Crash of a Hawker 800XP in Farmingdale

Date & Time: Dec 20, 2020 at 2035 LT
Type of aircraft:
Operator:
Registration:
N412JA
Flight Type:
Survivors:
Yes
Schedule:
Miami - Farmingdale
MSN:
258516
YOM:
2001
Flight number:
TFF941
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4188
Captain / Total hours on type:
2060.00
Copilot / Total flying hours:
10000
Copilot / Total hours on type:
4100
Aircraft flight hours:
12731
Circumstances:
The flight crew were conducting an instrument landing system (ILS) approach in night instrument meteorological conditions when they were advised by the tower controller that the weather had deteriorated below minimums. The captain was the pilot monitoring, and the first officer was the pilot flying during the approach. Since the airplane was inside the final approach fix and stabilized, both pilots agreed to continue with the approach. Both pilots stated that they had visual contact with the runway approach lighting system at the 200 ft above ground level (agl) decision altitude, and they decided to continue the approach. The first officer said he then returned to flying the airplane via instruments. As the first officer continued the approach, the captain told him the airplane was drifting right of the runway centerline. The first officer said that he looked outside, saw that the weather had deteriorated, and was no longer comfortable with the approach. The first officer said he pressed the takeoff and go-around switch, while at the same time, the captain called for a go-around. The captain said that he called for the go-around because the airplane was not aligned with the runway. Although both pilots stated that the go-around was initiated when the airplane was about 50 to 100 ft agl, the cockpit voice recorder (CVR) recording revealed that the first officer flew an autopilot-coupled approach to 50 ft agl (per the approach procedure, a coupled approach was not authorized below 240 ft agl). As the airplane descended from 30 to 20 ft agl, the captain told the first officer three times to “flare” then informed him that the airplane was drifting to right and he needed to make a left correction to get realigned with the runway centerline. Three seconds passed before the first officer reacted by trying to initiate transfer control of the airplane to the captain. The captain did not take control of the airplane and called for a go-around. The first officer then added full power and called for the flaps to be retracted to 15º; however, the airplane impacted the ground about 5 seconds later, resulting in substantial damage to the fuselage. Data downloaded from both engines’ digital electronic engine control units revealed no anomalies. No mechanical issues with the airplane or engines were reported by either crew member or the operator. The sequence of events identified in the CVR recording revealed that the approach most likely became unstabilized after the autopilot was disconnected and when the first officer lost visual contact with the runway environment. The captain, who had the runway in sight, delayed calling for a go-around after the approach became unstabilized, and the airplane was too low to recover.
Probable cause:
The flight crew’s delayed decision to initiate a go-around after the approach had become unstabilized, which resulted in a hard landing.
Final Report:

Crash of a Beechcraft 60 Duke in Loveland: 1 killed

Date & Time: May 15, 2019 at 1248 LT
Type of aircraft:
Operator:
Registration:
N60RK
Flight Type:
Survivors:
No
Schedule:
Broomfield – Loveland
MSN:
P-79
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7000
Captain / Total hours on type:
100.00
Aircraft flight hours:
3119
Circumstances:
The commercial pilot was relocating the multiengine airplane following the completion of an extensive avionics upgrade, which also included the installation of new fuel flow transducers. As the pilot neared the destination airport, he reported over the common traffic advisory frequency that he had "an engine out [and] smoke in the cockpit." Witnesses observed and airport surveillance video showed fire emanating from the airplane's right wing. As the airplane turned towards the runway, it entered a rightrolling descent and impacted the ground near the airport's perimeter fence. The right propeller was found feathered. Examination of the right engine revealed evidence of a fire aft of the engine-driven fuel pump. The fuel pump was discolored by the fire. The fire sleeves on both the fuel pump inlet and outlet hoses were burned away. The fuel outlet hose from the fuel pump to the flow transducer was found loose. The reason the hose was loose was not determined. It is likely that pressurized fuel sprayed from the fuel pump outlet hose and was ignited by the hot turbocharger, which resulted in the inflight fire.
Probable cause:
A loss of control due to an inflight right engine fire due to the loose fuel hose between the engine-driven fuel pump and the flow transducer.
Final Report:

Crash of a Piper PA-46-350P Malibu near Makkovik: 1 killed

Date & Time: May 1, 2019 at 0816 LT
Operator:
Registration:
N757NY
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Goose Bay - Narsarsuaq
MSN:
46-36657
YOM:
2015
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3500
Captain / Total hours on type:
20.00
Copilot / Total flying hours:
1300
Copilot / Total hours on type:
0
Circumstances:
On 01 May 2019 at 0723, the aircraft departed CYYR on a VFR flight plan direct to BGBW. The ferry pilot, who was the pilot-in-command, occupied the left seat while the co-owner occupied the right seat. The aircraft climbed to 2000 feet ASL and proceeded on a direct track to destination. The altitude and heading did not change significantly along the route, therefore it is likely that the autopilot was engaged. At 0816, the aircraft collided with a snow-covered hill 2250 feet in elevation, located 35 nautical miles (NM) southeast of Makkovik Airport (CYFT), Newfoundland and Labrador. The impact happened approximately 200 feet below the top of the hill. The aircraft came to rest in deep snow on steep sloping terrain. The aircraft sustained significant damage to the propeller, nose gear, both wings, and fuselage. Although the cabin was crush-damaged, occupiable space remained. There was no post-impact fire. The ferry pilot was seriously injured and the co-owner was fatally injured. The Joint Rescue Coordination Centre (JRCC) in Halifax received an emergency locator transmitter (ELT) signal from the aircraft at 0823. The ferry pilot carried a personal satellite tracking device, a personal locator beacon (PLB) and a handheld very high frequency (VHF) radio, which allowed communication with search and rescue (SAR). Air SAR were dispatched to the area; however, by that time, the weather had deteriorated to blizzard conditions and aerial rescue was not possible. Ground SAR then deployed from the coastal community of Makkovik and arrived at the accident site approximately 4 hours later because of poor weather conditions and near zero visibility. The ferry pilot and the body of the co-owner were transported to Makkovik by snowmobile. The following day, they were airlifted to CYYR.
Probable cause:
Controlled flight into terrain.
Final Report:

Crash of a Beechcraft B200 Super King in Whatì: 2 killed

Date & Time: Jan 30, 2019 at 0915 LT
Operator:
Registration:
C-GTUC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Yellowknife – Whatì – Wekweèti – Ekati
MSN:
BB-268
YOM:
1977
Flight number:
8T503
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2762
Captain / Total hours on type:
1712.00
Copilot / Total flying hours:
566
Copilot / Total hours on type:
330
Aircraft flight hours:
20890
Aircraft flight cycles:
18863
Circumstances:
At 0851 Mountain Standard Time on 30 January 2019, the Air Tindi Ltd. Beechcraft King Air 200 aircraft (registration C-GTUC, serial number BB-268) departed Yellowknife Airport (CYZF), Northwest Territories, as flight TIN503, on an instrument flight rules flight itinerary to Whatì Airport (CEM3), Northwest Territories, with 2 crew members on board. At 0912, as the aircraft began the approach to CEM3, it departed controlled flight during its initial descent from 12 000 feet above sea level, and impacted terrain approximately 21 nautical miles east-southeast of CEM3, at an elevation of 544 feet above sea level. The Canadian Mission Control Centre received a signal from the aircraft’s 406 MHz emergency locator transmitter and notified the Joint Rescue Coordination Centre in Trenton, Ontario. Search and rescue technicians arrived on site approximately 6 hours after the accident. The 2 flight crew members received fatal injuries on impact. The aircraft was destroyed.
Probable cause:
Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
- For undetermined reasons, the left-side attitude indicator failed in flight.
- Although just before take off the crew acknowledged that the right-side attitude indicator was not operative, they expected it to become operative at some point in the flight. As a result, they did not refer to the minimum equipment list, and departed into instrument meteorological conditions with an inoperative attitude indicator.
- The crew’s threat and error management was not effective in mitigating the risk associated with the unserviceable right-side attitude indicator.
- The crew’s crew resource management was not effective, resulting in a breakdown in verbal communication, a loss of situation awareness, and the aircraft entering an unsafe condition.
- The captain did not have recent experience in flying partial panel. As a result, the remaining instruments were not used effectively and the aircraft departed controlled flight and entered a spiral dive.
- The captain and first officer likely experienced spatial disorientation.
- Once the aircraft emerged below the cloud layer at approximately 2000 feet above ground, the crew were unable to recover control of the aircraft in enough time and with enough altitude to avoid an impact with terrain.

Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
- If flight crews do not use the guidance material provided in the minimum equipment list when aircraft systems are unserviceable, there is a risk that the aircraft will be operated without systems that are critical to safe aircraft operation.
- If flight crews do not use all available resources at their disposal, a loss in situation awareness can occur, which can increase the risk of an accident.

Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
- A review of Air Tindi Ltd.'s pilot training program revealed that all regulatory requirements were being met or exceeded.
Final Report:

Crash of a Cessna 208B Supervan 900 in the Pacific Ocean: 1 killed

Date & Time: Sep 27, 2018 at 1528 LT
Type of aircraft:
Operator:
Registration:
VH-FAY
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Saipan - Sapporo
MSN:
208B-0884
YOM:
2001
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
13600
Aircraft flight hours:
9291
Circumstances:
The pilot of a Cessna 208B aircraft, registered VH-FAY (FAY), was contracted to ferry the aircraft from Jandakot Airport, Western Australia (WA), to Greenwood, Mississippi in the United States (US). The pilot planned to fly via the ‘North Pacific Route’. At 0146 Coordinated Universal Time (UTC) on 15 September 2018, the aircraft took off from Jandakot Airport, WA, and landed in Alice Springs, Northern Territory at 0743. After landing, the pilot advised the aircraft operator that the aircraft had a standby alternator fault indication. In response, two company licenced aircraft maintenance engineers went to Alice Springs and changed the alternator control unit, which fixed the problem. Late the next morning, the aircraft departed Alice Springs for Weipa, Queensland, where the pilot refuelled the aircraft and stayed overnight. On the morning of 17 September, the pilot conducted a 1-hour flight to Horn Island, Queensland. About an hour later, the aircraft departed Horn Island with the planned destination of Guam, Micronesia. While en route, the pilot sent a message to the aircraft operator advising that he would not land in Guam, but would continue another 218 km (118 NM) to Saipan, Northern Mariana Islands. At 1003, the aircraft landed at Saipan International Airport. The next morning, the pilot refuelled the aircraft and detected damage to the propeller anti-ice boot. The aircraft was delayed for more than a week while a company engineer travelled to Saipan and replaced the anti-ice boot. At 2300 UTC on 26 September, the aircraft departed Saipan, bound for New Chitose Airport, Hokkaido, Japan. Once airborne, the pilot sent a message from his Garmin device, indicating that the weather was clear and that he had an expected flight time of 9.5 hours. About an hour after departure, the aircraft levelled out at flight level (FL) 220. Once in the cruise, the pilot sent a message that he was at 22,000 feet, had a tailwind and the weather was clear. This was followed by a message at 0010 that he was at FL 220, with a true airspeed of 167 kt and fuel flow of 288 lb/hr (163 L/hr). At 0121, while overhead reporting point TEGOD, the pilot contacted Tokyo Radio flight information service on HF radio. The pilot was next due to report when the aircraft reached reporting point SAGOP, which the pilot estimated would occur at 0244. GPS recorded track showed that the aircraft passed SAGOP at 0241, but the pilot did not contact Tokyo Radio as expected. At 0249, Tokyo Radio made several attempts to communicate with the pilot on two different HF frequencies, but did not receive a response. Tokyo Radio made further attempts to contact the pilot between 0249 and 0251, and at 0341, 0351 and 0405. About 4.5 hours after the pilot’s last communication, two Japan Air Self-Defense Force (JASDF) aircraft intercepted FAY. The pilot did not respond to the intercept in accordance with international intercept protocols, either by rocking the aircraft wings or turning, and the aircraft continued to track at FL 220 on its planned flight route. The JASDF pilots were unable to see into the cockpit to determine whether the pilot was in his seat or whether there was any indication that he was incapacitated. The JASDF pilots flew around FAY for about 30 minutes, until the aircraft descended into cloud. At 0626 UTC, the aircraft’s GPS tracker stopped reporting, with the last recorded position at FL 220, about 100 km off the Japanese coast and 589 km (318 NM) short of the destination airport. Radar data showed that the aircraft descended rapidly from this point and collided with water approximately 2 minutes later. The Japanese authorities launched a search and rescue mission and, within 2 hours, searchers found the aircraft’s rear passenger door. The search continued until the next day, when a typhoon passed through the area and the search was suspended for two days. After resuming, the search continued until 27 October with no further parts of the aircraft found. The pilot was not located.
Probable cause:
From the evidence available, the following findings are made with respect to the uncontrolled flight into water involving a Cessna Aircraft Company 208B, registered VH-FAY, that occurred 260 km north-east of Narita International Airport, Japan, on 27 September 2018. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing factors:
• During the cruise between Saipan and New Chitose, the pilot very likely became incapacitated and could no longer operate the aircraft.
• The aircraft’s engine most likely stopped due to fuel starvation from pilot inaction, which resulted in the aircraft entering an uncontrolled descent into the ocean.
Other factors that increased risk:
• The pilot was operating alone in the unpressurised aircraft at 22,000 ft and probably not using the oxygen system appropriately, which increased the risk of experiencing hypoxia and being unable to recover.
Final Report:

Crash of a Beechcraft 200 Super King Air in Oscoda: 1 killed

Date & Time: Sep 25, 2018 at 0613 LT
Operator:
Registration:
N241CK
Flight Type:
Survivors:
No
Schedule:
Detroit - Oscoda
MSN:
BB-272
YOM:
1977
Flight number:
K985
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3806
Captain / Total hours on type:
201.00
Aircraft flight hours:
13933
Circumstances:
The airline transport pilot of the multiengine airplane was cleared for the VOR approach. The weather at the airport was reported as 400 ft overcast with 4 miles visibility in drizzle. When the airplane failed to arrive at the airport as scheduled, a search was initiated, and the wreckage was located soon thereafter. Radar data indicated that the pilot was provided vectors to intercept the final approach course. The last radar return indicated that the airplane was at 2,200 ft and 8.1 miles from the runway threshold. It impacted terrain 3.5 miles from the runway threshold and left of the final approach course. According to the published approach procedure, the minimum descent altitude was 1,100 feet, which was 466 ft above airport elevation. Examination of the wreckage revealed that the airplane had impacted the tops of trees and descended at a 45° angle to ground contact; the airplane was destroyed by a postcrash fire, thus limiting the examination; however, no anomalies were observed that would have precluded normal operation. The landing gear was extended, and approach flaps had been set. Impact and fire damage precluded an examination of the flight and navigation instruments. Autopsy and toxicology of the pilot were not performed; therefore, whether a physiological issue may have contributed to the accident could not be determined. The location of the wreckage indicates that the pilot descended below the minimum descent altitude (MDA) for the approach; however, the reason for the pilot's descent below MDA could not be determined based on the available information.
Probable cause:
The pilot's descent below minimum descent altitude during the non precision instrument approach for reasons that could not be determined based on the available information.
Final Report:

Crash of a Piper PA-31-310 Navajo C in Zielona Góra: 1 killed

Date & Time: Nov 24, 2016 at 1205 LT
Type of aircraft:
Operator:
Registration:
D-IFBU
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Zielona Góra - Nordhorn
MSN:
31T-8012050
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
9418
Captain / Total hours on type:
7371.00
Aircraft flight hours:
6641
Circumstances:
While taking off from a grassy runway at Zielona Góra-Przylep Airport, the airplane nosed down, impacted ground and crashed. Both engines were torn off and the aircraft was destroyed by impact forces. There was no fire. The pilot, sole on board, was killed. He was completing a ferry flight to Nordhorn, Lower Saxony.
Probable cause:
The pilot mistakenly retracted the undercarriage at liftoff. There was no immediate decision of the pilot to abandon the takeoff procedure when both propellers contacted the runway surface.
Final Report:

Crash of a Beechcraft B100 King Air in Jackson

Date & Time: Sep 21, 2016 at 1620 LT
Type of aircraft:
Registration:
N66804
Flight Type:
Survivors:
Yes
Schedule:
Memphis – Jackson
MSN:
BE-82
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11295
Captain / Total hours on type:
570.00
Aircraft flight hours:
4013
Circumstances:
The commercial pilot reported that he had completed several uneventful flights in the multiengine airplane earlier on the day of the accident. He subsequently took off for a return flight to his home airport. He reported that the en route portion of the flight was uneventful, and on final approach for the traffic pattern for landing, all instruments were indicating normal. He stated that the airplane landed "firmly," that the right wing dropped, and that the right engine propeller blades contacted the runway. He pulled back on the yoke, and the airplane became airborne again momentarily before settling back on the runway. The right main landing gear (MLG) collapsed, and the airplane then veered off the right side of the runway and struck a runway sign and weather antenna. Witness reports corroborated the pilot's report. Postaccident examination revealed that the right MLG actuator was fractured and that the landing gear was inside the wheel well, which likely resulted from the hard landing. The pilot reported that there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. Based on the pilot and witness statements and the wreckage examination, it is likely that the pilot improperly flared the airplane, which resulted in the hard landing and the collapse of the MLG.
Probable cause:
The pilot's improper landing flare, which resulted in a hard landing.
Final Report:

Crash of a De Havilland DHC-2 Beaver I in Elwyn Creek: 1 killed

Date & Time: Jul 15, 2016 at 2220 LT
Type of aircraft:
Operator:
Registration:
C-GWDW
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Telegraph Creek – Mowdade Lake
MSN:
306
YOM:
1952
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The Beaver floatplane departed Telegraph Creek Water Aerodrome, BC (CAH9) destined for Mowdade Lake, BC, at approximately 2040 PDT on 15 July 2016 on a VFR flight itinerary round-trip with one pilot on board. When the aircraft did not arrive at Mowdade Lake and did not return to CAH9, a search was initiated. The aircraft's wreckage was located at approximately 2000 PDT the following day in a ravine at an elevation of about 5,000 feet near the headwaters of Elwyn Creek, BC. The aircraft was consumed by fire and the pilot was fatally injured.

Crash of a De Havilland DHC-2 Beaver near Barkárdal: 1 killed

Date & Time: Aug 9, 2015 at 1445 LT
Type of aircraft:
Operator:
Registration:
N610LC
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Akureyri – Keflavik
MSN:
1446
YOM:
1960
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
22000
Captain / Total hours on type:
250.00
Circumstances:
At 14:01 on August 9th, 2015, a pilot along with a friend, a contracted ferry flight pilot, planned to fly airplane N610LC, which is of the type De Havilland DHC-2 Beaver, under Visual Flight Rules (VFR) from Akureyri Airport to Keflavik Airport in Iceland. The purpose of the flight was to ferry the airplane from Akureyri to Minneapolis/St. Paul in the United States, where the airplane was to be sold. The airplane was initially flown in Eyjafjörður in a northernly direction from Akureyri, over Þelamörk and then towards and into the valley of Öxnadalur. The cloud ceiling was low and it was not possible to fly VFR flight over the heath/ridge of Öxnadalsheiði. The airplane was turned around in the head of the valley of Öxnadalur and flown towards the ridge of Staðartunguháls, where it was then flown towards the heath/ridge of Hörgárdalsheiði at the head of the valley of Hörgárdalur. In the valley of Hörgárdalur it became apparent that the cloud base was blocking off the heath/ridge of Hörgárdalsheiði, so the airplane was turned around again. The pilots then decided to fly around the peninsula of Tröllaskagi per their original backup plan, but when they reached the ridge of Staðartunguháls again the pilots noticed what looked like a break in the cloud cover over the head of the valley of Barkárdalur. A spontaneous decision was made by the pilots to fly into the valley of Barkárdalur. The valley of Barkárdalur is a long narrow valley with 3000 – 4500 feet high mountain ranges extending on either side. At the head of the valley of Barkárdalur there is a mountain passage at an elevation of approximately 3900 ft. About 45 minutes after takeoff the airplane crashed in the head of the valley of Barkárdalur at an elevation of 2260 feet. The pilot was severely injured and the ferry flight pilot was fatally injured in a post crash fire.
Probable cause:
Causes:
- According to the ITSB calculations the airplane was well over the maximum gross weight and the airplane’s performance was considerably degraded due to its overweight condition.
Weather
- VFR flight was executed, with the knowledge of IMC at the planned flight route across Tröllaskagi. The airplane was turned around before it entered IMC on two occasions and it crashed when the PF attempted to turn it around for the third time.
- Favorable weather on for the subsequent flight between Keflavik Airport and Greenland on August 10th may have motivated the pilots to fly the first leg of the flight in poor weather conditions on August 9th.
Terrain
- The pilots failed to take into account the geometry of the valley of Barkárdalur, namely its narrow width and the fast rising floor in the back of the valley.
Contributing factors:
CRM - Inadequate planning
- The W&B calculations performed by the PF prior to the flight were insufficient, as the airplane’s weight was well over the maximum gross weight of the airplane.
- The plan was to look for an opening (in the weather), first in the head of the valley of Öxnadalur, then the head of Hörgárdalur and finally in the head of Barkárdalur.
- The decision to fly into the valley of Barkárdalur was taken spontaneously, when flying out of the valley of Hörgárdalur and the pilots noticed what looked like a break in the cloud cover over the head of the valley of Barkárdalur.
CRM – Failed to conduct adequate briefing
- A failure of CRM occurred when the PNF did not inform the PF of the amount of fuel he added to the airplane prior to the flight.
Overconfidence
- The special ferry flight permit the pilots received for the ferry flight to Iceland in 2008 may have provided the pilots with a misleading assumption that such loading of the airplane in 2015 was also satisfactory.
Continuation bias
- The pilots were determined to continue with their plan to fly to Keflavik Airport, over the peninsula of Tröllaskagi, in spite of bad weather condition.
Loss of situational awareness
- The pilots were not actively managing the flight or staying ahead of the aircraft, taking into account various necessary factors including performance, weather and terrain.
- The airplane most likely incurred severe carburetor icing in Barkárdalur.
Final Report: