Crash of a Britten-Norman BN-2A-27 Islander in Port Hope Simpson: 1 killed

Date & Time: Jun 7, 2009 at 0830 LT
Type of aircraft:
Operator:
Registration:
C-FJJR
Flight Type:
Survivors:
No
Schedule:
Lourdes-de-Blanc-Sablon - Port Hope Simpson
MSN:
424
YOM:
1975
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
13500
Captain / Total hours on type:
600.00
Circumstances:
The pilot was tasked with a medical evacuation flight to take a patient from Port Hope Simpson to St. Anthony, Newfoundland and Labrador. The aircraft departed the company’s base of operations at Forteau, Newfoundland and Labrador, at approximately 0620 Newfoundland and Labrador daylight time. At approximately 0650, he made radio contact with the airfield attendant at the Port Hope Simpson Airport, advising that he was four nautical miles from the airport for landing. The weather in Port Hope Simpson was reported to be foggy. There were no further transmissions from the aircraft. Although the aircraft could not be seen, it could be heard west of the field. An application of power was heard, followed shortly thereafter by the sound of an impact. Once the fog cleared about 30 minutes later, smoke was visible in the hills approximately four nautical miles to the west of the Port Hope Simpson Airport. A ground search team was dispatched from Port Hope Simpson and the wreckage was found at approximately 1100. The sole occupant of the aircraft was fatally injured. The aircraft was destroyed by impact forces and a severe post-crash fire. There was no emergency locator transmitter signal.
Probable cause:
Finding as to Causes and Contributing Factors:
1. The aircraft departed controlled flight, likely in an aerodynamic stall, and impacted terrain for undetermined reasons.
Other Finding:
1. The lack of onboard recording devices prevented the investigation from determining the reasons why the aircraft departed controlled flight.
Final Report:

Crash of a McDonnell Douglas MD-90-30 in Riyadh

Date & Time: May 8, 2009 at 1558 LT
Type of aircraft:
Operator:
Registration:
HZ-APW
Flight Type:
Survivors:
Yes
Schedule:
Jeddah - Riyadh
MSN:
53513/2257
YOM:
1999
Flight number:
SVA9061
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
A Saudi Arabian Airlines MD-90 was substantially damaged during a runway excursion accident Riyadh (RUH). The seven crew members escaped unhurt. The airplane operated on a repositioning flight from Jeddah. During the flight, the captain discussed the use of manual spoilers during landing with the first officer. He further stated that; as he "had only around 400 hours in the aircraft" as a captain, he wanted to "see the effect' of landing with manual spoilers. He further explained that the flight provided an opportunity to "do it manually" (use manual spoilers) as it was a repositioning flight and, the weather and dry runway conditions were ideal. As such, he discussed the procedure with the first officer and elected to land with the auto ground spoiler system unarmed. The flight was uneventful. During the approach to Riyadh the Landing Checklist was completed, which included the arming of the auto ground spoiler system for landing. After the Landing Checklist was completed, the captain disarmed the auto ground spoiler system with the intention of applying manual ground spoilers after landing. The auto braking system was also not armed prior to landing. The final approach and touchdown to runway 15 Left at Riyadh were uneventful. The touchdown airspeed was 135 knots calibrated air speed (CAS). On touchdown, the captain manually extended the spoiler/speed brake lever, but did not latch it in the fully extended (EXT) position (fully aft and latched upwards). The captain then removed his right hand from the speed brake lever in order to deploy the thrust reversers. The first officer noted the movement of the spoiler/speed brake lever and called "Spoilers Deployed". Since the spoiler/speed brake lever was not fully pulled aft and latched upwards, the lever automatically returned to the forward retracted (RET) position. This movement of the spoiler/speed brake lever was not noticed by the captain and the first officer. In response, the ground spoilers re-stowed before being fully deployed and, a speed brake/flap configuration (SPD BRK/FLP CONFIG) Level 1 Amber Alert occurred. This alert occurred as the aircraft was not yet fully weight on wheels (WOW) and the aircraft still sensed a flight condition with speed brakes deployed and flaps extended beyond six degrees. Six seconds after touchdown on the right main landing gear, the nose gear touched down and the aircraft transferred to a ground condition (WOW on nose gear and main wheel spin up). The SPD BRK/FLP CONFIG alert extinguished when the nose gear oleo actuated ground shift on landing. After touchdown, the aircraft banked to the right and began to drift right of the runway centerline. In response, he applied left rudder, deployed the thrust reversers and applied left aileron. But this did not have any noticeable effect. The captain saw the approaching G4 taxiway exit and in an attempt to keep the aircraft from leaving the runway surface beyond the G4 taxiway exit, he decided to direct the aircraft towards the taxiway. He then applied a right rudder input which caused the aircraft to commence a rapid sweeping turn to the right towards the G4 taxiway exit. The aircraft left the runway at high speed, traversed the full width of the G4 taxiway, and exited the surface at its southern edge. The aircraft then entered a sand section and travelled the distance infield between the edge of the G4 taxiway and the adjacent section of taxiway GOLF. The left main landing gear collapsed during this time. The aircraft came to rest on taxiway GOLF. There was no post impact fire.
Probable cause:
Cause Related Findings
1. The Captain decided to land with manual ground spoilers when the auto ground spoiler system was fully operational.
2. The initiative by the Captain to conduct this improvised exercise contravened the Standard Operating Procedures (SOPs) and the Flight Operations Policy Manual (FOPM).
3. The auto ground spoiler system was disarmed prior to landing.
4. The spoiler/speed brake lever was partially applied manually after landing.
5. The spoiler/speed brake lever was released before it was fully extended and latched.
6. The spoiler/speed brake lever automatically retracted as per design.
7. The ground spoilers never fully deployed.
8. The loss of lift and aircraft deceleration were greatly reduced by the lack of ground spoiler deployment.
9. Brakes were not used in an attempt to control or slowdown the aircraft.
10. The Captain applied a large right rudder input with the intention of directing the aircraft onto the G4 taxiway exit.
11. The aircraft exited the runway at high speed and was travelling too fast to successfully negotiate the right turn onto the G4 taxiway.

Crash of a PZL-Mielec AN-2T in Pokrovsk: 3 killed

Date & Time: Apr 30, 2009 at 2325 LT
Type of aircraft:
Operator:
Registration:
RF-00842
Flight Type:
Survivors:
No
Schedule:
Krasnoyarsk - Lensk - Yakutsk
MSN:
1G195-55
YOM:
1980
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The crew was completing a positioning flight from Krasnoyarsk to Yakutsk with an intermediate stop in Lensk. The intended destination was in fact Prokovsk located about 70 km southwest of Yakutsk but the airfield was not suitable for night movements. On approach to Yakutsk-Magan Airport, the crew continued to Prokovsk where several cars were parked along the runway with their lights ON. Due to low visibility caused by night and snow falls, the crew was unable to establish a visual contact with the ground and two approaches were missed. During a third attempt to land, the aircraft collided with pine trees and power cables and crashed in an open field, bursting into flames. All three occupants were killed.
Probable cause:
The decision of the crew to land on an airfield that was not equipped for night movements.

Crash of a Cessna 421C Golden Eagle III off Hamburg

Date & Time: Apr 28, 2009 at 1835 LT
Operator:
Registration:
D-IKST
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Hamburg – Altenburg – Thüringen
MSN:
421C-1024
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
175
Captain / Total hours on type:
28.00
Aircraft flight hours:
5482
Circumstances:
Shortly after take off from Hamburg-Fuhlsbüttel Airport, the pilot informed ATC that he lost all his navigational instruments and was cleared to divert to Hamburg-Finkenwerder Airport. On final, he encountered difficulties to lower the gears and eventually ditched the aircraft in the Elbe River. The aircraft came to rest upside down in 0,8 meter of water and was destroyed. The pilot escaped with minor injuries.
Final Report:

Crash of a Lockheed P2V-7 near Stockton: 3 killed

Date & Time: Apr 25, 2009 at 1004 LT
Type of aircraft:
Operator:
Registration:
N442NA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Missoula - Alamogordo
MSN:
726-7286
YOM:
1958
Flight number:
Tanker 42
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
7334
Captain / Total hours on type:
916.00
Copilot / Total flying hours:
15075
Copilot / Total hours on type:
350
Aircraft flight hours:
3554
Circumstances:
The multi-engine fire bomber, which was not carrying retardant, was established at its cruise altitude while en route to a fire base where it would be used as part of the effort to fight a local fire. While en route, the flight crew encountered a forecast area of instrument meteorological conditions, whereupon they began a series of descents to lower altitudes in order to stay in visual flight rules (VFR) conditions beneath the clouds. During the last few minutes of their flight, the flight crew had descended to an altitude that was less than 1,300 feet above ground level (agl) over nearly level terrain. As they approached rapidly rising terrain at the end of the broad open valley they had been flying over, they inadvertently entered instrument meteorological conditions (IMC). Soon thereafter, while still in a nearly wings-level attitude, the airplane impacted a ridge about 240 feet below its top. The First Officer, who was flying at the time, had asked the Captain about ten minutes prior to the impact if their altitude was high enough to clear the upcoming terrain, but the Captain did not respond, and the First Officer did not challenge the Captain about the issue. Witnesses in the area reported low clouds with ceilings about 200 feet above ground level with a visibility of one-quarter mile or less, with rain and fog. One of the witnesses reported momentarily viewing the airplane flying "very low," while the others reported only being able to hear the airplane.
Probable cause:
The flight crew's failure to maintain terrain clearance during low altitude flight in low ceiling and visibility conditions. Contributing to the accident was the flight crew's failure to adequately monitor their location with respect to the rising terrain environment ahead, and, their lack of crew resource management communication as a crew.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Fort Lauderdale: 1 killed

Date & Time: Apr 17, 2009 at 1115 LT
Operator:
Registration:
N1935G
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Fort Lauderdale - Fernandina Beach
MSN:
421B-0836
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
23000
Captain / Total hours on type:
5000.00
Circumstances:
Prior to the accident flight witnesses observed the pilot "haphazardly" pouring oil into the right engine. The pilot then ran the engines at mid-range power for approximately 20 minutes. The airplane subsequently taxied out of the ramp area and departed. Fire was observed emanating from the right engine after rotation. The airplane continued in a shallow climb from the runway, flying low, with the right engine on fire. The airplane then banked right to return to the airport and descended into a residential area. Examination of the right engine revealed an exhaust leak at the No. 4 cylinder exhaust riser flange. Additionally, one of the flange boltholes was elongated, most likely from the resulting vibration. The fuel nozzle and B-nut were secure in the No. 4 cylinder; however, its respective fuel line was separated about 8 inches from the nozzle. No determination could be made as to when the fuel line separated (preimpact or postimpact) due to the impact and postcrash fire damage. Examination of the right engine turbocharger revealed that the compressor wheel exhibited uniform deposits of an aluminum alloy mixture, consistent with ingestion during operation, and most likely from the melting of the aluminum fresh air duct. Additionally, the right propeller was found near the low pitch position, which was contrary to the owner's manual emergency procedure to secure the engine and feather the propeller in the event of an engine fire.
Probable cause:
The pilot's failure to maintain aircraft control and secure the right engine during an emergency return to the airport after takeoff. Contributing to the accident was an in-flight fire of the right engine for undetermined reasons.
Final Report:

Crash of a Cessna 650 Citation III in Trigoria: 2 killed

Date & Time: Feb 7, 2009 at 0602 LT
Type of aircraft:
Operator:
Registration:
I-FEEV
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Rome - Bologna
MSN:
650-0105
YOM:
1986
Flight number:
AOE301
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6077
Captain / Total hours on type:
877.00
Copilot / Total flying hours:
3000
Copilot / Total hours on type:
58
Aircraft flight hours:
6977
Circumstances:
The crew was engaged in a positioning flight from Rome to Bologna to pick up a medical team for an ambulance mission. At 0554LT, the crew was cleared for takeoff. The aircraft departed Rome-Ciampino Airport runway 15 at 0600LT. During initial climb, after being cleared to Bolsena at FL240, the aircraft entered an uncontrolled descent and crashed near a cattle barn. The aircraft disintegrated on impact and both pilots were killed. At the time of the accident, weather conditions were as follow: wind from 140 at 18 knots, light rain, few at 1,800 feet, broken 3,000 feet and scattered at 7,000 feet with an OAT of 13° C.
Probable cause:
The cause of the accident was due to an impact with the ground resulting from the loss of control of the aircraft by the captain, who was also the PF. It appears very likely that during the initial phase inadequate attention was replaced by a phase of spatial disorientation, resulting in a loss of situational awareness, which prompted an inadequate intervention on the flight controls by the PF, resulting in total loss of control of the aircraft (having accentuated the tilt to the left wing, instead of leveling the aircraft). It is reasonable to assume that the PF, based on the conviction of being in a right turn for Bolsena in IMC night conditions, misinterpreted the unusual turn, using the controls in order to accentuate the bank angle to the left, drastically reducing the vertical component of lift. This turn has consequently caused the aircraft to assume an attitude of increasing bank, a condition that has been aggravated by the continued application on the controls of a positive load factor in order to stop the sudden loss of altitude, without first leveling the wings. Or the aircraft is stabilized in a pronounced downward spiral to the left. The first officer (PNF), engaged in the management of navigation equipment, has created the unusual turn of the aircraft in conjunction with the commander (PF). Nevertheless, the considerable gradient of experience on the airplane and hierarchy within the organization between the captain and the first officer has probably prevented him to intervene in a more directive or authoritative way in the recovery phase of the situation. Also contributing to the outcome of the event was the lack of detail in the definition of the duties of the crew procedures and inadequate adherence to the basic principles of CRM/MCC, with reference to the monitoring and statement of the navigation modes active, navigation procedures and in particular to the lack of requests for inclusion of turns and routes, the deficiency in the performance of controls and optimization of automation that can lighten the workload in a time unfavorable from the point of view of the circadian rhythm and IMC night. In this respect, it seems fitting to remember the problem of spatial disorientation, although known and studied for decades, is still relevant, and that the only way to counter it is the application of proper use of instruments in compliance with the basic principles of CRM/MCC, which should be part of the normal operating procedures of an operator. This is especially true when working outside of normal circadian rhythms, when it is most easily seen a slowing of cognitive processes.
Final Report:

Crash of a Piper PA-42-720 Cheyenne IIIA in Königstein im Taunus: 1 killed

Date & Time: Jan 19, 2009 at 1240 LT
Type of aircraft:
Operator:
Registration:
D-IDIA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Frankfurt – Reichelsheim
MSN:
42-5501055
YOM:
1990
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2900
Captain / Total hours on type:
449.00
Aircraft flight hours:
9332
Aircraft flight cycles:
21133
Circumstances:
The pilot, sole on board, was completing a positioning flight from Frankfurt-Main Airport to Reichelsheim where the airplane was based. At 1235LT, the twin engine aircraft departed Frankfurt-Main Airport runway 25L and the pilot was instructed to make a left turn and to climb and maintain 1,500 feet. The aircraft climbed to 1,800 feet then descended to 1,400 feet. In rain falls, the aircraft struck trees and crashed in a wooded area located in Königstein im Taunus, about 15 km north of Frankfurt Airport. The aircraft was totally destroyed and the pilot was killed.
Probable cause:
Controlled flight into terrain.
Final Report:

Crash of a Beechcraft 100 King Air in Island Lake

Date & Time: Jan 16, 2009 at 2110 LT
Type of aircraft:
Operator:
Registration:
C-GNAA
Flight Type:
Survivors:
Yes
Schedule:
Thompson - Island Lake
MSN:
B-24
YOM:
1969
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3200
Captain / Total hours on type:
500.00
Copilot / Total flying hours:
1200
Copilot / Total hours on type:
620
Circumstances:
The crew was on a re-positioning flight from Thompson to Island Lake, Manitoba. On arrival in the Island Lake area, the crew commenced an instrument approach to Runway 12. On the final approach segment, the aircraft descended below the minimum descent altitude and the crew initiated a missed approach. During the missed approach, the aircraft struck trees. The crew was able to return for a landing on Runway 12 at Island Lake without further incident. The two crew members were not injured; the aircraft sustained damage to its right wing and landing gear doors. The accident occurred during hours of darkness at approximately 2110 Central Standard Time.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The crew conducted an Area Navigation (RNAV) approach for which they were not trained, with an aircraft that was not properly equipped nor approved for such purpose.
2. The aircraft descended 300 feet below the minimum descent altitude (MDA) as a result of a number of lapses, errors and adaptations which, when combined, resulted in the mismanaged approach.
3. The aural warning on the aircraft’s altitude alerter had been silenced prior to the approach, which precluded it from alerting the crew when the aircraft descended below minimum descent altitude.
4. The SkyNorth standard operating procedures for conducting a non-precision approach were not followed, which resulted in the aircraft descending below the minimum descent altitude. During the ensuing missed approach, the aircraft struck trees.
Findings as to Risk:
1. The lack of a more-structured training environment and the type of supervisory flying provided increased the risk that deviations from standard operating procedures (SOPs) would not be identified.
2. There are several instrument approach procedures in Canada that contain step-down fixes that are not displayed on global positioning system (GPS) units. This may increase the risk of collision with obstacles during step-downs on approaches.
Final Report:

Crash of a Learjet 45 in Telluride

Date & Time: Jan 3, 2009 at 1659 LT
Type of aircraft:
Operator:
Registration:
N279AJ
Flight Type:
Survivors:
Yes
Schedule:
Scottsdale - Telluride
MSN:
45-279
YOM:
2005
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3520
Captain / Total hours on type:
831.00
Copilot / Total flying hours:
3520
Copilot / Total hours on type:
831
Aircraft flight hours:
2338
Circumstances:
The airplane and two-person crew departed on a positioning flight. The pilot-in-command was not flying the airplane and sat in the right seat. The second-in-command was the pilot flying and sat in the left seat. The accident occurred on the second attempt to land at the destination airport on a snow-covered runway. While descending for the airport, the pilot not flying the airplane called the runway in sight. After assessing that they were too high the pilot not flying convinced the pilot flying to circle the airplane down to land on the runway. Circling at speeds greater than allowed by the approach categories, the crew performed a 360-degree turn to align themselves with the runway. The pilot flying did not have the runway in sight, and was verbally assisted by the pilot not flying. Both pilots stated that they were aligned with the center of the runway. During the flare to touchdown the pilot flying reported an unexpected gust of wind from the left requiring a correction. The airplane touched down about 20 feet off and to the right of the runway edge. Substantial damage was sustained to the airplane's wing and fuselage.
Probable cause:
The failure of both pilots to positively identify the runway prior to landing.
Final Report: