Crash of a Piper PA-31-325 near Purísima de la Concepción

Date & Time: Apr 9, 2017 at 1241 LT
Type of aircraft:
Operator:
Registration:
HP-1928
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tolú - Montería
MSN:
31-7612020
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14791
Captain / Total hours on type:
700.00
Aircraft flight hours:
6840
Circumstances:
The twin engine aircraft departed Cali-Alfonso Bonilla Aragón Airport in the morning on a flight to Tolú, carrying seven passengers and one pilot. After takeoff from Tolú, the pilot decided to position to Montería-Los Garzones Airport. Shortly after takeoff, the pilot encountered engine problems and elected to make an emergency landing in a pasture. Upon landing, the right wing collided with obstacles then the nose gear collapsed and the aircraft came to rest near Purísima de la Concepción, about 10 km east of Tolú. The pilot was uninjured and the aircraft was damaged beyond repair.
Probable cause:
Inadequate fuel management and incomplete execution of procedures by the Pilot, by not activating in time the fuel supply from the external tanks (OUTBD) to the internal tanks (INBD) for the feeding of both the engines, causing the fuel in the internal tanks to run out and causing both engines to stop due to fuel starvation.
Contributing Factors:
- Poor flight planning on part of the pilot by not considering the amount of minimum fuel needed and not complying with the minimum fuel amount required for domestic flights.
- Loss of situational awareness by the pilot by not following the standard operation procedures.
Final Report:

Crash of a Piper PA-42-720 Cheyenne III in Sorocaba: 2 killed

Date & Time: Mar 31, 2017 at 1445 LT
Type of aircraft:
Operator:
Registration:
PP-EPB
Flight Type:
Survivors:
No
Schedule:
Manaus - Sorocaba
MSN:
42-8001035
YOM:
1980
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3382
Captain / Total hours on type:
118.00
Circumstances:
The twin engine aircraft departed Manaus-Aeroclub de Flores Airport on a flight to Barra do Garças, carrying one passenger and one pilot. After takeoff from Manaus, the pilot changed his mind and decided to fly to Sorocaba. On final approach to Sorocaba-Bertram Luiz Leupolz Airport in good weather conditions, the aircraft impacted trees and crashed in a wooded area located about one km short of runway 18. The aircraft was destroyed and both occupants were killed. There was no fire.
Probable cause:
Contributing factors:
- Flight indiscipline – a contributor
The pilot failed to comply with the minimum fuel requirements laid down in the regulations, providing conditions for both engines to stop operating in flight, due to lack of fuel.
- Piloting judgment – a contributor
It was found in this flight an inadequate evaluation for certain parameters related to aircraft operation, particularly with regard to the influence of the chosen flight level on fuel consumption. This misjudgment led to the decision to proceed with the flight to the Aerodrome where it was intended to land, to the detriment of the more conservative option of finding a suitable place for an intermediate landing and a refueling, which led to the depletion of usable fuel in flight.
- Flight planning – a contributor
Inadequate flight preparation work, especially with regard to fuel calculation and cruise level selection, has degraded the safety level and also contributed to the actual accident.
- Decision-making process – undetermined
Difficulties in perceiving, analyzing, choosing alternatives, and acting appropriately due to inadequate judgment, may have resulted in poor assessment of flight parameters (available fuel, distance to destination, verified consumption, etc.), which may have favored the occurrence of lack of fuel failure.
Final Report:

Crash of a Beechcraft 200T Super King Air in West Palm Beach

Date & Time: Jan 27, 2017 at 1750 LT
Registration:
N60RA
Flight Type:
Survivors:
Yes
Schedule:
Treasure Cay - West Palm Beach
MSN:
BT-7
YOM:
1979
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14414
Captain / Total hours on type:
631.00
Copilot / Total flying hours:
1560
Aircraft flight hours:
15782
Circumstances:
The airline transport pilot reported that, before landing following an uneventful flight, he extended the wing flaps to the approach position and extended the landing gear; the gear indicator lights showed "3 green." After touchdown, he heard noises, and the airplane started to sink. After the airplane came to a stop on the right side of the runway, he noticed that the landing gear handle was up. The pilot stated to the copilot, "How did the gear handle get up?" then placed the handle to the down position and the flight crew exited the airplane. The copilot reported that he was acting as an observer during the flight and that he also saw three green landing gear down-and-locked indicator lights before landing. The airframe sustained substantial damage from contact with the runway. All three landing gear were found in a partially-extended position. Skid marks from all three tires were observed on the runway leading up to the main wreckage. Both propeller assemblies were damaged due to contact with the runway. The pressure vessel was compromised from contact with a propeller blade. The nose landing gear actuator was forced up, into the nose gear well and penetrated the upper nose skin. Examination of the landing gear components did not reveal evidence of a preexisting mechanical malfunction or malfunction. The skid marks leading to the wreckage and the partially-extended gear were inconsistent with the pilot's account that the gear handle was up after the airplane came to rest and was then lowered. The gear handle consisted of an electrical switch that required it to be pulled out of a detent before placing it up or down. There was no mechanical linkage between the gear handle and the landing gear, as the gear were driven by an electric motor. It is likely that the pilot realized that the gear were not extended just before touchdown and then tried to lower the gear, resulting in a touchdown with the gear only partially extended. The pilot reported that he had experienced several interruptions to his sleep the night before the accident. He also reported that he flew 7 legs on the day of the accident for a total of 5.2 hours, only eating a banana for breakfast during this time period. It is likely that the pilot's fatigue contributed to his failure to ensure that the landing gear were down and locked before landing.
Probable cause:
The pilot's failure to ensure that the landing gear were down and locked before touchdown. Contributing to the accident was the pilot's self-reported fatigue at the time of the accident.
Final Report:

Crash of a Pacific Aerospace 750XL Falcon 3000 near Tiniroto: 2 killed

Date & Time: Dec 12, 2016 at 0857 LT
Operator:
Registration:
ZK-JPU
Flight Phase:
Flight Type:
Survivors:
No
Site:
MSN:
117
YOM:
2005
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8518
Captain / Total hours on type:
3210.00
Aircraft flight hours:
8028
Circumstances:
At approximately 0500 hrs, 12 December 2016, the pilot of ZK-JPU, arrived at Gisborne Aerodrome. The pilot was accompanied by the operator’s recently employed (trainee) loader driver and already at the hangar was a senior loader driver. The pilot conducted the preflight checks of the aircraft for the day’s agricultural aircraft operations. Earlier that morning the Managing Director of the operator had called the pilot of ZK-JPU. The Managing Director requested that after finishing the first aerial topdressing task at Tauwharetoi Station and prior to the next planned task at Waimaha Station, the pilot complete a task at Pembroke Station. This was because the Managing Director was unwell and unable to undertake the Pembroke Station task as planned. The pilot of ZK-JPU agreed to the additional task. The original work plan for the day was for both loader drivers to attend the first task at Tauwharetoi Station, with the senior loader driver providing oversight for the trainee loader driver. The pilot and the senior loader driver were then to proceed to the second task of the day, while the trainee loader driver was scheduled to return to the aerodrome with the loader truck from the first task. The expectation was for the pilot to go straight from the Tauwharetoi Station task to the Pembroke Station task and then proceed to Waimaha Station. ZK-JPU departed Gisborne Aerodrome at approximately 0515 hrs with the pilot and both loader drivers on board. The aircraft was to operate from a nearby private airstrip where the loader truck was already located, as the task had been commenced the previous week. The aircraft landed at the airstrip at approximately 0530 hrs and the pilot assisted the senior loader driver to get the truck ready, double-checking the calibration of the weigh scales and fuel drain, before commencing the task at approximately 0600 hrs. On the day of the accident another pilot from the same operator, who was operating a similar Pacific Aerospace Ltd 750XL, ZK-XLA, was aerial topdressing an area of Bushy Knoll Station, operating off the Tongataha airstrip. Bushy Knoll Station is to the north of Tauwharetoi Station, alongside the route to the next two tasks scheduled for ZK-JPU at Pembroke and Waimaha Stations. The pilot of ZK-XLA commenced operating at approximately 0555 hrs and completed two to three loads before hearing the pilot of ZK-JPU over the radio at approximately 0615 hrs. The brief conversation that followed consisted of an exchange of greetings and description of locations and intentions. Both pilots then continued with their tasks without further direct communication. On completion of the first task the pilot of ZK-JPU landed at the private airstrip and instructed the senior loader driver to pack up the gear and head back to base. The senior loader driver refuelled the aircraft with 100 litres of fuel, packed up the gear and gave the trainee loader driver the radio which had been used to communicate with the pilot. After a 15 minute break the pilot of ZK-JPU was observed by the senior loader driver getting into the left seat of the aircraft and the trainee loader driver into the right seat. The senior loader driver observed ZK-JPU take off, and then departed the airstrip in the loader truck, to return to the aerodrome. At approximately 0850 the pilot of ZK-XLA received a radio call from the pilot of ZKJPU asking “are you breaking left or right?” followed by the pilot of ZK-JPU stating “I am to your left”. ZK-JPU was then observed by the pilot of ZK-XLA flying behind and to the left of ZK-XLA. The pilot of ZK-XLA advised the pilot of ZK-JPU that he was “sowing the boundary of Bushy Knoll Station […] finishing my run and […] turning right to head back to the airstrip”. Spanning the valley near the boundary of Bushy Knoll Station, near to where the pilot of ZK-XLA was operating were a set of 110 kV high voltage power lines (consisting of six wires termed ‘conductors’, supported by towers). These conductors comprised the two circuits supplying electricity to Gisborne and the East Coast region. The span traverses the valley approximately east-west and the height above terrain at the mid-span of the bottom two conductors (the lowest point of the span) was approximately 200 ft. At 0857 hrs the power supply to Gisborne and the East Coast was interrupted. Finishing the topdressing run, the pilot of ZK-XLA commenced a right climbing turn in order to return to the airstrip and sighted ZK-JPU over his right shoulder. At this point the pilot of ZK-XLA noted that something was trailing from the left wing of ZKJPU. Realising that the item trailing from ZK-JPU’s wing was a wire, the pilot of ZKXLA transmitted “you are trailing wire’’, however no response was received from ZK-JPU. The pilot of ZK-XLA witnessed ZK-JPU continue down the valley, slowly rolling to the left before impacting terrain, approximately 700 m further to the south. A postimpact fire ensued with the pilot of ZK-XLA observing “a lot of black smoke”. The pilot of ZK-XLA immediately commenced circling the accident site and attempted to call the operator via cellphone. Unable to make contact the pilot activated the emergency communications facility on the flight following equipment installed in the aircraft and reported the accident to Gisborne Tower. The accident occurred in daylight at 0857 hrs, approximately 24 NM W of Gisborne Aerodrome, at Latitude: S 38° 44' 30.85" Longitude: E 177° 28' 37.41".
Probable cause:
Conclusions
3.1 The aircraft struck six 110 kV high voltage power lines.
3.2 The pilot likely experienced inattentional blindness, in that the pilot’s attention was likely engaged on the other aircraft and thus the pilot failed to perceive the visual stimuli.
3.3 The pilot was appropriately rated and licensed to conduct the flight.
3.4 Research has shown that striking a wire that the pilot was aware of usually occurred because something changed, such as a last minute change of plan.
3.5 The pilot elected to change the plan at the last minute and detour during the positioning flight to an area where a pilot from the same operator was also conducting aerial topdressing.
3.6 The pilot did not conduct a hazard briefing for the area about to be flown and thus did not afford himself the most accurate and well informed mental model of the area the pilot elected to operate in.
3.7 Several human factors likely influenced the pilot’s decision-making and risk perception leading to the decision to change the original plan and deviate from the minimum heights as stipulated by CAR 91.311 and operators SOPs.
3.8 The safety investigation did not identify any mechanical defects which may have contributed to the accident.
3.9 The accident was not survivable.
Final Report:

Crash of a Beechcraft A100 King Air in Saint-Frédéric

Date & Time: Dec 12, 2016 at 0730 LT
Type of aircraft:
Operator:
Registration:
C-FONY
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Saint-Frédéric - Quebec
MSN:
B-154
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from runway 05 at Saint-Frédéric Airport, the twin engine deviated to the left. The pilot-in-command elected to correct the deviation and to maintain the airplane on the runway centerline but it veered off runway to the left and came to rest in the snow. Both pilots evacuated safely and the aircraft was damaged beyond repair.

Crash of a Quest Kodiak 100 in Moab: 1 killed

Date & Time: Dec 12, 2016 at 0537 LT
Type of aircraft:
Operator:
Registration:
N772RT
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Moab – Salt Lake City
MSN:
100-0140
YOM:
2015
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4635
Captain / Total hours on type:
243.00
Aircraft flight hours:
504
Circumstances:
The commercial pilot was departing on a routine positioning flight in dark night visual meteorological conditions. Footage from a security camera at the airport showed the airplane
take off normally and initiate a right turn, which was the established direction of traffic for the takeoff runway. The airplane continued the right turn, then entered an increasingly rapid descent and subsequently impacted terrain about 1 mile southwest from the airport. The wreckage distribution was consistent with a high-energy impact. Examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or anomalies that would have precluded normal operation. Autopsy and toxicology testing of the pilot did not reveal any evidence of impairment or incapacitation. Visual conditions prevailed in the area at the time of the accident; however, the setting Moon was obscured by cloud cover, and the airport was located in an area of remote, sparsely-populated high desert terrain. This would have resulted in few visual references to which the pilot could have oriented the airplane. Although the pilot had experience operating in this environment in night conditions and held an instrument rating, the circumstances of the accident are consistent with the known effects of spatial disorientation. The investigation could not determine the initiating event which led to the pilot's mismatch between the airplane's perceived and actual attitude; however, he likely experienced a sensory illusion as a result of spatial disorientation, which led to a loss of control.
Probable cause:
The pilot's loss of control shortly after takeoff due to spatial disorientation.
Final Report:

Crash of a Dornier DO328Jet-310 in Toluca

Date & Time: Oct 24, 2016 at 2029 LT
Type of aircraft:
Operator:
Registration:
XA-ALA
Flight Type:
Survivors:
Yes
Schedule:
Chetumal - Toluca
MSN:
3167
YOM:
2000
Location:
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14140
Captain / Total hours on type:
1699.00
Copilot / Total flying hours:
3623
Copilot / Total hours on type:
38
Aircraft flight hours:
13058
Aircraft flight cycles:
13493
Circumstances:
Following an uneventful positioning flight by night from Chetumal, the crew was cleared to land on runway 33 at Toluca Airport. Upon touchdown, the airplane went out of control and veered off runway to the right. While contacting soft grounf, the airplane lost its undercarriage and came to rest in a grassy area. All four occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
Loss of control upon landing due to the exhaust gases of the three turbofan engines and wake turbulences from an heavy category aircraft, causing a runway excursion, and an additional presence of crosswind, resulting in the aircraft rolling over uneven terrain of the safety strip resulting in severe damage.
Contributing factors:
- Safety strip in poor condition,
- Failure to attach times and separation distance between an aircraft taking off and landing on the same runway, to avoid the formation of wake turbulence and the presence of the exhaust gases of turbofan engines.
Final Report:

Crash of a Cessna 550 Citation II in Charallave: 2 killed

Date & Time: Aug 16, 2016 at 1540 LT
Type of aircraft:
Operator:
Registration:
YV3051
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Charallave - Barinas
MSN:
550-0071
YOM:
1979
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Charallave-Óscar Machado Zuloaga Airport Runway 10, while in initial climb, the aircraft banked right, lost altitude and eventually crashed in a huge explosion in a dense wooded area located down below the airfield. The aircraft disintegrated on impact and both pilots were killed. They were completing a positioning flight to Barinas.

Crash of a PZL-Mielec AN-2R near Krapivninsky: 3 killed

Date & Time: Jul 31, 2016 at 1335 LT
Type of aircraft:
Operator:
Registration:
RA-54790
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Berdsk – Mansky
MSN:
1G183-54
YOM:
1979
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
5787
Captain / Total hours on type:
1342.00
Aircraft flight hours:
8853
Circumstances:
The single engine airplane was completing a positioning flight from Berdsk to Mansky where insecticides should be pulverized on wooded area. On board were a pilot, a mechanic and a passenger. Following a night in Berdsk, the airplane took off at 1201LT for the last leg to Mansky. En route, weather conditions deteriorated and the visibility was poor. Too low, the aircraft impacted trees and crashed in a wooded area located on the slope of Mt Abatova (747 metres high) located 40 km east of Krapivninsky. The airplane was destroyed by impact forces and a post crash fire. The wreckage was found the following day at an altitude of 541 metres. All three occupants were killed.
Crew:
R. Rodzhapov, pilot,
I. Valiullin, mechanic.
Passenger:
Yuri Pakhomov, maybe acting as a copilot on this flight, despite he was not licensed anymore.
Probable cause:
Controlled flight into terrain following the decision of the pilot to fly under VFR mode in IMC conditions in an uncontrolled area. Poor flight planning and flying without a copilot were considered as contributing factors.
Final Report:

Crash of a Cessna 207 Stationair 7 near Goodnews Bay

Date & Time: Jun 17, 2016 at 1200 LT
Operator:
Registration:
N91170
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Quinhagak - Goodnews Bay
MSN:
207-00101
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1150
Captain / Total hours on type:
78.00
Aircraft flight hours:
15089
Circumstances:
During cruise flight through an area of mountainous terrain, the commercial pilot became geographically disoriented and selected the incorrect route through the mountains. Upon realizing it was the incorrect route, he initiated a steep climb while executing a 180° turn. During the steep climbing turn, the airplane inadvertently entered instrument meteorological conditions, and the airplane subsequently impacted an area of rocky, rising terrain. The pilot reported there were no mechanical malfunctions or anomalies that would have precluded normal operation of the airplane.
Probable cause:
The pilot's failure to select the correct route through the mountains as a result of geographic disorientation, and his subsequent visual flight into instrument meteorological conditions, which resulted in collision with terrain.
Final Report: