Crash of a Cessna 402B in Rome: 2 killed

Date & Time: Sep 7, 2012 at 1300 LT
Type of aircraft:
Operator:
Registration:
I-ERJA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Rome - Brescia
MSN:
402B-0918
YOM:
1975
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Rome-Ciampino Airport, while in initial climb, the twin engine aircraft went out of control and crashed in a car demolition, bursting into flames. The aircraft was totally destroyed by impact forces and a post impact fire as well as more than 30 cars. Both crew were killed.

Crash of a Cessna 500 Citation I in Santiago de Compostela: 2 killed

Date & Time: Aug 2, 2012 at 0618 LT
Type of aircraft:
Operator:
Registration:
EC-IBA
Flight Type:
Survivors:
No
Schedule:
Oviedo - Santiago de Compostella
MSN:
500-0178
YOM:
1974
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3600
Captain / Total hours on type:
500.00
Copilot / Total flying hours:
678
Copilot / Total hours on type:
412
Aircraft flight hours:
9460
Circumstances:
Based on the information available, at 20:40 the ONT (National Transplant Organization) informed the Santiago Airport (LEST) that they were going to make a “hospital flight”. The aircraft was refueled at the Santiago Airport with 1062 liters of fuel. According to communications, the crew of aircraft EC-IBA contacted the Santiago tower at 21:46 to request permission to start up and information on the weather and the runway in use at Asturias. At 21:54 they were cleared to take off. According to the airport operations office, the aircraft landed in Asturias (LEAS) at 22:27. The hospital flight service commenced at 22:15. The RFFS accompanied the ambulance to the aircraft at 22:30 and at 22:44 the aircraft took off en route to Porto. The aircraft was transferred from Madrid control to Santiago approach at 22:52 at flight level 200 and cleared straight to Porto (LPPR). Based on the information provided by Porto Airport, the aircraft landed at 23:40. While waiting for the medical team to return, the crew remained in the airport’s facilities. According to some of the personnel there, the crew made some comments regarding the bad weather. There was fog, especially on the arrival route. At 01:34 and again at 02:01 the crew was supplied with the flight plan information, information from the ARO-LPPR office and updated weather data. The aircraft was refueled at the Porto Airport with 1,000 l of fuel and took off at 02:34. At 02:44 the aircraft contacted approach control at Santiago to report its position. Four minutes later the crew contacted the Santiago tower directly to ask about the weather conditions at the field (see Appendix C). The aircraft landed once more in Asturias at 03:28. At 03:26 the RFFS was again activated to escort the ambulance to the aircraft. The service was deactivated at 04:00. The crew requested updated weather information from the tower, which provided the information from the 03:00 METAR. According to the flight plan filed, the estimated off-block time (EOBT) for departing from the Asturias Airport was 03:45, with an estimated flight time to Santiago of 40 minutes. The alternate destination airport was Vitoria (LEVT). The aircraft took off from Asturias at 03:38. At 03:56 the crew established contact with Santiago approach control, which provided the crew with the latest METAR from 03:30, which informed that the runway in use was 17, winds were calm, visibility was 4,000 m with mist, few clouds at 600 ft, temperature and dew point of 13° and QNH of 1,019. The aircraft was then cleared to conduct an ILS approach to runway 17 at the Santiago Airport. At 04:15 the crew contacted the tower controller, who reported calm winds and cleared them to land on runway 17. At 04:18 the COSPAS-SARSAT system detected the activation of an ELT. The system estimated the position for the beacon as being in the vicinity of the LEST airport. At 04:38 the tower controller informed airport operations of a call he had received from SAR that a beacon was active in the vicinity of the airport, and requested that a marshaller go to the airport where the airplane normally parked to see if it was there. At 04:44 the marshaller confirmed that the aircraft was not in its hangar and the emergency procedure was activated, with the various parties involved in the search for the airplane being notified. At 05:10 the control tower called the airport to initiate the preliminary phase (Phase I) before activating the LVP. At 05:15 the RFFS reported that the aircraft had been found in the vicinity of the VOR. At 05:30 the LVP was initiated (Phase II). At 07:51 the LVP was terminated. The last flight to arrive at the Santiago Airport before the accident had landed at 23:33, and the next flight to arrive following the accident landed at 05:25.
Probable cause:
The ultimate cause of the accident could not be determined. In light of the hypothesis considered in the analysis, the most likely scenario is that the crew made a non-standard precision approach in manual based primarily on distances. The ILS frequency set incorrectly in the first officer’s equipment and the faulty position indicated on the DME switch would have resulted in the distance being shown on the captain’s HSI as corresponding to the VOR and not to the runway threshold. The crew shortened the approach maneuver and proceeded to a point by which the aircraft should already have been established on the localizer, thus increasing the crew’s workload. The crew then probably lost visual contact with the ground when the aircraft entered a fog bank in the valleys near the airport and did not realize they were making an approach to the VOR and not to the runway.
The contributing factors were:
- The lack of operational procedures of an aircraft authorized to be operated by a single pilot operated by a crew with two members.
- The overall condition of the aircraft and the instruments and the crew’s mistrust of the onboard instruments.
- The fatigue built up over the course of working at a time when they should have been sleeping after an unplanned duty period.
- The concern with having to divert to the alternate without sufficient fuel combined with the complacency arising from finally reaching their destination.
Final Report:

Crash of a Beechcraft C90GT King Air in Morgantown: 1 killed

Date & Time: Jun 22, 2012 at 1001 LT
Type of aircraft:
Registration:
N508GT
Flight Type:
Survivors:
No
Schedule:
Tidioute - Farmington - Morgantown
MSN:
LJ-1775
YOM:
2008
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
22000
Aircraft flight hours:
1439
Circumstances:
The airplane, operated by Oz Gas Aviation LLC, was substantially damaged when it struck a communications tower near Morgantown, West Virginia. The certificated airline transport pilot was fatally injured. No flight plan had been filed for the positioning flight from Nemacolin Airport (PA88), Farmington, Pennsylvania, to Morgantown Municipal Airport (MGW), Morgantown, West Virginia conducted under Title14 Code of Federal Regulations (CFR) Part 91. At 0924 on the morning of the accident, the airplane departed from Rigrtona Airport (13PA), Tidioute, Pennsylvania for PA88 with the pilot and three passengers onboard. The airplane landed on runway 23 at PA88 at 0944. The pilot then parked the airplane; shutdown both engines, and deplaned the three passengers. He advised them that he would be back on the following day to pick them up. After the passengers got on a shuttle bus for the Nemacolin Woodlands Resort, the pilot started the engines. He idled for approximately 2 minutes, and then back taxied on runway 23 for takeoff. At 0957, he departed from runway 23 for the approximately 19 nautical mile positioning flight to MGW, where he was going to refuel and spend the night. After departure from PA88, the airplane climbed to 3,100 feet above mean sea level (msl) on an approximately direct heading for MGW. The pilot then contacted Clarksburg Approach Control and was given a discrete code of 0130. When the airplane was approximately nine miles east of the Morgantown airport, the air traffic controller advised the pilot that he had "radar contact" with him. The airplane then descended to 3,000 feet, and approximately one minute later struck the communications tower on an approximate magnetic heading of 240 degrees. According to a witness who was cutting timber across the road from where the accident occurred; the weather was cloudy with lighting and thunder, and it had just started "sprinkling". He then heard a loud "bang", turned, and observed the airplane descending upside down, and then impact. About 20 minutes later it stopped "sprinkling". He advised that he could still see the top of the tower when it was "sprinkling".
Probable cause:
The pilot's inadequate preflight route planning and in-flight route and altitude selection, which resulted in an in-flight collision with a communications tower in possible instrument
meteorological conditions. Contributing to the accident were the pilot's improper use of the enhanced ground proximity warning system's terrain inhibit switch and the air traffic controller's failure to issue a safety alert regarding the proximity of the tower.
Final Report:

Crash of a Cessna 208B Grand Caravan in Barra do Vento

Date & Time: May 23, 2011 at 0750 LT
Type of aircraft:
Registration:
PT-OSG
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Barra do Vento – Boa Vista
MSN:
208B-0300
YOM:
1992
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6200
Captain / Total hours on type:
4800.00
Circumstances:
The pilot, sole on board, departed Barra do Vento Airport on a ferry flight to Boa Vista-Atlas Brasil-Cantanhede Airport, Roraima. Shortly after rotation, he noticed abnormal vibrations. At the same time, the 'door warning' light came ON on the instrument panel. He decided to land back but lost control of the airplane that veered off runway to the right and collided with an earth mound, bursting into flames. The aircraft was totally destroyed by a post crash fire and the pilot was seriously injured.
Probable cause:
It is possible that the pilot applied the flight controls inappropriately when the aircraft returned to the runway, making it impossible to maintain direction. After the 'door warning' light activated, the pilot made the decision to land when, according to the manufacturer, the situation did not require such immediate action but a continuation of the climb. It is possible that the pilot's training was not adequate or sufficient, because after the 'door warning' light came ON and the abnormal vibrations, the pilot carried out a procedure different from the one recommended by the manufacturer, and placed the plane in an irreversible condition.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Castries

Date & Time: Apr 13, 2011 at 1140 LT
Operator:
Registration:
N511LC
Flight Type:
Survivors:
Yes
Schedule:
Bridgetown – Castries
MSN:
421B-0423
YOM:
1973
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Bridgetown-Grantley Adams Airport, the pilot landed at Castries-George F. L. Charles (Vigie) Airport. Upon touchdown, the left main gear collapsed. The aircraft veered off runway and came to rest against a fence. The pilot was uninjured and the aircraft was damaged beyond repair.

Ground accident of a Boeing 737-2T5 at Hoedspruit AFB

Date & Time: Jan 10, 2011 at 2050 LT
Type of aircraft:
Operator:
Registration:
ZS-SGX
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Hoedspruit - Johannesburg
MSN:
22396/730
YOM:
1981
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
26512
Copilot / Total flying hours:
1300
Copilot / Total hours on type:
1100
Aircraft flight hours:
70094
Circumstances:
The aircraft was flown on a non-scheduled charter flight from O. R. Tambo International Airport to Hoedspruit military aerodrome, where it landed safely and all 97 passengers disembarked. The crew then prepared to return to O. R. Tambo International Airport with no passengers on board. Whilst taxiing to the cleared holding point for takeoff, the pilot switched off the landing lights to avoid blinding an approaching aircraft. As a result, he overshot the turning point in the darkness and found himself at the end of the taxiway with insufficient space to turn around. According to him, he decided to manoeuvre the aircraft out of the "dead end" by turning into the last taxiway, which led to military hangars, and then reversing the aircraft to carry out a 180° turn. This was to be done without external guidance. Whilst reversing the aircraft, the pilot failed to stop it in time, the main wheels rolled off the edge of the taxiway and the aircraft slipped down a steep embankment, coming to rest with the nose-wheel still on the taxiway. The aeroplane was substantially damaged, but no-one was injured.
Probable cause:
Inappropriate decision by the captain to reverse the aircraft at night without external guidance.
Final Report:

Crash of an Antonov AN-22A near Krasny Oktyabr: 12 killed

Date & Time: Dec 28, 2010 at 2130 LT
Type of aircraft:
Operator:
Registration:
RA-09343
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Voronezh - Tver
MSN:
043482272
YOM:
1974
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
12
Circumstances:
The crew was returning to his base at Tver-Migalovo after he delivered a MiG-31 to the Voronezh Military Aviation Engineering University. While in cruising flight, the four engine aircraft entered an uncontrolled descent and crashed in a snow covered prairie located near Krasny Oktyabr. The aircraft was totally destroyed and all 12 occupants were killed.

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Cleburne

Date & Time: Jul 22, 2010 at 1100 LT
Operator:
Registration:
N601AT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cleburne - Mena
MSN:
61-0332-095
YOM:
1976
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
28000
Captain / Total hours on type:
332.00
Circumstances:
After takeoff, the right engine experienced a loss of power followed by the left engine losing power. The pilot maneuvered the airplane toward the nearest open field and the airplane impacted terrain during landing, resulting in a circumferential split in fuselage near the aft pressure bulkhead. The airplane was equipped with 4 fuel tanks: 2 located in each wing outboard of the engine nacelle (65-gallon capacity), 1 main fuselage tank (about 44-gallon capacity), and 1 auxiliary tank located in forward section of baggage compartment (45-gallon capacity). The airplane was capable of carrying 209.5 gallons usable fuel and the pilot stated that prior to departure he filled the main fuselage tank to capacity, added 20 gallons in the auxiliary tank and 25 gallons in each wing tank, which he equated to a total of 131 gallons on board. The fuselage contained two fuel filler necks, one for each fuselage tank (main and auxiliary). The auxiliary tank was clearly placarded with a red placard visibly standing out against a silver paint stripe; the main tank was not clearly placarded, with a red placard blending easily with red paint stripe. A salvage retriever recalled that during recovery the left wing contained 17 gallons of fuel, the right wing contained 57 gallons of fuel, the main fuselage tank contained 2.5 gallons of fuel, and the auxiliary fuselage tank contained 28 gallons of fuel. A postaccident examination of the airplane and engines revealed no anomalies that would have precluded normal operation. The main fuselage tank and auxiliary fuselage tank were not breached and the fuel sumps contained check valves which prevent the back-flow of fuel from one fuel tank to another. Based on the evidence it is likely that the pilot exhausted the airplane's fuel supply in the main fuselage tank, which resulted in the loss of power to both engines.
Probable cause:
A total loss of engine power due to fuel starvation as a result of the pilot’s improper fuel management. Contributing to the accident were the critical fuel placards that were difficult to see due to the airplane's paint scheme.
Final Report:

Crash of a Tupolev TU-204-100 in Moscow

Date & Time: Mar 22, 2010 at 0235 LT
Type of aircraft:
Operator:
Registration:
RA-64011
Flight Type:
Survivors:
Yes
Schedule:
Hurghada - Moscow
MSN:
14507413640
YOM:
1993
Flight number:
TUP1906
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5388
Captain / Total hours on type:
1868.00
Copilot / Total flying hours:
1973
Copilot / Total hours on type:
979
Aircraft flight hours:
18335
Aircraft flight cycles:
4795
Circumstances:
The aircraft was returning to Moscow on a ferry flight after passengers have been dropped off in Hurghada. On approach to Moscow-Domodedovo Airport, the visibility was low due to foggy conditions. Horizontal visibility on runway 14L threshold was 1,300 meters and vertical visibility was 200 feet. In flight, the flight computer failed and the crew continued the approach below minimums. Despite he was not able to establish a visual contact with the runway, the captain continued the approach and failed to initiate a go-around procedure. The aircraft descended below the glide, impacted trees and crashed in a dense wooded area located 1,450 metres short of runway. All eight occupants were injured, three seriously. The aircraft was destroyed.
Probable cause:
The crew performed an approach in below-minima weather conditions for an airplane with a defective flight computer. The crew failed to initiate a go-around procedure while unable to establish a visual contact with the runway.
Contributing factors were:
- Insufficient training of the crew to perform approaches at or near weather minimums,
- Lack of control over the activities of the crew, which led to poor resource management (CRM) of the captain,
- Failure of the flight control computer system, which led to an increase in the allowed weather minima of the aircraft,
- Failure of captain to divert to another airport,
- Failure of captain to decide about a missed approach when there was visual contact with the approach lights,
- Failure of the co-pilot to call for a missed approach,
- Unsatisfactory interaction in the crew, resulting in a descent below safe altitude.
Final Report:

Crash of a Fletcher FU-24-950 in Ketapang: 2 killed

Date & Time: Dec 31, 2009 at 0826 LT
Type of aircraft:
Operator:
Registration:
PK-PNX
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Ujung Tanjung - Jambi - Pangkal Pinang - Ketapang - Tangar
MSN:
187
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2892
Captain / Total hours on type:
641.00
Circumstances:
The aircraft was completing a ferry flight from Ujung Tanjung/Pekanbaru home base to Tangar airstrip, Center of Kalimantan, with reference flight approval number D09-038960 and Security Clearance number AU05-033328, person on board was one pilot and one engineer. On 29 December 2009, the aircraft departed from Ujung Tanjung, transit at Jambi and stop overnight at Pangkal Pinang Airport, Bangka with total flight time was 3 hours. On the next day 30 December 2009, the aircraft continuing flight from Pangkal Pinang to Rahadi Oesman Airport, Ketapang, West Kalimantan and overnight at Ketapang with total flight time is 1:40 hours. On the next day 31 December 2009, the aircraft plan to continued flight to Tangar Airstrip. The aircraft was airworthy prior departure and dispatched from Ketapang with the following sequence:
a. The pilot requested for start the engine at 01:17 UTC4 (08:17 Local Time);
b. At 01:24 the pilot requested for taxi, and the ATC gave clearance via taxiway “A”. The pilot requested intersection runway 17 and approved by ATC
c. The ATC requested for reported when ready for departure, and the pilot reported ready for departure, then the ATC gave the departure clearance.
d. At 01:25, the aircraft was departed and crashed at 01:26 striking the roof of the hospital and broken down into pieces at the parking area in which have had approximate 1.5 Kilometer to the left side from the flight path centreline. The aircraft was substantially damage and the crew on board consist of one pilot in command and one aircraft maintenance engineer; both of them were fatally injured.
Probable cause:
The investigation concluded that the aircraft engine was not in power during impact with the hospital roof. There was a corroded fuel pump, that indicated of contaminated fuel.
Findings:
• The aircraft was airworthy prior departure.
• The pilot was fit for flight.
• The booster pump was found of an evident of surface corrosion on the spring, plate and van pump indicated that contaminated fuel.
• Referred to the Fletcher Flight Manual and Pilot Operating Handbook chapter 3.10. Fuel System Failure, the booster pump must have been operated prior to flight.
• The propeller blades were on fine pitch and no sign of rotating impact. The engine was not in powered when hit the ground.
• No evidence damage related to the engine prior to the occurrence.
Final Report: