Crash of a PZL-Mielec AN-2R in Sarybulak: 2 killed

Date & Time: Jun 24, 2010 at 1730 LT
Type of aircraft:
Operator:
Registration:
UP-A0161
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Taiynsha - Sorochinskiy
MSN:
1G206-40
YOM:
1984
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was on a positioning flight for a crop-spraying mission in North Kazakhstan when he lost his orientation between the villages of Taiynsha and Sorochinskiy. He landed on a small field near the village of Sarybulak to establish his position. After takeoff with a slight tail wind, at a height of 15 metres, the pilot-in-command initiated a left turn when the left lower wing struck a tree. The aircraft stalled and crashed, bursting into flames. Both pilots were killed while the engineer was seriously injured. The aircraft was totally destroyed by a post crash fire.
Probable cause:
The following findings were identified:
- Takeoff from a limited area,
- Failure to take into account obstacles by the crew during takeoff,
- Incorrect selection of the take-off site;
- High outside air temperature and tailwind component.

Crash of a Socata TBM-700 in Gaithersburg

Date & Time: Mar 1, 2010 at 1715 LT
Type of aircraft:
Operator:
Registration:
N700ZR
Flight Type:
Survivors:
Yes
Schedule:
Chapel Hill - Gaithersburg
MSN:
87
YOM:
1993
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4215
Captain / Total hours on type:
1240.00
Circumstances:
The pilot of the single-engine turboprop was on an instrument flight rules (IFR) flight and cancelled his IFR flight plan after being cleared for a visual approach to the destination airport. He flew a left traffic pattern for runway 32, a 4,202-foot-long, 75-foot-wide, asphalt runway. The pilot reported that the airplane crossed the runway threshold at 81 knots and touched down normally, with the stall warning horn sounding. The airplane subsequently drifted left and the pilot attempted to correct with right rudder input; however, the airplane continued to drift to the left side of the runway. The pilot then initiated a go-around and cognizant of risk of torque roll at low speeds did not apply full power. The airplane climbed to about 10 feet above the ground. At that time, the airplane was in a 20-degree left bank and the pilot applied full right aileron input to correct. The airplane then descended in a left turn, the pilot retarded the throttle, and braced for impact. A Federal Aviation Administration inspector reported that the airplane traveled about 100 feet off the left side of the runway, nosed down in mud, and came to rest in trees. Examination of the wreckage by the inspector did not reveal any preimpact mechanical malfunctions, nor did the pilot report any. The reported wind, about the time of the accident, was from 310 degrees at 10 knots, gusting to 15 knots.
Probable cause:
The pilot’s failure to maintain aircraft control while performing a go-around.
Final Report:

Crash of a Cessna 550 Citation Bravo in Reinhardtsdorf-Schöna: 2 killed

Date & Time: Feb 14, 2010 at 2038 LT
Type of aircraft:
Operator:
Registration:
OK-ACH
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Prague - Karlstad
MSN:
550-1111
YOM:
2005
Flight number:
TIE039C
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1700
Copilot / Total flying hours:
1600
Aircraft flight hours:
1830
Aircraft flight cycles:
1686
Circumstances:
During the early evening, at 1946 hrs, after a flight time of one hour and 50 minutes the airplane came back to Prague, Czech Republic, after a flight to France. For the Pilot in Command (PIC) it was the first flight of the day. The co-pilot left the airplane after the landing and was replaced by the copilot of the subsequent accident flight. The co-pilot had already flown two flights that day - around midday - with a total flight time of one hour and 40 minutes. There were no passengers on board. The aircraft departed Prague at 2008 hrs for a ferry flight to Karlskrona, Sweden. The flight was conducted in accordance with Instrument Flight Rules (IFR). The course of events is described based on the analysis of the recordings of the Flight Data Recorder (FDR), the Cockpit Voice Recorder (CVR), radar and radio communications. The appendix shows two different FDR recording diagrams. Diagram 1 shows the entire flight (time in UTC) and diagram 2 shows the flight from 1918:30 UTC on. Take-off took place on runway 31. The co-pilot was Pilot Flying (PF). The flight was conducted manually, neither of the two autopilots was engaged. From 2012 hrs on, after a right hand turn, the flight proceeded toward the north. The airplane was in climb attitude. At 2014:16 hrs, still in climb, the PIC said "I didn't fly night time for long time". The co-pilot asked: "Have you already experienced a roll during night?" She answered laughing: "Yes, really." He: "Better we won't." She laughing: "Do you enjoy that thing?" Co-pilot: "You are the first one with whom I talked about it, don't tell it [...]." PIC: "Whom shall I not tell?" [...] She again: "I also do it always, but I persuade [...] to do that." Co-pilot: "[...] Bravo does it better." At 2015:00 hrs, during this short conversation, the crew received the instruction from ATC Prague to climb to FL260 and to level off above reporting point DEKOV. The conversation in the cockpit continued. Co-pilot: "Bravo does the roll faster with the ailerons but the spoilers are slower." At 2015:33 hrs ATC repeated the instruction. At 2015:40 hrs the PIC acknowledged the instruction. Between 2017:10 hrs and 2017:20 hrs the airplane rolled about its longitudinal axis; initially to the left up to a bank angle of 30°, and right afterwards to the right up to a bank angle of 20°, then back again to the horizontal. At 2017:20 hrs the PIC responded to it with the words: "Let's go, we are already high enough, you nettle me - come on [...]." At 2017:22rs ATC Prague instructed the crew to contact ATC Munich; at 2017:35 hrs the PIC confirmed the instruction. At 2017:42 hrs she said: "Later but." The co-pilot replied: "Let's do it at higher altitude." At 2018:29 hrs, the PIC contacted ATC Munich. At 2018:36 hrs the crew received the instruction from ATC Munich to climb to FL330. This was confirmed at 2018:44 hrs. Between 2018:51 hrs and 2019:00 hrs the following conversation took place:
- 2018:51 hrs PIC: "Sufficient, is it sufficient?"
- 2018:53 hrs Co-pilot: "For what?"
- 2018:54 hrs PIC: "Sufficient."
- 2018:56 hrs PIC: "The altitude."
- 2018:58 hrs Co-pilot: "For what?"
- 2018:58 hrs PIC: "For that,"
- 2019:00 hrs Co-pilot: "It is sufficient."
At 2019:00 hrs the airplane levelled off in FL270, at 2019:05 hrs the airplane nose moved upward until a pitch angle of about 14° was reached. At 2019:09 hrs the aircraft began to roll about its longitudinal axis to the right. Within 4 seconds the airplane reached the inverted flight attitude and in another 4 seconds it rolled another 90°. Simultaneously the heading changed right toward the east, then toward the south and finally toward the west. During the roll the pitch angle decreased to almost -85° which is almost a vertical nose dive. The computed airspeed increased
significantly. The airplane crashed near Reinhardtsdorf-Schöna, Saxon Switzerland, about 500 m north of the border to the Czech Republic.
Probable cause:
The accident was due to:
- The crew tried to conduct a flight manoeuvre (roll) which is not part of commercial air transport,
- The crew suffered loss of spatial orientation and subsequently did no longer have the ability to recover the flight attitude.
The following factors contributed:
- The pilots were not trained in aerobatics,
- It was night and therefore there were no visual references,
- The relationship between the two pilots resulted in the departure from professional behavior in regard to crew coordination,
- The airplane was neither designed nor certified for aerobatics.
Final Report:

Crash of a Cessna 208B Grand Caravan in Beagle Bay

Date & Time: Jan 14, 2010 at 0645 LT
Type of aircraft:
Operator:
Registration:
VH-NTQ
Flight Type:
Survivors:
Yes
Schedule:
Broome - Koolan Island
MSN:
208B-0635
YOM:
1997
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Broome on a charter flight to Koolan Island, WA. At about 0645 Western Standard Time1, when the aircraft was at an altitude of about 9,500 feet, the pilot noticed a drop in the engine torque indication with a corresponding drop in the engine oil pressure indication. The pilot increased the power lever setting but the engine torque and oil indications continued to reduce, all other engine indications were normal. During an interview with the Australian Transport Safety Bureau (ATSB) the pilot stated that he felt a power loss associated with the drop in indicated engine torque. The pilot diverted to the nearest airstrip, which was Beagle Bay, WA. He stated that the low oil pressure warning light illuminated so he shut the engine down and prepared for an emergency landing. The pilot reported that on the final approach to the airstrip he realized that the aircraft was too high and its airspeed was too fast. The aircraft touched down about mid way along the runway and overran the end of the runway by about 200 metres. The aircraft impacted a mound of dirt, coming to rest upside down. The pilot, who was the only occupant sustained minor injuries. Examination of the aircraft by a third party and inspection of the photographs taken of the accident site, revealed that the engine, left main gear and nose gear had separated from the airframe during the accident sequence. There was a significant amount of oil present on the underside of the aircraft, indicating that the oil had leaked from the engine during operation. The
engine was removed from the accident site as an assembly by a third party. The propeller was removed and the engine was shipped to an engine overhaul facility where a disassembly and
examination was conducted under the supervision of the ATSB.
Probable cause:
From the evidence available it was evident that the engine had a substantial in-flight oil leak, which necessitated the in-flight shut down of the engine and a diversion to the nearest available airstrip. The accident damage to the engine in the area of the apparent oil leak precluded a conclusive finding as to the source of the leak. Although the detailed examination of the oil tube attachment lug fracture surfaces was inconclusive, the oil tube remained the most likely source of the oil leak. Evidence from other oil tube failures indicated that significant vibratory loading can cause the oil tube attachment lugs to fracture in the manner observed in the oil tube fitted to VH-NTQ. There was no evidence that the transfer tube was subjected to vibration from a compressor turbine or power turbine blade failure or of an incorrectly fitted engine mount. There was also no evidence of a pre-accident defect that would have caused a reduction in actual engine torque.
Final Report:

Crash of a Learjet C-21A at Talil AFB

Date & Time: Nov 2, 2009 at 1430 LT
Type of aircraft:
Operator:
Registration:
84-0094
Flight Type:
Survivors:
Yes
MSN:
35-540
YOM:
1985
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a positioning flight to Talil AFB (Imam Ali), Iraq. On approach, the aircraft was too high and descended with an excessive speed and a tailwind component of 10 knots. The crew failed to initiate a go-around and the aircraft landed about two-third down the runway. Unable to stop within the remaining distance, the aircraft overran, lost its undercarriage and came to rest in a sandy area about 60 metres past the runway end. Both pilots escaped uninjured while the aircraft was damaged beyond repair and later destroyed by soldiers from the 68th Transportation Company.
Probable cause:
The accident investigation board (AIB) president found clear and convincing evidence that the mishap crew failed to sufficiently reduce speed and altitude during their approach to execute a normal landing, failed to complete the appropriate checklist for a high speed partial flap landing, and failed to recognize that there was insufficient runway remaining to safely land. Finally, the mishap crew failed to initiate a 'Go-Around' to correct the aforementioned deviations. Additionally, the AIB president also found sufficient evidence that skill-based errors, judgment and decision-making errors, cognitive factors, psycho-behavioural factors, coordination, communication and planning factors, and planning inappropriate operations all were substantially contributing factors to the mishap.

Crash of an Ilyushin II-76MD in Mirny: 11 killed

Date & Time: Nov 1, 2009 at 0849 LT
Type of aircraft:
Registration:
RF-76801
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mirny – Irkutsk – Chita
MSN:
00934 95866
YOM:
1989
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The four engine aircraft departed Mirny on a positioning flight to Chita with an intermediate stop in Irkutsk, carrying four passengers and a crew of seven on behalf of the Russian Ministry of the Interior. Shortly after takeoff by night, the aircraft rolled to the right to an angle of 90° then crashed at a speed of 364 km/h some 1,893 metres past the runway end. The aircraft was totally destroyed and all 11 occupants were killed. The accident occurred 59 seconds after takeoff.
Probable cause:
The day before the accident, the aircraft arrived in Mirny following a cargo flight, delivering various goods. After landing, the crew activated the electrical locking system for the rudder and the ailerons, and the 'lock on' light came on in the cockpit panel. In the morning of the accident, prior to takeoff, the crew followed the pre-takeoff checklist and deactivated the electrical locking system, but the 'lock on' light remained illuminated. Considering this as a false alarm, the captain decided to take off and proceeded with a manuel control of the ailerons. The left aileron moved normally while the right aileron got locked because of the locking mechanism. During the takeoff roll, because the four engine were not in full power mode, there was no sound alarm about the aileron locked mechanism. The aircraft deviated to the right and after lift off, it rolled to the right to angle of 8°. The pilot-in-command elected to counteract the banking but this maneuver was limited due to the right aileron locked mechanism. The aircraft continued to roll to the right to an angle of 90° until control was lost.

Crash of an Embraer EMB-500 Phenom 100 in Angra dos Reis

Date & Time: Oct 12, 2009 at 1310 LT
Type of aircraft:
Registration:
PP-AFM
Flight Type:
Survivors:
Yes
Schedule:
Campo de Marte – Angra dos Reis
MSN:
500-00049
YOM:
2009
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7200
Captain / Total hours on type:
39.00
Copilot / Total flying hours:
1400
Copilot / Total hours on type:
39
Aircraft flight hours:
14
Circumstances:
Following an uneventful flight from Campo de Marte, the crew initiated the approach to runway 10 which is 961 metres long. After touchdown, the crew started the braking procedure but the aircraft skidded on runway and cartwheeled. It overran, lost its both main gears and came to rest six metres further. Both pilots escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
The following findings were identified:
- The crew considered the operation at Angra dos Reis Airport as unsafe, but operated the aircraft at that airport several times due to pressures from the aircraft's owner,
- The landing was completed with a tailwind component and a high aircraft weight, without considering the possibility to use runway 28, which demonstrated a poor assessment of the existing landing conditions,
- The relative short landing distance available, less than one km,
- The possible pressure exerted by the owner to carry out the flights, as well as the need to maintain the job or the professional image, may have contributed to the complacency behavior of the crew on the issues that lead to the operation of aircraft under conditions below acceptable safety standards,
- Poor flight planning,
- The relative low experience of the crew on this type of aircraft.
Final Report:

Crash of a Partenavia P.68C-TC in Canevare: 2 killed

Date & Time: Oct 9, 2009 at 1030 LT
Type of aircraft:
Operator:
Registration:
I-ATAT
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Reggio de Calabre – Parma
MSN:
254-14-TC
YOM:
1981
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
En route from Reggio de Calabre to Parma, the twin engine aircraft crashed in unknown circumstances in hilly terrain near Canevare, about 50 km south of Modena. Both occupants were killed and the aircraft was destroyed.

Crash of a Bae 4121 Jetstream 41 in Durban: 1 killed

Date & Time: Sep 24, 2009 at 0757 LT
Type of aircraft:
Operator:
Registration:
ZS-NRM
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Durban - Pietermaritzburg
MSN:
41069
YOM:
1995
Flight number:
LNK911
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2956
Captain / Total hours on type:
751.00
Copilot / Total flying hours:
2002
Copilot / Total hours on type:
1027
Aircraft flight hours:
27429
Circumstances:
During the take-off roll, the cockpit crew of another airliner observed smoke pouring from the right engine of ZS-NRM. They were shocked, yet reluctant to tell the crew of ZS-NRM to abort the take-off as they felt that they might be blamed had the abort gone wrong. Instead, the witnessing pilots enquired from the tower whether the aircraft was aware of the smoke. By the time the ATC responded, the aircraft was already in the air, but with its landing gear not yet retracted. Another aircraft lining up at the holding point informed ZS-NRM that their undercarriage was still extended, and the captain of ZS-NRM then transmitted (instead of using the intercom) an instruction to his co-pilot to raise the gear. During this transmission, the sound of what was possibly a warning sound could be heard in the background. The aircraft became airborne and climbed to approximately 500 ft above mean sea level before losing altitude and making a forced landing on a small field in the Merebank residential area, about 1,4 km from the end of the runway. During the forced landing, a member of the public was struck by the wing of the aircraft and the three crew members were seriously injured in the accident. The captain subsequently died from his injuries.
Probable cause:
Engine failure after takeoff followed by inappropriate crew response, resulting in the loss of both lateral and directional control, the misidentification of the failed engine, and subsequent shutdown of the remaining serviceable engine.
Contributing factors:
- Separation of the second-stage turbine seal plate rim;
- Failure of the captain and first officer to implement any crew resource management procedures as prescribed in the operator’s training manual;
- The crew’s failure to follow the correct after take-off engine failure procedures as prescribed in the aircraft’s flight manual.
Final Report:

Crash of a Beechcraft B200 Super King Air in Hayward

Date & Time: Sep 16, 2009 at 1215 LT
Registration:
N726CB
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Hayward - San Carlos
MSN:
BB-1750
YOM:
2001
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2913
Captain / Total hours on type:
1707.00
Aircraft flight hours:
1229
Circumstances:
The airplane just had undergone a routine maintenance and this was planned to be the first flight after the inspection. During the initial climb, the pilot observed that the airplane was drifting to the left. The pilot attempted to counteract the drift by application of right aileron and right rudder, but the airplane continued to the left. The pilot reported that, despite having both hands on the control yoke, he could not maintain directional control and the airplane collided into a building. The airplane subsequently came to rest on railroad tracks adjacent to the airport perimeter. A post accident examination revealed that the elevator trim wheel was located in the 9-degree NOSE UP position; normal takeoff range setting is between 2 and 3 degrees NOSE UP. The rudder trim control knob was found in the full left position and the right propeller lever was found about one-half inch forward of the FEATHER position; these control inputs both resulted in the airplane yawing to the left. The pilot did not adequately follow the airplane manufacturer's checklist during the preflight, taxi, and before takeoff, which resulted in the airplane not being configured correctly for takeoff. This incorrect configuration led to the loss of directional control immediately after rotation. A post accident examination of the airframe, engines, and propellers revealed no anomalies that would have precluded normal operation.
Probable cause:
The pilot's failure to maintain directional control after takeoff. Contributing to the accident was the pilot's inadequate preflight and failure to follow the airplane manufacturer's checklist to ensure that the rudder trim control and right propeller control lever were positioned correctly.
Final Report: