Crash of a PZL-Mielec AN-2T in Alta Mesa

Date & Time: Oct 14, 2021 at 1600 LT
Type of aircraft:
Operator:
Registration:
N857PF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Alta Mesa – Reno
MSN:
1G108-57
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9811
Captain / Total hours on type:
70.00
Aircraft flight hours:
3500
Circumstances:
The pilot stated that the departure started normally but that, after becoming airborne, the airplane controls were not responding to his inputs as expected. The airplane continued to pitch up in a nose-high attitude and he was unable to push the control yoke forward, which he described as feeling like he was “stretching” cables with forward pressure. With the airplane’s pitch uncontrollable, he elected to make a rapid maneuver toward an unpopulated area. The airplane descended into trees; after coming to a stop, a fire erupted. A postaccident examination of the flight control system revealed no definitive evidence of preimpact mechanical malfunctions or failures. Because the elevator system was extensively damaged and was partially consumed by fire, the investigation was not able to determine the cause of the pitch control anomaly. The airplane’s weight and center of gravity (CG) could not be confirmed. The burned remains of items found in the airplane could not be identified and the location of those items at impact could not be confirmed.
Probable cause:
The pilot’s inability to control the airplane’s pitch during departure for reasons that could not be determined because of the extensive fragmentation and thermal damage the airplane sustained in the accident sequence.
Final Report:

Crash of a Cessna 340A in Santee: 2 killed

Date & Time: Oct 11, 2021 at 1214 LT
Type of aircraft:
Registration:
N7022G
Flight Type:
Survivors:
No
Site:
Schedule:
Yuma – San Diego
MSN:
340A-0695
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1566
Circumstances:
The pilot was on a cross-country flight, receiving vectors for an instrument approach while in instrument meteorological conditions (IMC). The approach controller instructed the pilot to descend to 2,800 ft mean sea level (msl) until established on the localizer, and subsequently cleared the flight for the instrument landing system (ILS) approach to runway 28R, then circle to land on runway 23. About 1 minute later, the controller told the pilot that it looked like the airplane was drifting right of course and asked him if he was correcting back on course. The pilot responded “correcting, 22G.” About 9 seconds later, the pilot transmitted “SoCal, is 22G, VFR runway 23” to which the controller told the pilot that the airplane was not tracking on the localizer and subsequently canceled the approach clearance and instructed the pilot to climb and maintain 3,000 ft. As the pilot acknowledged the altitude assignment, the controller issued a low altitude alert, and provided the minimum vectoring altitude in the area. The pilot acknowledged the controller’s instructions shortly after. At this time, recorded advanced dependent surveillance-broadcast (ADS-B) data showed the airplane on a northwesterly heading at an altitude of 2,400 ft msl. Over the course of the following 2 minutes, the controller issued multiple instructions for the pilot to climb to 4,000 ft, which the pilot acknowledged; however, ADS-B data showed that the airplane remained between 2,500 ft and 3,500 ft. The controller queried the pilot about his altitude and the pilot responded, “2,500 ft, 22G.” The controller subsequently issued a low altitude alert and advised the pilot to expedite the climb to 5,000 ft. No further communication was received from the pilot despite multiple queries from the controller. ADS-B data showed that the airplane had begun to climb and reached a maximum altitude of 3,500 ft before it began a descending right turn. The airplane remained in the right descending turn at a descent rate of about 5,000 ft per minute until the last recorded target at 900 ft msl, located about 1,333 ft northwest of the accident site. The airplane and two houses were destroyed. The pilot and the driver of a UPS truck were killed. Two other people on the ground were injured.
Probable cause:
Loss of control due to spatial disorientation.
Final Report:

Crash of a Socata TBM-910 in Westlock

Date & Time: Oct 10, 2021 at 1102 LT
Type of aircraft:
Registration:
C-FFYM
Flight Type:
Survivors:
Yes
Schedule:
Vernon – Calgary – Westlock
MSN:
1190
YOM:
2017
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
235.00
Aircraft flight hours:
449
Circumstances:
The airplane was conducting an instrument flight rules flight from Vernon Airport, British Columbia, to Westlock Aerodrome, Alberta, with a stop at Calgary/Springbank Airport, Alberta, to pick up passengers, after which 1 pilot and 3 passengers were on board. At 1102:26 Mountain Daylight Time, while the aircraft was landing on Runway 28 at Westlock Aerodrome, the aircraft bounced and the pilot initiated a go-around. During the application of engine power for the go-around, the aircraft rolled to the left, struck the runway inverted, and came to rest on the runway’s south side. The 3 passengers exited the aircraft through the main cabin door with the assistance of persons nearby. One passenger received serious injuries, and the other 2 had minor injuries. The pilot, who was seriously injured, was trapped in the cockpit for approximately 2 hours before first responders could safely rescue him from the wreckage. An emergency locator transmitter signal was received by the search and rescue satellite system. The aircraft was significantly damaged and there was no post-impact fire.
Probable cause:
Findings as to causes and contributing factors:
1. The aircraft joined the final approach well above the optimal 3° descent path and, during the steep approach that followed, the aircraft’s airspeed continually decelerated and resulted in an unstabilized approach.
2. On short final, the pilot reduced the rate of descent by increasing pitch rather than by adding power. As a result, the airspeed continued to decrease and the aircraft entered a stall, resulting in a hard landing and a subsequent bounce.
3. During the attempted rejected landing, the aircraft entered a 25° nose-high attitude and approached a stall condition. This low-speed condition combined with the high power setting resulted in the aircraft entering a rapid roll to the left and striking the runway in an inverted attitude.
4. The passengers did not receive a safety briefing before departure or before landing, and multiple items in the cabin were not secured. As a result, 1 passenger sustained serious injuries due to the deceleration forces and the loose items that were thrown around in the cabin during the accident.
5. The pilot was not wearing the available shoulder harness, and his torso was unrestrained during the impact. As a result, he sustained serious injuries.

Findings as to risk:
1. If pilots do not declare all health issues to Transport Canada Civil Aviation Medical Examiners and pilots’ family physicians do not declare issues assessed to be a risk to aviation safety to Transport Canada, there is an increased risk that pilots will operate with diagnosed medical conditions or medical side effects that could affect flight safety.
2. If an aircraft propeller is rotating and passengers are not supervised during boarding operations, there is a risk that passengers may inadvertently contact the propeller, potentially causing fatal injuries.

Other findings:
1. Following a review of the pilot’s medical history and prescription medication use, the investigation determined that the medication did not contribute to the accident.
Final Report:

Crash of a Pilatus PC-12/47E in Milan: 8 killed

Date & Time: Oct 3, 2021 at 1307 LT
Type of aircraft:
Registration:
YR-PDV
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Milan - Olbia
MSN:
1532
YOM:
2015
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
1025
Captain / Total hours on type:
400.00
Aircraft flight hours:
504
Circumstances:
The single engine aircraft departed Milan-Linate Airport runway 36 at 1304LT, bound to Olbia with 8 people on board, seven passengers and one pilot. Ten seconds after takeoff, the pilot engaged the autopilot and the LNAV mode but both were disengaged about 1 minute and 40 seconds later. Instead of following the Standard Instrument Departure heading 130 after takeoff, the aircraft continued to turn to the west. Milano Area Control Center instructed the pilot to turn left heading 120 but instead, the aircraft turned right again then the altitude was stabilized. At an altitude of 5,300 feet, the aircraft entered an uncontrolled descent and crashed in a vertical attitude on an industrial building under construction and located about 1,8 km southwest of the runway 36 threshold. The aircraft disintegrated on impact and all 8 occupants were killed, among them the Romania businessman Dan Petrescu. The building suffered severe damages as well as few vehicles in the street. There were no injuries on the ground.
Probable cause:
The limitations imposed by the considerable level of destruction of the aircraft and the absence of data recorded by the LDR referable to the accident, did not allow to identify, with incontrovertible certainty, the cause of the event.
For the above reasons, it has not been possible to categorically exclude the occurrence of a failure that may have compromised the controlability of the aircraft; however, such hypothesis, on the basis of the evidence acquired, appears to be the least probable.
The cause of the event is reasonably attributable to the pilot's loss of control of the aircraft, which occurred during the execution of a SID in daytime IMC conditions, with the aircraft manually piloted.
It can be assumed that at the origin of the loss of control, there may have been a saturation of the pilot's cognitive processes, with consequent channeling of attention to the navigation system, which would have likely diverted the pilot's attention from the basic and manual conduct of the aircraft.
It cannot be excluded that a non-catastrophic technical issue may have contributed to this task saturation.
It is believed that a recurring lack of training may have contributed to the failure to control the aircraft, as well as an inadequate handling of a possible non-catastrophic technical failure
Due to the lack of flight data it was not possible to determine if the disengagement was voluntary by the pilot or caused by a failure.
Final Report:

Crash of a Cessna 560XLS+ Citation Excel in Plainville: 4 killed

Date & Time: Sep 2, 2021 at 0951 LT
Registration:
N560AR
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Plainville – Manteo
MSN:
560-6026
YOM:
2009
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
17400
Copilot / Total flying hours:
5594
Aircraft flight hours:
2575
Circumstances:
The flight crew was conducting a personal flight with two passengers onboard. Before departure, the cockpit voice recorder (CVR) captured the pilots verbalizing items from the before takeoff checklist, but there was no challenge response for the taxi, before takeoff, or takeoff checklists. Further, no crew briefing was performed and neither pilot mentioned releasing the parking brake. The left seat pilot, who was the pilot flying (PF) and pilot-in-command (PIC), initiated takeoff from the slightly upsloping 3,665-ft-long asphalt runway. According to takeoff performance data that day and takeoff performance models, the airplane had adequate performance capability to take off from that runway. Flight data recorder (FDR) data indicated each thrust lever angle was set and remained at 65° while the engines were set and remained at 91% N1. During the takeoff roll, the CVR recorded the copilot, who was the pilot monitoring (PM) and second-in-command (SIC), making callouts for “airspeed’s alive,” “eighty knots cross check,” “v one,” and “rotate.” A comparison of FDR data from the accident flight with the previous two takeoffs showed that the airplane did not become airborne at the usual location along the runway, and the longitudinal acceleration was about 33% less. At the time of the rotate callout, the airspeed was about 104 knots calibrated airspeed, and the elevator was about +9° airplane nose up (ANU). Three seconds after the rotate callout, the CVR recorded the sound of physical straining, suggesting the pilot was likely attempting to rotate the airplane by pulling the control yoke. The CVR also captured statements from both the copilot and pilot expressing surprise that the airplane was not rotating as they expected. CVR and FDR data indicated that between the time of the rotate callout and the airplane reaching the end of the airport terrain, the airspeed increased to about 120 knots, the weight-on-wheels (WOW) remained in an on-ground state, and the elevator position increased to a maximum value of about +16° ANU. However, the airplane’s pitch attitude minimally changed. After the airplane cleared the end of the airport terrain where the ground elevation decreased 20 to 25 ft, FDR data indicate that the WOW transitioned to air mode with near-full ANU elevator control input, and the airplane pitched up nearly 22° in less than 2 seconds. FDR data depicted forward elevator control input in response to the rapid pitch-up, and the CVR recorded a stall warning then stick shaker activation. An off airport witness reported seeing the front portion of the right engine impact a nearby pole past the departure end of the runway. The airplane then rolled right to an inverted attitude, impacted the ground, then impacted an off airport occupied building. The airplane was destroyed by impact forces and a post crash fire and all four occupants were killed. On ground, four other people were injured, one seriously.
Probable cause:
The pilot-in-command’s failure to release the parking brake before attempting to initiate the takeoff, which produced an unexpected retarding force and airplane-nose-down pitching moment that prevented the airplane from becoming airborne within the takeoff distance available and not before the end of the airport terrain. Contributing to the accident were the airplane’s lack of a warning that the parking brake was not fully released and the Federal Aviation Administration’s process for certification of a derivative aircraft that did not identify the need for such an indication.
Final Report:

Crash of a Cirrus Vision SF50 in Lansing

Date & Time: Aug 24, 2021 at 1858 LT
Type of aircraft:
Operator:
Registration:
N1GG
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lansing – Melbourne
MSN:
0202
YOM:
2020
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2000
Captain / Total hours on type:
600.00
Aircraft flight hours:
293
Circumstances:
The airport tower controller initially assigned the pilot to take off from runway 28L, which presented a 7-knot headwind. Shortly afterward, the controller informed the pilot of “a storm rolling in . . . from west to east,” and offered runway 10R. The pilot accepted the opposite direction runway for departure and added, “we’re ready to go when we get to the end . . . before the storm comes.” About 4 seconds after the airplane began accelerating during takeoff, the controller advised the pilot of a wind shear alert of plus 20 knots (kts) at a 1-mile final for runway 28L, and the pilot acknowledged the alert. In a postaccident statement, the pilot stated that departing with a 7-kt tailwind was within the operating and performance limitations of the airplane. The pilot reported that after a takeoff ground roll of about 4,000 ft “the left rudder didn’t seem to be functioning properly” and he decided to reject the takeoff. However, when he applied full braking, the airplane tended to turn to the right. He used minimal braking consistent with maintaining directional control of the airplane. The airplane ultimately overran the runway, impacted the airport perimeter fence, and encountered a ditch before it came to a rest. A postimpact fire ensued and consumed a majority of the fuselage. All four occupants evacuated safely.
Probable cause:
The pilot’s decision to depart with a tailwind as a thunderstorm approached, which resulted in a loss of airplane performance due to an encounter with a significant tailwind gust and a subsequent runway excursion.
Final Report:

Crash of a Socata TBM-700 near Urbana: 1 killed

Date & Time: Aug 20, 2021 at 1440 LT
Type of aircraft:
Operator:
Registration:
N700DT
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Port Clinton – Cincinnati
MSN:
134
YOM:
1998
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2156
Captain / Total hours on type:
17.00
Aircraft flight hours:
2624
Circumstances:
The pilot was performing a short cross-country flight, which was his third solo flight in the high-performance single-engine airplane. The airplane departed and climbed to 20,000 ft mean sea level (msl) before beginning to descend. About 8 minutes before the accident, the airplane was southbound, descending to 11,000 ft, and the pilot established communications with air traffic control (ATC). About 4 minutes later, the controller cleared the pilot to descend to 10,000 ft msl and proceed direct to his destination; the pilot acknowledged the clearance. While descending through 13,000 ft msl, the airplane entered a descending left turn. The controller observed the left turn and asked the pilot if everything was alright; there was no response from the pilot. The controller’s further attempts to establish communications were unsuccessful. Following the descending left turn, the airplane entered a high speed, nose-down descent toward terrain. A witness observed the airplane at a high altitude in a steep nose-down descent toward the terrain. The witness noted no signs of distress, such as smoke, fire, or parts coming off the airplane, and he heard the airplane’s engine operating at full throttle. The airplane impacted two powerlines, trees, and the terrain in a shallow descent with a slightly left-wing low attitude. Examination of the accident site revealed a long debris field that was consistent with an impact at a high speed and relatively shallow flightpath angle. All major components of the airplane were located in the debris field at the accident site. Examination of the airframe and engine revealed no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation. A performance study indicated the airplane entered a left roll and dive during which the airplane exceeded the airspeed, load factor, and bank angle limitations published in the Pilot’s Operating Handbook (POH). An important but unknown factor during these maneuvers was the behavior of the pilot and his activity on the flight controls during the initial roll and dive. The pilot responded normally to ATC communications only 98 seconds before the left roll started. It is difficult to reconcile an alert and attentive pilot with the roll and descent that occurred, but there is insufficient information available to determine whether the pilot was incapacitated or distracted during any part of the roll and dive maneuver. Although all the available toxicological specimens contained ethanol (the alcohol contained in alcoholic drinks such as beer and wine), the levels were very low and below the allowable level for flight (0.04 gm/dl). While it is possible that some of the identified ethanol had been ingested, it is also possible that all or most of the identified ethanol was from sources other than ingestion (such as postmortem production). In either case, the levels were too low to have caused incapacitation. It is therefore unlikely that any effects from ethanol contributed to the circumstances of the accident. There was minimal available autopsy evidence to support any determination of incapacitation. As a result, it could not be determined from the available evidence whether medical incapacitation contributed to the accident.
Probable cause:
The pilot’s failure to arrest the airplane’s left roll and rapid descent for reasons that could not be determined based on the available evidence.
Final Report:

Crash of a Rockwell Grand Commander 690B in Thunder Bay: 1 killed

Date & Time: Aug 16, 2021 at 2109 LT
Operator:
Registration:
C-GYLD
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Thunder Bay – Dryden
MSN:
690-11426
YOM:
1977
Flight number:
BD160
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2662
Captain / Total hours on type:
230.00
Aircraft flight hours:
7620
Circumstances:
The airplane, operated by MAG Aerospace Canada Corp. as flight BD160, was conducting a visual flight rules flight from Thunder Bay Airport, Ontario, to Dryden Regional Airport, Ontario, with only the pilot on board. At 2109 Eastern Daylight Time, the aircraft began a takeoff on Runway 12. Shortly after rotation, the aircraft entered a left bank, continued to roll, and then struck the surface of Runway 07 in an inverted attitude. The pilot was fatally injured. The aircraft was destroyed by the impact and postimpact fire. The emergency locator transmitter activated on impact.
Probable cause:
Findings as to causes and contributing factors:
1. After takeoff from Runway 12 at Thunder Bay Airport, Ontario, as the pilot conducted a rapid, low-level, climbing steep turn, the aircraft entered an accelerated stall that resulted in a loss of control and subsequent collision with the surface of Runway 07 in an inverted attitude.
2. The decision to conduct the rapid, low-level, climbing steep turn was likely influenced by an altered perception of risk from previous similar takeoffs that did not result in any adverse consequences.

Findings as to risk:
1. If air traffic controllers engage in communications that may be perceived by pilots to encourage unusual flight manoeuvres, pilots may perceive this encouragement as a confirmation that the manoeuvres are acceptable to perform, increasing the risk of an accident.
2. If NAV CANADA’s reporting procedures do not contain specific criteria for situations where air traffic services personnel perceive aircraft to be conducting unsafe flight manoeuvres, there is a risk that these manoeuvres will continue and result in an accident.

Other findings
1. Most of the wires that comprised the elevator trim cable failed before the impact as a result of excessive wear; however, this did not contribute to the occurrence because the trim tab remained in the normal take-off position.
Final Report:

Crash of a Cessna 425 Conquest I in Helena

Date & Time: Aug 11, 2021 at 0900 LT
Type of aircraft:
Operator:
Registration:
N783MB
Flight Type:
Survivors:
Yes
Schedule:
Faribault - Missoula
MSN:
425-0103
YOM:
1982
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6000
Captain / Total hours on type:
800.00
Aircraft flight hours:
9576
Circumstances:
The pilot stated that on the morning of the accident he filled both wing fuel tanks to full. After takeoff, he climbed to his planned cruise altitude of 24,000 ft mean sea level (msl). While en route to his destination, the pilot reported that the left engine experienced a flame-out. The pilot opted to divert from the originally planned destination and descended. When the airplane was about 7,900 ft msl, the pilot reported that the right engine experienced a loss of power and that he was not going to be able to make it to the airport. Shortly thereafter, the airplane collided with trees and the airplane came to rest with the right wing and empennage severed from the fuselage.
Probable cause:
A flameout of both engines due to fuel starvation for reasons that could not be determined due to the airplane’s damage. There was fuel in the wing tanks at the time of the impact. Postaccident examination of the wreckage did not reveal any anomalies. A partial amount of fuel was found in both of the filter bowls, but it is unknown if fuel was able to reach the engines. A complete examination of the fuel system could not be completed due to the damage incurred to the airplane at impact. Both engines flaming out within a short time of one another is likely indicative of a fuel supply or delivery issue; however, the nature of the problem could not be identified during postaccident examination.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Courchevel: 1 killed

Date & Time: Aug 6, 2021 at 1144 LT
Operator:
Registration:
F-HYGA
Flight Type:
Survivors:
Yes
Schedule:
Cannes - Courchevel
MSN:
46-36483
YOM:
2010
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
345
Captain / Total hours on type:
80.00
Circumstances:
The single engine airplane departed Cannes-Mandelieu Airport on a private flight to Courchevel with two passengers and one pilot on board. The goal of the flight was to maintain the validity of the pilot to access to the Courchevel Altiport. Following a right hand base leg, the pilot configured the airplane to land on runway 22. On final, the altimeter showed an altitude close to the runway threshold, and the aircraft was levelled off to the runway threshold. A few seconds before landing, the stall warning sounded, the engine power was increased and then reduced completely. The undercarriage impacted an embankment above the runway threshold and were torn off. The airplane lifted a bit then fell back onto the runway. It slid for about 100 metres before coming to rest. A fire erupted on the right side of the fuselage. The pilot and the front passenger exited the aircraft through the rear door and managed to extract the rear passenger, who was unconscious and died a few minutes later.
Probable cause:
The accident was the consequence of a premature descent during the approach. The pilot started the descent on the base leg, whereas mountain landing practices call for a descent on final approach after interception of the descent plan, combined with an erroneous assessment of the aircraft's position in relation to the final descent plan. Investigations revealed that the aircraft was flying at an altitude of 6,600 feet during the last turn, about 400 feet below the altitude indicated on the approach chart.
The following factors may have contributed to the accident:
- The period of training received by the pilot was probably insufficient;
- A lack of landing experience at Courchevel;
- A misunderstandings between the pilot and the passenger seated on the right about his role during the flight, himself being an airline pilot and instructor.
Final Report: