Phase:
Survivors:
Yes
Schedule:
Bazaruto Island - Vilanculos
MSN:
402B-0207
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3291
Captain / Total hours on type:
215.00
Aircraft flight hours:
1068
Circumstances:
The single engine airplane was departing Bazaruto Island on a flight to Vilanculos, carrying six passengers and one pilot. During the takeoff roll on runway 20, after a course of about 400 metres, the aircraft started to veer to the left, departed the runway despite successive attempt to correct the flight trajectory. The aircraft crashed into bushed and came to rest in the opposite direction of the takeoff, some 60 metres from the runway centerline.
Probable cause:
The most likely cause of this accident was human failure. The following contributing factors were identified:
- The fact that the pilot has exceeded the aircraft's capacity from 8 (1+7) to 10 (1+9), associated with prevailing meteorological conditions, may have influenced the attitude of the aircraft during take-off.
- The fact that the pilot did not properly follow the pre-flight procedures, given the hurry he showed at departure and being distracted at the time of the pre-flight inspection may have contributed to forgetting to remove the lock) of the Vertical Stabilizer.
- The fact that the pilot probably did not remove the Lock of the Vertical Stabilizer caused it to remain fixed in its position and could not give the directional control to the aircraft.
Final Report:

Crash of a De Havilland DHC-2 Beaver off Cottage Point: 6 killed

Date & Time: Dec 31, 2017 at 1515 LT
Type of aircraft:
Operator:
Registration:
VH-NOO
Flight Phase:
Survivors:
No
Schedule:
Cottage Point - Sydney
MSN:
1535
YOM:
1963
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
10762
Aircraft flight hours:
21872
Circumstances:
On 31 December 2017, at about 1045 Eastern Daylight-saving Time, five passengers arrived via water-taxi at the Sydney Seaplanes terminal, Rose Bay, New South Wales (NSW) for a charter fly-and-dine experience to a restaurant at Cottage Point on the Hawkesbury River. Cottage Point is about 26 km north of Sydney Harbour in the Ku-ring-gai Chase National Park, a 20 minute floatplane flight from Rose Bay. At about 1130, prior to boarding the aircraft, the passengers received a pre-flight safety briefing. At about 1135, the pilot and five passengers departed the Rose Bay terminal for the flight to Cottage Point via the northern beaches coastal route, in a de Havilland Canada DHC-2 Beaver floatplane, registered VH-NOO and operated by Sydney Seaplanes. The flight arrived at Cottage Point just before midday and the passengers disembarked. The pilot then conducted another four flights in VH-NOO between Cottage Point and Rose Bay. The pilot arrived at Cottage Point at about 1353. After securing the aircraft at the pontoon and disembarking passengers from that flight, the pilot walked to a kiosk at Cottage Point for a drink and food. At about 1415, the pilot received a phone call from the operator via the kiosk, asking the pilot to move the aircraft off the pontoon, which could only accommodate one aircraft at a time. This was to allow the pilot of the operator’s other DHC-2 aircraft (VH-AAM) to pick-up other restaurant passengers. The pilot of VH-NOO immediately returned to the aircraft and taxied away from the pontoon into Cowan Creek. The operator’s records indicated that VH-AAM arrived at the pontoon and shut down the engine at about 1419, and subsequently departed at about 1446. The pilot of VH-NOO returned to the pontoon after having taxied in Cowan Creek with the engine running for up to 27 minutes, while waiting for the other aircraft. During the taxi, closed-circuit television footage from a private residence at Cottage Point showed VH-NOO at 1444, with the pilot’s door ajar. After shutting down the aircraft, the pilot briefly went into the restaurant to see if the passengers were ready to leave, and then returned to the aircraft. The return flight to Rose Bay, scheduled to depart at 1500, provided sufficient time for the passengers to meet a previously booked water-taxi to transport them from Rose Bay to their hotel at 1545. At about 1457, the passengers commenced boarding the aircraft and at around 1504, the aircraft had commenced taxiing toward the designated take-off area in Cowan Creek. At about 1511, the aircraft took off towards the north-north-east in Cowan Creek, becoming airborne shortly before passing Cowan Point. The aircraft climbed straight ahead before commencing a right turn into Cowan Water. A witness, who was travelling east in a boat on the northern side of Cowan Water, photographed the aircraft passing over a location known as ‘Hole in the wall’. These photographs indicated that the aircraft was turning to the right with a bank angle of 15-20°. Witnesses observed the right turn continue above Little Shark Rock Point and Cowan Water. The last photograph taken by the passenger was when the aircraft was heading in a southerly direction towards Cowan Bay. At that time, the aircraft was estimated to be at an altitude of about 30 m (98 ft).Shortly after the turn in Cowan Water, several witnesses observed the aircraft heading directly towards and entering Jerusalem Bay flying level or slightly descending, below the height of the surrounding terrain. Witnesses also reported hearing the aircraft’s engine and stated that the sound was constant and appeared normal. About 1.1 km after entering Jerusalem Bay, near the entrance to Pinta Bay, multiple witnesses reported seeing the aircraft flying along the southern shoreline before it suddenly entered a steep right turn at low-level. Part-way through the turn, the aircraft’s nose suddenly dropped before the aircraft collided with the water, about 95 m from the northern shore and 1.2 km from the end of Jerusalem Bay. The aircraft came to rest inverted and with the cabin submerged. A number of people on watercraft who heard or observed the impact, responded to render assistance. Those people could not access the (underwater) aircraft cabin. The entire tail section and parts of both floats were initially above the waterline, but about 10 minutes later had completely submerged. The pilot and five passengers received fatal injuries.
Probable cause:
Contributing factors:
- The aircraft entered Jerusalem Bay, a known confined area, below terrain height with a level or slightly descending flight path. There was no known operational need for the aircraft to be
operating in the bay.
- While conducting a steep turn in Jerusalem Bay, it was likely that the aircraft aerodynamically stalled at an altitude too low to effect a recovery before colliding with the water.
- It was almost certain that there was elevated levels of carbon monoxide in the aircraft cabin, which resulted in the pilot and passengers having higher than normal levels of carboxyhaemoglobin in their blood.
- Several pre-existing cracks in the exhaust collector ring, very likely released exhaust gas into the engine/accessory bay, which then very likely entered the cabin through holes in the main
firewall where three bolts were missing.
- A 27 minute taxi before the passengers boarded, with the pilot’s door ajar likely exacerbated the pilot’s elevated carboxyhaemoglobin level.
- It was likely that the pilot's ability to safely operate the aircraft was significantly degraded by carbon monoxide exposure.
- Disposable chemical spot detectors, commonly used in general aviation, can be unreliable at detecting carbon monoxide in the aircraft cabin. Further, they do not draw a pilot's attention to a hazardous condition, instead they rely on the pilot noticing the changing colour of the sensor.
- There was no regulatory requirement from the Civil Aviation Safety Authority for piston-engine aircraft to carry a carbon monoxide detector with an active warning to alert pilots to the presence of elevated levels of carbon monoxide in the cabin. (Safety issue)

Other factors that increased risk:
- It was likely that the effectiveness of the disposable carbon monoxide chemical spot detector fitted to the aircraft was reduced due to sun bleaching.
- Although detectors were not required to be fitted to their aircraft, Sydney Seaplanes had no mechanism for monitoring the serviceability of the carbon monoxide detectors. (Safety issue)
- The in situ bolts used by the maintenance organisation to secure the magneto access panels on the main firewall were worn, and were a combination of modified AN3-3A bolts and non-specific bolts. This increased the risk of the bolts either not tightening securely on installation and/or coming loose during operations.
- The operator relied on volunteered passenger weights without allowances for variability, rather than actual passenger weights obtained just prior to a flight. This increased the risk of underestimating passenger weights and potentially overloading an aircraft.
- The standard passenger weights specified in Civil Aviation Advisory Publication (CAAP) 235-1(1) Standard passenger and baggage weights did not accurately reflect the average weights of the current Australian population. Further, the CAAP did not provide guidance on the use of volunteered passenger weights as an alternative to weights derived just prior to a flight.
- Australian civil aviation regulations did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and other accidents, have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in the non-identification of safety issues, which continue to present a hazard to current and future passengercarrying operations. (Safety issue)
- Annex 6 to the Convention of International Civil Aviation did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and numerous other accidents have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in important safety issues not being identified, which may remain a hazard to current and future passenger carrying operations. (Safety issue)

Other findings:
- It was very likely that the middle row right passenger did not have his seatbelt fastened at the time of impact, however, the reason for this could not be determined.
- The accident was not survivable due to the combination of the impact forces and the submersion of the aircraft.
- The pilot had no known pre-existing medical conditions that could explain the accident.
Final Report:

Crash of a Cessna 208B Grand Caravan in Punta Islita: 12 killed

Date & Time: Dec 31, 2017 at 1216 LT
Type of aircraft:
Operator:
Registration:
TI-BEI
Flight Phase:
Survivors:
No
Schedule:
Punta Islita – San José
MSN:
208B-0900
YOM:
2001
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
14508
Captain / Total hours on type:
11587.00
Copilot / Total flying hours:
453
Aircraft flight hours:
12073
Circumstances:
The two pilots were conducting a commercial charter flight to take 10 passengers to an international airport for connecting flights. The flight departed a nontower-controlled airport that was in a valley surrounded on all sides by rising terrain, with the exception of the area beyond the departure end of runway 21, which led directly toward the Pacific Ocean. The accident airplane was the second of a flight of two; the first airplane departed runway 3 about 15 minutes before the accident airplane and made an immediate right turn to the east/southeast after takeoff, following a pass in the hills over lower terrain that provided time for the airplane to climb over the mountains. Both a witness and surveillance video footage from the airport indicated that, 15 minutes later, the accident airplane also departed from runway 3 but instead continued on runway heading, then entered a left turn and descended into terrain. Analysis of the video determined that the airplane reached a maximum bank angle of about 75° and an airspeed below the airplane's published aerodynamic stall speed before impact. Examination of the airplane was limited due to impact and postcrash fire damage; however, no defects consistent with a preimpact failure or malfunction were observed, and the engine exhibited signatures consistent with production of power during impact. The captain was appropriately rated and had extensive experience in the accident airplane make and model. He had been employed by the accident operator for about a year in 2006 and had recently been re-hired by the operator; however, records provided by the operator did not indicate that he had completed all of the training and check flights required by the operator's General Operations Manual (GOM). The first officer was appropriately rated but had little experience in the accident airplane. The GOM also stated that pilots would receive additional, airport-specific training before operating to or from airports with special characteristics; however, the operator provided no listing of such airports, including the airport from which the accident flight departed. The pilots' experience at the departure airport could not be determined. It is possible the psychiatric diagnoses in 2011 were correct and the pilot suffered from a number of conditions which can cause a variety of symptoms. However, given the extremely limited information, what his symptoms were around the time of the accident, whether they were being addressed or effectively treated, and what his mental state was at the time could not be determined from the available information. Therefore, whether or not the pilot's medical or psychological conditions or their treatment played a role in the accident circumstances could not be determined by this investigation. There were no weather reporting facilities in the vicinity of the airport. Although the airport was equipped with two frames for windsocks, no windsocks were installed at the time of the accident to aid pilots in determining wind direction and intensity. Although a takeoff from runway 21 afforded the most favorable terrain since the airplane would fly over lower terrain to the ocean, it is possible that a significant enough tailwind existed for runway 21 that the pilots believed the airplane's maximum tailwind takeoff limitation may be exceeded and chose to depart from runway 3 in the absence of any information regarding the wind velocity. Performance calculations showed that the airplane would have been able to take off with up to a 10-kt tailwind, which was the manufacturer limitation for tailwind takeoffs. The witness who saw the accident reported that he spoke with the pilots of both airplanes before the flights departed and that the pilots acknowledged the need to use the eastern pass in order to clear terrain when departing from runway 3. The reason that the flight crew of the accident airplane failed to use this path after takeoff could not be determined. It is likely that, after entering the valley ahead of the runway, with rising terrain and peaks that likely exceeded the climb capability of the airplane, they attempted to execute a left turn to exit the valley toward lower terrain. During the steep turn, the pilots failed to maintain adequate airspeed and exceeded the airplane's critical angle of attack, which resulted in an aerodynamic stall and impact with terrain. Performance calculations using weights that would allow the airplane to operate within manufacturer weight and balance limitations at the time of the accident indicated that it was unlikely that the airplane would have had sufficient climb performance to clear the terrain north of the airport. However, the airplane would likely have had sufficient climb performance to clear terrain east of the airport had the crew performed a right turn immediately after takeoff like the previous airplane.
Probable cause:
The flight crew's failure to maintain airspeed while maneuvering to exit an area of rising terrain, which resulted in an exceedance of the airplane's critical angle of attack and an aerodynamic stall. Contributing to the accident was the flight crew's decision to continue the takeoff toward rising terrain that likely exceeded the airplane's climb capability, the lack of adequate weather reporting available for wind determination, and the lack of documented training for an airport requiring a non-standard departure.
Final Report:

Crash of a Cessna 207 Skywagon near Playa del Carmen

Date & Time: Dec 21, 2017 at 0950 LT
Operator:
Registration:
XA-UHL
Flight Phase:
Survivors:
Yes
Schedule:
Playa del Carmen – Chichén Itzá
MSN:
207-0261
YOM:
1974
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1506
Captain / Total hours on type:
37.00
Aircraft flight hours:
5090
Circumstances:
Few minutes after takeoff from Playa del Carmen, while flying at an altitude of 1,500 feet, the engine lost power and failed. The pilot attempted to make an emergency landing when the aircraft collided with trees and crashed in a wooded area located 18 km from its departure point. The pilot and all four passengers, a British family on vacations, were uninjured. The aircraft was damaged beyond repair.
Probable cause:
Engine failure caused by an oil leak following the failure of the 5th cylinder.
Final Report:

Crash of a Cessna 510 Citation Mustang in Sieberatsreute: 3 killed

Date & Time: Dec 14, 2017 at 1814 LT
Operator:
Registration:
OE-FWD
Survivors:
No
Schedule:
Egelsbach – Friedrichshafen
MSN:
510-0049
YOM:
2007
Flight number:
STC228B
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2816
Captain / Total hours on type:
2000.00
Copilot / Total flying hours:
800
Copilot / Total hours on type:
140
Aircraft flight hours:
3606
Circumstances:
The airplane departed Egelsbach Airport at 1743LT on a charter flight to Friedrichshafen, carrying one passenger and two pilots. Following an uneventful flight at FL210, the crew contacted Zurich ARTCC and was cleared to start the descent and later told to expect a runway 24 ILS approach to Friedrichshafen-Bodensee Airport. After passing 4,000 feet on descent, at a speed of 240 knots, the crew was completing a last turn in clouds when the airplane entered a rapid and uncontrolled descent until it crashed in a wooded area located in Sieberatsreute, some 15 km short of runway 24. The airplane disintegrated on impact and all three occupants were killed.
Probable cause:
The aircraft accident was caused by a sudden loss of control of the aircraft in clouds while turning in for the approach to Friedrichshafen at night. Probably the frontal weather with light to moderate turbulence, snowfall and icing contributed to this. The absence of information about the events on board the aircraft meant that it was not possible to determine the causes of the loss of control.
Final Report:

Crash of a Cessna 208B Grand Caravan off Placencia

Date & Time: Nov 17, 2017 at 0846 LT
Type of aircraft:
Operator:
Registration:
V3-HGX
Flight Phase:
Survivors:
Yes
Schedule:
Placencia – Punta Gorda
MSN:
208B-1162
YOM:
2005
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19040
Captain / Total hours on type:
12092.00
Aircraft flight hours:
2106
Circumstances:
On 17 November, 2017, a Tropic Air Cessna 208B Grand Caravan with registration V3-HGX, departed from the Sir Barry Bowen Municipal Airport at approximately 7:15 a.m. local time with one aircraft captain, 11 passengers and 1 crew on board. The flight was a regular operated commercial passenger flight with scheduled stops in Dangriga, Placencia and with the final destination being Punta Gorda. The pilot reported that the portion of the flight from Belize City to Dangriga was uneventful and normal and so was the landing at Placencia. At approximately 8:40 a.m. local time the airplane taxied from the Tropic Air ramp and taxied towards the west on runway 25. The pilot did a turnaround using all the available runway at normal speed and started his takeoff run to the east on runway 07. The pilot proceeded down the runway in a normal takeoff roll with normal takeoff speed and prior to reaching the end of the runway, he rotated the aircraft and lifted the nose wheel to get airborne. At exactly 28 feet past the end of runway 07 and during the initial climb phase, a part of the aircraft landing gear made contact with the upper part of the front righthand passenger door frame of a vehicle that had breached the area in front of the runway which is normally protected by traffic barriers. The impact caused the aircraft to deviate from its initial climb profile, and the pilot reported that the engine was working for a couple seconds and it abruptly shut down shortly after. The pilot realized that he was unable to return to the airport. The pilot carried out emergency drills for engine loss after take-off over water and decided to ditch the aircraft in the sea, which was approximately 200-300 feet from the main shoreline in front of the Placencia airport. The flight crew and all passengers were safely evacuated from the fuselage with the assistance of witnesses and passing boats which provided an impromptu rescue for the passengers. All passengers received only minor injuries.
Probable cause:
The following are factors that are derived from the failures in the areas mentioned in section 3.00 (conclusions):
a. There is a lack of traffic surveillance to ensure that drivers comply with the warning signs of low flying aircraft and do not breach the barriers when they are down or inoperative. The left barrier at Placencia was reportedly inoperative and the right barrier was said to be working. As a result, this removed a significant level of protection for vehicles which operate on the portion of the road which intersects the departure path of aircraft. The purpose of the barriers is to protect vehicles from coming in close contact with low flying aircraft. The driver of the vehicle failed to adhere to traffic warning signs regarding low flying aircraft and drove his vehicle directly into the departure path of an aircraft (Probable cause).
b. ADAS data calculations showed that the pilot had a period of 13.33 seconds when he achieved take off performance, but he did not rotate the aircraft. Although the aircraft engine performance was normal, the actual take-off weight was within limits and the distance available to the pilot to abort the take-off was 872 feet; the pilot still flew the aircraft at a dangerously low altitude over the road and did not properly assess the risk at hand which was a vehicle advancing into the aircraft’s departure path which could cause a collision. (Probable cause).
c. The angle at which the aircraft made contact with the vehicle was not a direct head on angle, but the contact was made when the vehicle was off to the right-hand side of the extended centerline of runway 07. The aircraft did not follow the direct path of the extended center line of runway 07 prior to making contact, but instead it made a slight right turn shortly after the wheels left the ground. The pilot did not take collision avoidance (evasive) measures in a timely manner (probable cause).
d. The pilot did not demonstrate adequate knowledge of proper ditching procedures which led to an inadequate response to the emergency at hand. The operator did not provide the flight crew with the proper ditching training.

Probable causes:
1. The driver of the vehicle failed to adhere to traffic warning signs regarding low flying aircraft and drove his vehicle directly into the departure path of an aircraft.
2. The pilot flew the aircraft at a dangerously low altitude over the road and did not properly assess the risk at hand which was a vehicle advancing into the aircraft’s departure path which could cause a collision.
3. The pilot did not take collision avoidance (evasive) measures in a timely manner.
Final Report:

Crash of a Cessna 208B Grand Caravan in Empakaai Camp: 11 killed

Date & Time: Nov 15, 2017 at 1113 LT
Type of aircraft:
Operator:
Registration:
5H-EGG
Flight Phase:
Survivors:
No
Site:
MSN:
208B-0476
YOM:
1995
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The single engine airplane departed Arusha Airport on a charter flight to the Serengeti National Park, carrying 10 tourists and one pilot. While flying in marginal weather conditions, the aircraft impacted hilly terrain near Empakaai Camp and was destroyed upon impact. All 11 occupants were killed.
Probable cause:
Controlled flight into terrain.

Crash of a Cessna 208B Grand Caravan in Lobo

Date & Time: Oct 25, 2017 at 1430 LT
Type of aircraft:
Operator:
Registration:
5H-THR
Survivors:
Yes
Schedule:
Lake Manyara - Lobo
MSN:
208B-0571
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown at Lobo Airstrip deserving the Lobo Wildlife Lodge located in the Serengeti National park, the single engine aircraft went out of control, veered off runway to the left and came to rest against a tree. The pilot and two passengers were injured while eight other occupants were unhurt. The aircraft was damaged beyond repair. There was no fire.

Crash of a Beechcraft B200C Super King Air in Nuevo Saposoa

Date & Time: Oct 19, 2017 at 1149 LT
Operator:
Registration:
OB-2077-P
Flight Phase:
Survivors:
Yes
Schedule:
Contamana – Pucallpa
MSN:
BL-5
YOM:
1980
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17659
Copilot / Total flying hours:
334
Copilot / Total hours on type:
131
Aircraft flight hours:
12334
Aircraft flight cycles:
9666
Circumstances:
The twin engine aircraft departed Contamana Airport at 1128LT on a charter flight to Pucallpa, carrying 11 passengers and two pilots. Few minutes after takeoff, while climbing to an altitude of 4,500 feet, the right engine lost power and failed. The crerw decided to return to Contamana but was able to transfer fuel from the left tank to the right tank to restart the right engine. Decision was taken to continue to Pucallpa at an altitude of 13,500 feet. At a distance of 42 km from Pucallpa, the crew started the descent when the right engine failed again, followed shortly later by the left engine. The captain declared an emergency and attempted an emergency landing when the aircraft crashed in a wooded area. All 13 occupants were injured and the aircraft was destroyed.
Probable cause:
Double engine failure in flight due to fuel starvation, forcing the crew to attempt an emergency landing in trees.
The following contributing factors were identified:
- Recurrent failures on the ground and in flight of the aircraft fuel quantity indicators, a situation that was maintained because the Maintenance Programme did not include an inspection and calibration of the fuel quantity gauges.
- Initiating the flight with a fuel indication system inoperative.
- Complacency on part of the crew who decided to continue the flight by having an aerodrome nearby after the first engine failure.
Final Report: