Crash of a Cessna 208B Grand Caravan in Atqasuk

Date & Time: Apr 11, 2018 at 0818 LT
Type of aircraft:
Operator:
Registration:
N814GV
Flight Type:
Survivors:
Yes
Schedule:
Utqiagvik – Atqasuk
MSN:
208B-0958
YOM:
2002
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7713
Aircraft flight hours:
9778
Circumstances:
The pilot was on a visual flight rules flight transporting mail to a remote village. He reported that when he was about 15 minutes from the destination, he checked the automated weather observing system (AWOS) for updated weather information for the destination and recalled that the visibility was reported as 7 miles. However, the information he recalled was not consistent with what was actually reported by the AWOS; 18 minutes before the accident, the AWOS reported no more than 1 3/4 miles visibility. As he descended the airplane from 2,500 ft to 1,500 ft in the terminal area, he observed reduced visibility conditions that would require an instrument approach procedure. According to the pilot, while maneuvering toward the initial approach fix, he heard the autopilot disconnect, and the airplane began an uncommanded descent. He said that he remembered pulling on the control wheel and thought he had leveled off, but then the airplane impacted terrain, which resulted in substantial damage to the fuselage, vertical stabilizer, and rudder. He could not recall if he had heard terrain warnings or alerts before the impact. An airplane performance study indicated that the airplane was in a continuous descent from 2,500 ft until the final data point about 12 ft above the surface; the airplane was not leveled off at any time during the descent. In the final 15 seconds of recorded data, the rate of descent increased from about 500 fpm to about 2,300 fpm before decreasing to 1,460 fpm at the last recorded data point. Postaccident examinations of the airframe, engine, flight control, and autopilot components revealed no mechanical malfunctions or failures that would have precluded normal operation or affected flight controllability. It is likely that the unexpected instrument approach procedure increased the pilot's workload as he maneuvered to set up for the approach. Further, when the autopilot disconnected, the airplane continued to descend; although the pilot reported that he heard the autopilot disconnect, he did not arrest the airplane's descent rate. Given the low visibility conditions, it is likely that the pilot did not detect the airplane's descent, and the airplane descended into the terrain.
Probable cause:
The pilot's decision to continue a visual flight rules flight into an area of instrument meteorological conditions and his subsequent failure to level the airplane after the autopilot disconnected, which resulted in a collision with terrain.
Final Report:

Mishap of a Fokker F27 Friendship 500F in Paris-Roissy-CDG

Date & Time: Oct 25, 2013 at 0125 LT
Type of aircraft:
Operator:
Registration:
I-MLVT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Paris - Dole
MSN:
10373
YOM:
1968
Flight number:
MNL5921
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing a night mail flight from Paris-Roissy-CDG Airport to Dole-Jura (Tavaux) Airport on behalf of Europe Airpost. Shortly after takeoff, while climbing to an altitude of 1,000 feet, the left propeller detached and impacted the left part of the fuselage, causing a large hole. The crew declared an emergency and was cleared for an immediate return. The aircraft landed safely less than 10 minutes later and was parked on the apron. Both pilots were uninjured and the aircraft was damaged beyond repair. The propeller was found in an open field in Mesnil-Amelot, near the airport. Nobody on ground was injured.
Probable cause:
The n°2 propeller blade root on the left engine failed due to fatigue, resulting in separation from the propeller hub and then interaction with the n°1 blade and its disconnection from the propeller hub. The imbalance created by the loss of these two blades led to the front part of the engine being torn off. The cause of the fatigue cracking could not be determined with certainty. The following may have contributed to the fatigue fracture of the propeller blade root:
- Insufficient preloading of the propeller, increasing the stress exerted on it. The lack of maintenance documentation made it impossible to determine the preload values of the bearings during the last general overhaul;
- The presence of manganese sulphide in a heavily charged area of the propeller. The presence of this sulphide may have generated a significant stress concentration factor, raising the local stress level.
The tests and research carried out as part of this investigation show that the propeller blade root is made of a steel whose microstructure and composition are not optimal for fatigue resistance. However, the uniqueness of the rupture more than 50 years after commissioning makes it unlikely that the rate of inclusions, their distribution, size, or sulphur content of the propeller is a contributing factor in the accident.
Final Report:

Crash of a Beechcraft 1900C in Billings: 1 killed

Date & Time: May 23, 2008 at 0124 LT
Type of aircraft:
Operator:
Registration:
N195GA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Billings - Great Falls
MSN:
UB-65
YOM:
1986
Flight number:
AIP5008
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4770
Captain / Total hours on type:
362.00
Aircraft flight hours:
34651
Circumstances:
About one minute after takeoff on a night Instrument Flight Rules (IFR) contract cargo flight, the tower controller advised the pilot that he was squawking the wrong transponder code. Although the pilot reset the transponder to the correct code, he was advised that he was still squawking the wrong code. He then realized that he had selected the wrong transponder, and then switched to the correct one. During the time the pilot was dealing with this issue, the airplane drifted about 30 degrees right of the assigned heading, but the pilot returned to the correct heading as he was contacting the departure controller. The departure controller cleared him to continue his climb and instructed him to turn left about 120 degrees, which he did. About 40 seconds after initiating his left turn of about 120 degrees, while climbing straight ahead through an altitude about 4,700 feet above ground level (AGL), the pilot was instructed to turn 20 degrees further left. Almost immediately thereafter, the airplane began turning to the right, and then suddenly entered a rapidly descending right turn. The airplane ultimately impacted the terrain in a nearly wings-level nose-down attitude of greater than 45 degrees. At the moment of impact the airplane was on a heading about 220 degrees to the right of the its last stabilized course. The investigation did not find any indication of an airframe, control system, or engine mechanical failure or malfunction that would have precluded normal flight, and no autopsy or toxicological information could be acquired due to the high amount of energy that was released when the airplane impacted the terrain. The determination of the initiating event that led to the uncontrolled descent into the terrain was not able to be determined.
Probable cause:
The pilot's failure to maintain aircraft control during the initial climb for undetermined reasons.
Final Report:

Crash of a Beechcraft 1900C in Lihue: 1 killed

Date & Time: Jan 14, 2008 at 0508 LT
Type of aircraft:
Operator:
Registration:
N410UB
Flight Type:
Survivors:
No
Schedule:
Honolulu - Lihue
MSN:
UC-070
YOM:
1989
Flight number:
AIP253
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3098
Captain / Total hours on type:
1480.00
Aircraft flight hours:
19123
Circumstances:
The pilot was flying a night, single-pilot, cargo flight over water between two islands. He had routine contact with air traffic control, and was advised by the controller to maintain 6,000 feet at 0501 hours when the airplane was 11 miles from the destination airport. Two minutes later the flight was cleared for a visual approach to follow a preceding Boeing 737 and advised to switch to the common traffic advisory frequency at the airport. The destination airport was equipped with an air traffic control tower but it was closed overnight. The accident flight's radar-derived flight path showed that the pilot altered his flight course to the west, most likely for spacing from the airplane ahead, and descended into the water as he began a turn back toward the airport. The majority of the wreckage sank in 4,800 feet of water and was not recovered, so examinations and testing could not be performed. As a result, the functionality of the altitude and attitude instruments in the cockpit could not be determined. A performance study showed, however, that the airspeed, pitch, rates of descent, and bank angles of the airplane during the approach were within expected normal ranges, and the pilot did not make any transmissions during the approach that indicated he was having any problems. In fact, another cargo flight crew that landed just prior to the accident airplane and an airport employee reported that the pilot transmitted that he was landing on the active runway, and was 7 miles from landing. Radar data showed that when the airplane was 6.5 miles from the airport, at the location of the last recorded radar return, the radar target's mode C altitude report showed an altitude of minus 100 feet mean sea level. The pilot most likely descended into the ocean because he became spatially disoriented. Although visual meteorological conditions prevailed, no natural horizon and few external visual references were available during the visual approach. This increased the importance of monitoring flight instruments to maintain awareness of the airplane attitude and altitude. The pilot's tasks during the approach, however, included maintaining visual separation from the airplane ahead and lining up with the destination runway. These tasks required visual attention outside the cockpit. These competing tasks probably created shifting visual frames of reference, left the pilot vulnerable to common visual and vestibular illusions, and reduced his awareness of the airplane's attitude, altitude and trajectory.
Probable cause:
The pilot's spatial disorientation and loss of situational awareness. Contributing to the accident were the dark night and the task requirements of simultaneously monitoring the cockpit instruments and the other airplane.
Final Report:

Crash of a Cessna 208B Grand Caravan in Bethel

Date & Time: Dec 18, 2007 at 0856 LT
Type of aircraft:
Operator:
Registration:
N5187B
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Bethel - Hooper Bay - Scammon Bay
MSN:
208B-0270
YOM:
1991
Flight number:
CIR218
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4054
Captain / Total hours on type:
190.00
Aircraft flight hours:
12204
Circumstances:
About 0800, the commercial pilot did a preflight inspection of the accident airplane, in preparation for a cargo flight. Dark night, visual meteorological conditions prevailed. He indicated that the weather conditions were clear and cold, and frost was on the airplane. He said the frost was not bonded to the skin of the airplane, and he was able to use a broom to clean off the frost, resulting in a clean wing and tail surface. He reported that no deicing fluid was applied. After takeoff, he retracted the flaps to about 5 degrees at 110 knots of airspeed. The airplane then rolled to the right about three times in a manner he described as a wave, or vortex-like movement. He applied left aileron and lowered the flaps to 20 degrees, but the roll to the right was more severe. The pilot said the engine power was "good." He then noticed that the airplane was descending toward the ground, so he attempted to put the flaps completely down. His next memory was being outside the airplane after it collided with the ground. The airplane's information manual contains several pages of limitations and warnings about departing with even small amounts of frost, ice, snow, or slush on the airplane, as it adversely affects the airplane's flight characteristics. The manufacturer requires a visual or tactile inspection of the wings, and horizontal stabilizer to ensure they are free of ice or frost if the outside air temperature is below 10 degrees C, (50 degrees F), and notes that a heated hangar or approved deicing fluids should be used to remove ice, snow and frost accumulations. The weather conditions included clear skies, and a temperature of -11 degrees F. Post accident examination of the airplane revealed no observed mechanical malfunction. An examination of the engine revealed internal over-temperature damage, and minor external fire damage consistent with a massive spike of fuel flow at the time of ground impact. Damage to the propeller blades was consistent with high power at the time of ground impact. The rolling/vortex motion of the airplane was consistent with airframe contamination due to frost.
Probable cause:
The pilot's failure to adequately remove frost contamination from the airplane, which resulted in a loss of control and subsequent collision with terrain during an emergency landing after takeoff.
Final Report:

Crash of a Piper PA-31-310 Navajo in Wetaskiwin

Date & Time: Jan 11, 2006 at 2045 LT
Type of aircraft:
Registration:
C-FBBC
Flight Type:
Survivors:
Yes
Schedule:
Fort Vermilion – Wetaskiwin
MSN:
31-48
YOM:
1968
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was landing on runway 30 at Wetaskiwin Airport following an IFR mail flight from Fort Vermilion. During the landing, the crew lost sight of the runway in a thin layer of dense fog that covered the airport. They aborted the landing, and the aircraft settled into a field about ½ mile northwest of the airport. Both pilots sustained serious injuries and the aircraft was damaged beyond repair. The flight crew used a cell phone to call for help. The emergency locator transmitter (ELT) activated during impact.

Crash of a Let L-410UVP-E4 in Iaşi: 2 killed

Date & Time: Jan 27, 2005 at 1130 LT
Type of aircraft:
Operator:
Registration:
HA-LAR
Flight Type:
Survivors:
No
Schedule:
Budapest – Bucharest – Iaşi
MSN:
87 19 23
YOM:
1987
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was performing a mail flight from Bucharest-Băneasa Airport to Iaşi on behalf of the National Romanian Postal Service. On board were two pilots and a load of 310 kilos of mail. On approach to runway 15, the crew encountered poor visibility due to bad weather conditions and initiated a go-around procedure. During the second attempt to land, at an altitude of 2,700 feet, the crew informed ATC he would make a right turn outbound when the aircraft entered a left circuit and descended until it crashed in a wooded area located 300 metres west of the tower. The aircraft was totally destroyed and both pilots were killed.

Crash of an Embraer EMB-110 Bandeirante in Uberaba: 3 killed

Date & Time: Dec 11, 2004 at 0516 LT
Operator:
Registration:
PT-WAK
Flight Type:
Survivors:
No
Site:
Schedule:
São Paulo – Uberaba
MSN:
110-071
YOM:
1975
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4920
Captain / Total hours on type:
596.00
Copilot / Total flying hours:
659
Copilot / Total hours on type:
459
Aircraft flight hours:
11689
Circumstances:
When the crew departed São Paulo-Guarulhos Airport, weather conditions at destination were considered as good. These conditions deteriorated en route and when the crew started the approach to Uberaba Airport by night, the visibility was below IFR minimums. Nevertheless, the crew attempted to land, continued the approach, descended below the MDA by 240 feet when the aircraft struck two houses and crashed in the district of Conjunto Pontal, bursting into flames. The wreckage was found about 800 metres short of runway 17 threshold. Both pilots as well as one people in a house were killed.
Probable cause:
The decision of the crew to descend below MDA in below weather minimums. The following contributing factors were identified:
- Low visibility (night),
- Poor judgment on part of the crew,
- Poor approach planning,
- Lack of supervision,
- The pilot acted on the controls of the aircraft to allow it to stall during the approach, losing its control and colliding with the obstacles,
- Poor crew coordination,
- Lack of discipline.
Final Report:

Crash of a Beechcraft 99 Airliner on Mt Big Baldy: 2 killed

Date & Time: Aug 17, 2004 at 2340 LT
Type of aircraft:
Operator:
Registration:
N199GL
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Billings – Kalispell
MSN:
U-15
YOM:
1968
Flight number:
AIP5071
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
15440
Captain / Total hours on type:
3000.00
Aircraft flight hours:
40521
Circumstances:
While on the return leg of a non-scheduled 14 CFR Part 135 VFR cross-country flight, the airplane collided with mountainous terrain at approximately 9,100 feet above mean sea level. Prior to the accident, the pilot informed air traffic control that he was VFR and level at 8,500 feet MSL. Dark night conditions prevailed at the time of the accident. The aircraft crashed on the south-facing slope of the 9,100-foot mountain near the last recorded radar position. Wreckage and impact signatures at the crash site were indicative of high energy and shallow impact with the terrain. The investigation revealed no evidence of any aircraft mechanical problems.
Probable cause:
The pilot's failure to maintain adequate terrain clearance during cruise, which resulted in the in-flight collision with mountainous terrain. Dark night conditions and mountainous terrain were contributing factors.
Final Report:

Crash of a PZL-Mielec AN-28PD in Tallinn: 2 killed

Date & Time: Feb 10, 2003 at 1942 LT
Type of aircraft:
Operator:
Registration:
ES-NOY
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tallinn - Helsinki
MSN:
1AJ006-04
YOM:
1989
Flight number:
ENI827
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
10856
Captain / Total hours on type:
510.00
Copilot / Total flying hours:
2827
Copilot / Total hours on type:
475
Aircraft flight hours:
1428
Aircraft flight cycles:
2141
Circumstances:
The twin engine aircraft departed Tallinn-Ülemiste Airport on a mail flight to Helsinki, carrying three crew members (two pilots and one mechanic) and a load consisting of 514 kilos of mail. Four seconds after lift off from runway 08, while climbing to a height of 12 metres and at a speed of 170 km/h, the left engine suffered vibrations. The power lever for the left engine was brought back to idle then in a full forward position. Nevertheless, the aircraft lost height, nosed down and crashed in a wooded area located one km past the runway end. Both pilots were killed and the mechanic was seriously injured.
Probable cause:
It was determined that the right engine failed during initial climb following the rupture of a turbine ball bearing due to poor lubrication.
Final Report: