Crash of a Beechcraft C90B King Air in Rocksprings: 1 killed

Date & Time: Dec 14, 2008 at 1500 LT
Type of aircraft:
Operator:
Registration:
N43KM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hondo – Goodyear
MSN:
LJ-1345
YOM:
1993
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3500
Captain / Total hours on type:
250.00
Aircraft flight hours:
3725
Circumstances:
The pilot was cleared to 17,000 feet approximately 7 minutes after takeoff. After arriving at 17,000 feet, radar showed the airplane in a meandering flight path increasingly off course that continued through the end of the flight, even after several prompts from the controller. The pilot was cleared to flight level 240 (24,000 feet) after about 6 minutes at 17,000 feet, and about 2 minutes later, while passing through about 18,000 feet, he made his last radio transmission, acknowledging a corrected heading. About 6 minutes later, the airplane arrived at 24,000 feet and the pilot did not make any intelligible responses to controller inquiries for the remainder of the flight. At 1456, radar showed the airplane in a descent to 21,000 feet before beginning a rapid descent and continuing to impact. The airplane was substantially damaged by the impact forces and the pilot, who was the only occupant, was fatally injured. During the review of the air traffic control recordings, it was determined that none of the voice transmissions from N43KM sounded as if the pilot was speaking through an oxygen mask microphone. At the accident scene both bleed air switches were observed to be in the closed position and the airplane pressurization switch on the console was observed to be in the dump position. No other preimpact anomalies were observed that would have prevented the normal operation of the airplane.
Probable cause:
The pilot's failure to properly configure the pressurization controls, resulting in his impairment and subsequent incapacitation due to hypoxia.
Final Report:

Crash of a Mitsubishi MU-2B-60 Marquise in Millington

Date & Time: Dec 9, 2008 at 1058 LT
Type of aircraft:
Registration:
N452MA
Flight Type:
Survivors:
Yes
Schedule:
Millington - Millington
MSN:
1533
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5311
Captain / Total hours on type:
662.00
Aircraft flight hours:
6094
Circumstances:
According to the pilot, after he took off for a nearby airport he raised the landing gear but did not raise the 20-degree flaps per the “after takeoff” checklist. Shortly thereafter, when the airplane was at an altitude of about 2,400 feet, and in "heavy rain," the pilot noticed that the right engine was losing power. He subsequently feathered the propeller as engine power reduced to 40 percent, but still did not raise the flaps. Weather, recorded shortly before the accident, included scattered clouds at 500 feet, and a broken cloud layer at 1,200 feet, and the pilot advised air traffic control (ATC) that he would fly an ILS (instrument landing system) approach if he could maintain altitude. After maneuvering, and advising ATC that he could not maintain altitude, the pilot descended the airplane to a right base leg where, about 1/4 nautical mile from the runway, it was approximately 300 feet above the terrain. The pilot completed the landing, with the airplane touching down about 6,200 feet down the 8,000-foot runway, heading about 20 degrees to the left. The airplane veered off the left side of the runway and subsequently went through an airport fence. The left engine was running at “high speed” when fire fighters responded to the scene. The right engine propeller was observed in the feathered position at the scene, and after subsequent examinations, the right engine was successfully run in a test cell with no noticeable loss of power. There was no determination as to why the right engine lost power in flight, although rain ingestion is a possibility. Airplane performance calculations indicated that with the landing gear up, a proper single-engine power setting and airspeed, and flaps raised, the airplane should have been able to climb about 650 feet per minute. Even with flaps at 20 degrees, it should have been able to climb at 350 feet per minute. In either case, unless the airplane was not properly configured, there was no reason why it should not have been able to maintain the altitudes needed to position it for a stabilized approach.
Probable cause:
The pilot’s improper configuration of the airplane following an engine shutdown, which resulted in a low-altitude, unstabilized approach. Contributing to the accident was a loss of engine power for undetermined reasons.
Final Report:

Crash of a Learjet 23 in Atlangatepec: 2 killed

Date & Time: Dec 7, 2008 at 1820 LT
Type of aircraft:
Operator:
Registration:
XC-LGD
Flight Type:
Survivors:
No
Schedule:
Puebla – Atlangatepec
MSN:
23-037
YOM:
1965
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew departed Puebla-Hermanos Serdán-Huejotzingo Airport on a positioning flight to Atlangatepec. On approach to runway 01, the crew made a low pass over the runway then initiated a go-around procedure followed by a circuit in an attempt to land on runway 19. On final approach in limited visibility due to the night and low clouds, the aircraft impacted the water surface and crashed in the Atlanga lagoon. The aircraft sank by a depth of about 30 metres some 800 metres short of runway threshold. Both pilots were killed.
Probable cause:
Controlled flight into terrain after the crew descended too low on final approach.
The following contributing factors were identified:
- Limited visibility due to the night and low clouds,
- The approach was completed with a tailwind component,
- The approach was started about an hour after sunset,
- The copilote was inexperienced.

Crash of a Beechcraft C90 King Air in Chandigarh: 2 killed

Date & Time: Oct 29, 2008 at 1125 LT
Type of aircraft:
Operator:
Registration:
VT-EHY
Flight Type:
Survivors:
No
Schedule:
Chandigarh - Ludhiana
MSN:
LJ-1008
YOM:
1982
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3152
Captain / Total hours on type:
9.00
Copilot / Total flying hours:
664
Copilot / Total hours on type:
13
Aircraft flight hours:
6530
Circumstances:
On 29.10.2008 Punjab Government King Air C90 aircraft, VT-EHY met with an accident while operating flight from Chandigarh to Ludhiana. This accident was notified to DGCA by ATC at Ludhiana and Punjab Government officials shortly after the occurrence. The accident occurred when the aircraft was in the process of making second attempt for landing at Ludhiana Airport. The accident was investigated by Inspector of Accident under Rule 71 of Aircraft Rules, 1937. As per the obligations under ICAO Annex 13, notification was sent to USA, the country of aircraft manufacture, Canada, the country of engine manufacture and ICAO. Transport Safety Board Canada appointed an accredited representative and authorized engine manufacturer M/s P&W to associate with investigation of engines. Low visibility conditions were prevailing at Ludhiana at the time of accident. Due to which the crew located the runway late. They were estimating their position based on GPS. Though they did spot the runway at some stage of the approach, they lost sight of it again and were unable to locate it subsequently. They carried out orbits on the right side (East Side) of R/w 12 in an effort to visually locate the runway and then followed non standard procedure to land. Not comfortable with the approach, the crew decided to go around. Due to low visibility and that they probably did not want to lose the sight of the airfield, carried out non-standard go around. In their anxiety not to lose the sight of the field they descended in three orbits in the vicinity of the airfield on the west side of R/w 12, perhaps to land after making the short circuit from the right. However, due to smoke in the cockpit, severe disorientation, lack of qualification & experience on type of aircraft and on sighting the communication tower, the panic gripped the crew. In their anxiety, the control was lost and aircraft impacted the ground in the steep left bank. Aircraft was destroyed in the crash due to impact and post impact fire. Both the occupant on board died due to fire and collapsing aircraft structure.
Probable cause:
The accident occurred due to loss of control while in base leg for landing at R/W 12 after executing go around on R/W 12.
Contributory Factors:
1) Low visibility reduced the margin of safety, may have caused severe disorientation, influenced their decision and played on crew for use of non standard procedures.
2) Both the crew lacked qualification/experience and familiarity with the type of aircraft and terrain.
3) Smoke in the cockpit further reduced the margin of safety and distracted the attention of the crew.
4) Obstruction in the flight path made the crew to take severe action and led to loss of control.
5) Lack of operational control and supervision by the organisation.
Final Report:

Crash of a Cessna 402C in Vineyard Haven: 1 killed

Date & Time: Sep 26, 2008 at 2003 LT
Type of aircraft:
Operator:
Registration:
N770CA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Vineyard Haven - Boston
MSN:
402C-0432
YOM:
1981
Flight number:
9K1055
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
16746
Captain / Total hours on type:
2330.00
Aircraft flight hours:
26809
Circumstances:
The pilot of the multi engine airplane, operated by a regional airline, was conducting a positioning flight in night instrument meteorological conditions. After takeoff, the airplane made a slight left turn before making a right turn that continued until radar contact was lost. The airplane reached a maximum altitude of 700 feet before impacting terrain about 3 miles northwest of the departure airport. Post accident examination of the wreckage did not reveal any preimpact failures. The weather reported at the airport, about the time of the accident, included a visibility of 5 statute miles in light rain and mist and an overcast ceiling at 400 feet. Analysis of the radar and weather data indicated that, with the flight accelerating and turning just after having entered clouds, the pilot likely experienced spatial disorientation.
Probable cause:
A loss of aircraft control due to spatial disorientation.
Final Report:

Crash of a Cessna 501 Citation I/SP off Santo Domingo: 1 killed

Date & Time: Aug 18, 2008 at 2029 LT
Type of aircraft:
Registration:
N223LC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Santo Domingo - San Juan
MSN:
501-0055
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft departed Santo Domingo-Las Améericas Airport at 2026LT on a positioning flight to San Juan, Porto Rico. While climbing in night conditions, the pilot lost control of the airplane that crashed in the sea few km offshore. SAR operations were initiated but no trace of the aircraft nor the pilot was found.

Crash of a Cessna 550 Citation II in Reading

Date & Time: Aug 3, 2008 at 1519 LT
Type of aircraft:
Operator:
Registration:
N827DP
Flight Type:
Survivors:
Yes
Schedule:
Pottstown - Reading
MSN:
550-0660
YOM:
1990
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12100
Captain / Total hours on type:
2690.00
Copilot / Total flying hours:
1779
Copilot / Total hours on type:
65
Aircraft flight hours:
5008
Circumstances:
The air traffic controller, with both ground and local (tower) responsibilities, cleared the accident airplane to land when it was about 8 miles from the runway. Another airplane landed in front of the accident flight, and the controller cleared that pilot to taxi to the hangar. The controller subsequently cleared a tractor with retractable (bat wing) mowers, one on each side, and both in the “up” position, to proceed from the terminal ramp and across the 6,350-foot active runway at an intersection about 2,600 feet from the threshold. The controller then shifted his attention back to the airplane taxiing to its hangar, and did not see the accident airplane land. During the landing rollout, the airplane’s left wing collided with the right side of the tractor when the tractor was “slightly” left of runway centerline. Calculations estimated that the airplane was about 1,000 feet from the collision point when the tractor emerged from the taxiway, and skid marks confirmed that the airplane had been steered to the right to avoid impact. Prior to the crossing attempt, the tractor operator did not scan the runway, and was concentrating on the left side bat wing. Federal Aviation Administration publications do not adequately address the need for ground vehicle operators to visually confirm that active runways/approaches are clear, prior to crossing with air traffic control authorization, thus overlooking an additional means to avoid a collision.
Probable cause:
The air traffic controller’s failure to properly monitor the runway environment. Contributing to the accident was the tractor operator’s failure to scan the active runway prior to crossing, and the Federal Aviation Administration’s inadequate emphasis on vehicle operator visual vigilance when crossing active runways with air traffic control clearance.
Final Report:

Crash of a Piper PA-31-310 Navajo Chieftain in Mount Isa

Date & Time: Jul 17, 2008 at 0915 LT
Type of aircraft:
Operator:
Registration:
VH-IHR
Flight Type:
Survivors:
Yes
Schedule:
Century Mine - Mount Isa
MSN:
31-8012077
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
469
Captain / Total hours on type:
30.00
Circumstances:
On 17 July 2008, at approximately 0915 Eastern Standard Time1, the pilot of a Piper Navajo PA-31 aircraft, registered VH-IHR, was en route from Century Mine, Qld to Mt Isa, Qld when the left engine lost power. The pilot transmitted an urgency broadcast (PAN) to air traffic control (ATC). A short time later, the right engine also lost power. The pilot then transmitted a distress signal (MAYDAY) to ATC stating his intention to carry out an off-field emergency landing. The aircraft impacted terrain 22 km north of Mt Isa, about 4 km from the Barkly Highway, in relatively flat, sparsely wooded bushland (Figure 1). The pilot, who was the sole occupant, sustained serious injuries.
Probable cause:
From the evidence available, the following findings are made with respect to the fuel starvation event and should not be read as apportioning blame or liability to any particular organisation or individual.
- The pilot did not monitor outboard fuel tank quantity during the flight.
- The pilot incorrectly diagnosed the engine power losses.
- The aircraft was not in the correct configuration for the forced landing.
Final Report:

Crash of a Beechcraft BeechJet 400A in São José dos Campos

Date & Time: Jul 15, 2008 at 1130 LT
Type of aircraft:
Operator:
Registration:
PT-WHF
Flight Type:
Survivors:
Yes
Schedule:
São Paulo - São José dos Campos
MSN:
RK-82
YOM:
1994
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4300
Captain / Total hours on type:
2811.00
Copilot / Total flying hours:
540
Copilot / Total hours on type:
35
Circumstances:
The crew departed São Paulo-Congonhas Airport on a positioning flight to São José dos Campos. While descending to São José dos Campos, the captain led the controls to the copilot who was still under instruction. On final, the aircraft was too high on the glide. The captain took over controls but his reaction was excessive. The aircraft suddenly rolled to the right, causing the right wing to struck the ground few dozen metres short of runway 15 threshold. The aircraft landed and came to rest on the main runway. Both pilots evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
The captain did not conduct a preflight briefing and then improvised during the descent by deciding to leave the controls to the copilot while he was still under instruction.
The following contributing factors were identified:
- The copilot who was pilot-in-command on final was in his initial training process,
- The captain authorized the copilot to be the PIC while he was still under initial training,
- The captain was not qualified to operate as an instructor,
- The captain did not make any simulator training for more than two years,
- The copilot had never completed any simulator training since the beginning of his training,
- Lack of crew coordination,
- Poor judgment on part of the captain.
Final Report:

Crash of a Beechcraft 1900D in Bushi: 3 killed

Date & Time: Mar 15, 2008 at 0920 LT
Type of aircraft:
Operator:
Registration:
5N-JAH
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Lagos - Bebi
MSN:
UE-322
YOM:
1998
Flight number:
TWD8300
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
9730
Captain / Total hours on type:
852.00
Copilot / Total flying hours:
444
Copilot / Total hours on type:
204
Aircraft flight hours:
5578
Circumstances:
The aircraft, Beech 1900D with flight number TWD8300 on a positioning flight, filed an Instrument Flight Rule (IFR) with Air Traffic Services (ATS) at Murtala Muhammed Airport (MMA) Lagos for departure to Bebi airstrip, Obudu on a filed flight plan LAG – UA609 – POTGO – DCT – ENU – DCT - OBUDU. But the actual route flown was LAG – UA609 – POTGO – LIPAR – LUNDO – IKROP – BUDU. The aircraft departed MMA at 0736 hrs as per the flight plan, climbed to FL250, estimated MOPAD at 0755 hrs, BEN at 0814hrs, POTGO at 0837hrs, LIPAR at 0844hrs, LUNDO at 0902 hrs and OBUDU destination at 0917hrs. The aircraft was transferred to Port Harcourt at 0845 hrs thereafter the crew requested descent. It was cleared to FL110 but on passing through FL160 requested further descent and was then released to Enugu at 0856 hrs by Port Harcourt. Enugu cleared it to FL050. The aircraft deviated from the flight plan route, and flew on airway UA609 direct to IKROP from POTGO. The inputs into Global Positioning System (GPS) gave the crew different distances to Bebi. The crew agreed on a coordinate to input and thereafter were busy trying to locate the airstrip physically. During this process the Ground Proximity Warning System (GPWS), warning signals and sound of “Terrain, terrain…..pull up” was heard several times without any of the pilot following the command. The aircraft flew into terrain, crashed and was destroyed. At 0923hrs, the Radio Operator at Bebi called the aircraft to confirm its position, but received no reply. The FDR showed that the aircraft crashed at about 0920:15 hrs at an altitude of about 3,400ft at Bushi Village during the hours of daylight with three fatalities. The aircraft flew for 103.75 minutes before impact.At 0924 hrs, Bebi Radio Operator called Calabar, to confirm if in contact with 5N-JAH, Calabar replied negative contact. The burnt wreckage was found by hunters in a dense wooded area on 30 August 2008.
Probable cause:
The flight crew conducted an approach into a VFR airfield in an instrument meteorological condition and did not maintain terrain clearance and minimum safe altitude which led to Controlled Flight Into Terrain. The crew did not respond promptly to GPWS warning.
Contributory Factors:
- The flight crew was not familiar with the route in a situation of low clouds, poor visibility and mountainous terrain.
- The Area Controllers did not detect the estimate as passed by the pilot for positions not in the filed flight plan (LIPAR and LUNDO) and omitting ENUGU.
- The flight crew changed from IFR flight to VFR flight without proper procedure and ATC clearance.
- The crew did not use Jeppesen charts as approved in WINGS AVIATION Operational Specifications by NCAA.
- The Lagos Area Control Center (ACC) did not detect or question the disparity in waypoints and routing as read back by the crew, compared with the filed flight plan.
Final Report: