Crash of a Piper PA-46-350P Malibu off Mayport: 2 killed

Date & Time: Dec 20, 2018 at 0904 LT
Registration:
N307JM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kissimmee - Princeton
MSN:
46-36253
YOM:
2000
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
390
Captain / Total hours on type:
30.00
Aircraft flight hours:
3785
Circumstances:
The aircraft impacted the Atlantic Ocean near Mayport, Florida. The private pilot and pilot-rated passenger were fatally injured. The airplane was destroyed. The airplane was privately owned and operated under the provisions of Title 14 Code of Federal Regulations Part 91. Instrument meteorological conditions prevailed at the time and the flight was operating on an instrument flight rules (IFR) flight plan. The personal flight originated from Kissimmee Gateway Airport, Orlando, Florida, about 0821, and was destined for Princeton Airport, Princeton/Rocky Hill, NJ. According to preliminary air traffic control radar and voice data provided by the Federal Aviation Administration (FAA), at 0859:02, one of the airplane's occupants contacted the Jacksonville Air Route Traffic Control Center (ZJX ARTCC) R-73 sector controller and reported passing through Flight Level (FL) 220 for FL230. The controller advised the pilot there were moderate and some heavy precipitation along the route of flight extending for 200 nautical miles. The occupant acknowledged the controller and advised they would be watching the weather. FAA radar data indicated at 0900:22 the flight reached FL227. Preliminary review of weather data revealed that this altitude was above the freezing level, and at that time the flight entered an area of weather radar returns with intensities between 10 to 30 dBZ (which equated to light to moderate precipitation). While in the weather radar-indicated precipitation, the flight climbed to FL230. At 0902:14, while at the edge of the precipitation, the airplane started a slight left turn before entering a right turn at 0902:28 at FL226. The turn had not been directed by the controller or announced by either occupant. Between 0902:28 and 0903:10, the airplane descended from FL226 to FL202. At 0903:10, the airplane was descending through FL202 when the controller attempted to contact the flight, but there was no reply. The controller attempted to communicate with the flight several more times, and at 0903:27 in response to one attempt, while at 14,500 feet mean sea level (msl), an occupant advised, "were not ok we need help." The controller asked the pilot if he was declaring an emergency and "whats going on." At 0903:35, while at 12,600 feet msl an occupant stated, "I'm not sure whats happening", followed by, "I have anti-ice and everything." At 0903:40 the controller asked the flight if it could maintain altitude, an occupant responded that they could not maintain altitude. The controller provided vectors to a nearby airport west of their position, but the flight did not reply to that transmission or a subsequent query. At about 0904:32 (which was the last communication from the airplane), while at 3,300 feet msl, an occupant advised the controller that the airplane was inverted and asked for assistance. The last radar recorded position with altitude read-out of the flight was at 0904:40, at an altitude of 1,700 feet msl, and 30.40069° north latitude and -81.3844° west longitude. The U.S. Coast Guard initiated a search for the missing airplane, but the wreckage was not located and the search was suspended on December 22, 2018. A privately-funded search for the airplane was initiated and the wreckage was located and recovered on February 6, 2019. The recovered wreckage was retained for further investigation.
Probable cause:
An in-flight loss of control following an encounter with supercooled large droplet icing conditions, which ultimately resulted in an uncontrolled descent and subsequent inflight breakup. Also causal was the pilot’s failure to maintain an appropriate airspeed for flight in icing conditions.
Final Report:

Crash of a Cessna 550 Citation II in Fargo

Date & Time: Nov 30, 2018 at 1353 LT
Type of aircraft:
Operator:
Registration:
N941JM
Flight Type:
Survivors:
Yes
Schedule:
Williston - Fargo
MSN:
550-0146
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1513
Captain / Total hours on type:
253.00
Aircraft flight hours:
7180
Circumstances:
The commercial pilot was conducting a cross-country, business flight with 10 passengers onboard the 8-passenger airplane. He reported that air traffic control cleared the flight for an instrument landing system (ILS) approach to the runway. While descending, the airplane entered instrument meteorological conditions (IMC) at 3,100 ft mean sea level (msl), and ice started to accumulate on the wing's leading edges, empennage, and windshield. The pilot activated the pneumatic deice boots multiple times during the approach and slowed the airplane to 120 knots. The airplane then exited the clouds about 400 ft above ground level (agl), and the pilot maintained 120 knots as the airplane flew over the airport fence; all indications for landing were normal. About 100 ft agl, the airplane started to pull right. He applied left correction inputs, but the airplane continued to pull right. He applied engine power to conduct a goaround, but the airplane landed in grass right of the runway, sustaining damage to the wings and landing gear. Witnesses and passengers reported that the airplane stalled. During examination of the airplane immediately after the accident, about 1/2 to 1 inch of mixed ice was found on the right wing's leading edge, the vertical and horizontal stabilizers, and the angle of attack probe. Ice was also observed on the windshield. The flaps were found in the "up" position. Flight control continuity was established. Although the airplane was originally certificated for two-pilot operation, the pilot was flying the airplane under a single-pilot exemption. The pilot received a logbook endorsement indicating that he had received single-pilot training and was properly qualified under the single-pilot exemption. However, he
had not met the turbine flight time qualifications (1,000 hours) to be properly authorized to conduct the flight under the single-pilot exemption because he only had 500 hours. A review of cockpit voice recorder information indicated that, although the pilot verbalized that the landing gear was "all green," followed by stating "check, check, check," he did not verbalize all the approach or landing checklist items nor did he make any audible comments about activating the pneumatic deice boots or windshield anti-ice. A review of radar data for the flight indicated that, during the last 2 minutes of flight, while the airplane was on final approach to the runway, the indicated airspeed got as low as 99 knots. The last recorded radar return indicated that the airplane had an airspeed of 104 knots at 900 ft msl. The pilot's lack of minimum flight experience required to fly the airplane without a copilot likely led to task saturation as he flew the airplane entered IMC and icing conditions while on an ILS approach. He subsequently failed to lower the flaps during the approach, which resulted in a no-flap approach instead of a full-flap landing. The ice on the leading edges of the wings, the no-flap approach, and the low airspeed likely led to the exceedance of the airplane's critical angle of attack, which resulted in an aerodynamic stall.
Probable cause:
The pilot's failure to lower the flaps during the approach and maintain sufficient airspeed while flying in instrument meteorological and icing conditions and the accumulation of ice on the wings' leading edges, which resulted in the exceedance of the airplane's critical angle of attack and subsequent aerodynamic stall. Contributing to the accident was the pilot's lack of proper qualification to operate the airplane under a single-pilot exemption due to his lack of total turbine time, which led to task saturation and his failure to properly configure the flaps for landing.
Final Report:

Crash of a Cessna 340A in Ponoka

Date & Time: Nov 13, 2018 at 1815 LT
Type of aircraft:
Operator:
Registration:
C-GMLS
Flight Type:
Survivors:
Yes
MSN:
340A-0771
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Ponoka-Labrie Field, the pilot encountered technical problems with the autopilot and decided to make a go-around. While in the circuit pattern, the autopilot failed to disconnect properly so the pilot attempted an emergency landing in a field. The airplane belly landed then contacted trees. Upon impact, the tail was torn off and the aircraft came to rest. The pilot was seriously injured.

Crash of a Piper PA-31T Cheyenne in the Atlantic Ocean: 5 killed

Date & Time: Oct 25, 2018 at 1119 LT
Type of aircraft:
Registration:
N555PM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Andrews - Governor's Harbour
MSN:
31T-7620028
YOM:
1976
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
2778
Copilot / Total flying hours:
12000
Aircraft flight hours:
7718
Circumstances:
The two pilots and three passengers were conducting a cross-country flight over the ocean from South Carolina to the Bahamas. About 30 minutes into the flight, while climbing through 24,300 ft to 25,000 ft about 95 miles beyond the coast, the pilot made a garbled radio transmission indicating an emergency and intent to return. At the time of the transmission the airplane had drifted slightly right of course. The airplane then began a descent and returned on course. After the controller requested several times for the pilot to repeat the radio transmission, the pilot replied, "we're descending." About 15 seconds later, at an altitude of about 23,500 ft, the airplane turned sharply toward the left, and the descent rate increased to greater than 4,000 ft per minute, consistent with a loss of control. Attempts by the air traffic controller to clarify the nature of the emergency and the pilot's intentions were unsuccessful. About 1 minute after the sharp left turn and increased descent, the pilot again declared an emergency. No further communications were received. Search efforts coordinated by the U.S. Coast Guard observed an oil slick and some debris on the water in the vicinity of where the airplane was last observed via radar, however the debris was not identified or recovered. According to recorded weather information, a shallow layer favorable for light rime icing was present at 23,000 ft. However, because the airplane was not recovered, the investigation could not determine whether airframe icing or any other more-specific issues contributed to the loss of control. One air traffic control communication audio recording intermittently captured the sound of an emergency locator transmitter (ELT) "homing" signal for about 45 minutes, beginning near the time of takeoff, and ending about 5 minutes after radar contact was lost. Due to the intermittent nature of the signal, and the duration of the recording, it could not be determined if the ELT signal had begun transmitting before or ceased transmitting after these times. Because ELT homing signals sound the same for all airplanes, the source could not be determined. However, the ELT sound was recorded by only the second of two geographic areas that the airplane flew through and began before the airplane arrived near either of those areas. Had the accident airplane's ELT been activated near the start of the flight, it is unlikely that it would be detected in the second area and not the first. Additionally, the intermittent nature of the ELT signal is more consistent with an ELT located on the ground, rather than an airborne activation. An airborne ELT is more likely to have a direct line-of-sight to one or more of the ground based receiving antennas, particularly at higher altitudes, resulting in more consistent reception. The pilot's initial emergency and subsequent radio transmissions contained notably louder background noise compared to the previous transmissions. The source or reason for the for the increase in noise could not be determined.
Probable cause:
An in-flight loss of control, which resulted in an impact with water, for reasons that could not be determined because the airplane was not recovered.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Hurricane

Date & Time: Oct 21, 2018 at 1500 LT
Registration:
N413LL
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Hurricane - Salt Lake City
MSN:
46-36413
YOM:
2007
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7000
Captain / Total hours on type:
1500.00
Aircraft flight hours:
1088
Circumstances:
Shortly after takeoff, the pilot smelled smoke. As he began to turn the airplane back to the airport, the engine lost total power. He conducted a forced landing in a field just short of the airport, during which the airplane struck a metal fence and pipe. All occupants egressed, and the pilot then noticed that a fire had erupted under the airplane's engine cowling. Postaccident examination revealed that the airplane sustained fire damage to the roof and forward end of the baggage compartment along with the engine accessory area between the firewall and aft air baffles. Further examination revealed that one of the engine exhaust crossover pipe assemblies was misaligned at the slip joint. An engine manufacturer service bulletin (SB) called for inspections of the exhaust system slip and flange joints to identify misaligned exhaust components. The last maintenance event occurred about 7 1/2 flight hours before the accident, during which the SB was performed and resulted in the replacement of crossover pipes. The mechanic who had performed the most recent maintenance did not follow the correct procedures for reinstallation of the crossover pipe, and the inspector who reviewed his work did not examine the installation as it progressed but instead inspected the pipes after they were installed and essentially hidden from view by their protective heat shield. As a result of the misaligned engine exhaust crossover pipe, hot exhaust gases escaped into the engine compartment and started a fire, which compromised critical engine fuel and oil lines, and resulted in the loss of engine power.
Probable cause:
The mechanic's failure to properly align the engine exhaust crossover pipe during replacement, and his supervisor's failure to properly inspect the installation, which resulted in an in-flight fire and the loss of engine power.
Final Report:

Crash of a PZL-Mielec AN-2T near Urimán

Date & Time: Oct 1, 2018 at 1415 LT
Type of aircraft:
Registration:
YV1719
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Santa Elena de Uairén – Urimán
MSN:
1G240-32
YOM:
1991
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew departed Santa Elena de Uairén on a flight to Urimán. En route, the engine failed, forcing the crew to attempt an emergency landing in a prairie located 42 km southeast of Urimán Airport. The airplane rolled for few dozen metres and eventually collided with trees and came to rest in a wooded area. Both pilots escaped uninjured and the aircraft was damaged beyond repair. Both pilots were recovered by the crew of an helicopter two days after the accident.

Crash of a Cessna 340A in Saint Clair County: 1 killed

Date & Time: Sep 6, 2018 at 2347 LT
Type of aircraft:
Operator:
Registration:
C-GLKX
Flight Type:
Survivors:
No
Schedule:
Saint Thomas - Saint Clair County
MSN:
340A-1221
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
690
Captain / Total hours on type:
51.00
Aircraft flight hours:
4038
Circumstances:
The private pilot of the multi-engine airplane was conducting an instrument approach during night visual meteorological conditions. About 1.3 nautical miles (nm) from the final approach fix, the right engine lost total power. The pilot continued the approach and notified air traffic control of the loss of power about 1 minute and 13 seconds later. Subsequently, the pilot contacted the controller again and reported that he was unable to activate the airport's pilot-controlled runway lighting. In the pilot's last radio transmission, he indicated that he was over the airport and was going to "reshoot that approach." The last radar return indicated that the airplane was about 450 ft above ground level at 72 kts groundspeed. The airplane impacted the ground in a steep, vertical nose-down attitude about 1/2 nm from the departure end of the runway. Examination of the wreckage revealed that the landing gear and the flaps were extended and that the right propeller was not feathered. Data from onboard the airplane also indicated that the pilot did not secure the right engine following the loss of power; the left engine continued to produce power until impact. The airplane's fuel system held a total of 203 gallons. Fuel consumption calculations estimated that there should have been about 100 gallons remaining at the time of the accident. The right-wing locker fuel tank remained intact and contained about 14 gallons of fuel. Fuel blight in the grass was observed at the accident site and the blight associated with the right wing likely emanated from the right-wing tip tank. The elevator trim tab was found in the full nose-up position but was most likely pulled into this position when the empennage separated from the aft pressure bulkhead during impact. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Although there was adequate fuel on board the airplane, the pilot may have inadvertently moved the right fuel selector to the OFF position or an intermediate position in preparation for landing instead of selecting the right wing fuel tank, or possibly ran the right auxiliary fuel tank dry, which resulted in fuel starvation to the right engine and a total loss of power. The airplane manufacturer's Pilot Operating Handbook (POH) stated that the 20-gallon right- and left-wing locker fuel tanks should be used after 90 minutes of flight. However, 14 gallons of fuel were found in the right-wing locker fuel tank which indicated that the pilot did not adhere to the POH procedures for fuel management. The fuel in the auxiliary fuel tank should be used when the main fuel tank was less than 180 pounds (30 gallons) per tank. As a result of not using all the fuel in the wing locker fuel tanks, the pilot possibly ran the right auxiliary fuel tank empty and was not able to successfully restart the right engine after he repositioned the fuel selector back to the right main fuel tank. Postaccident testing of the airport's pilot-controlled lighting system revealed no anomalies. The airport's published approach procedure listed the airport's common traffic advisory frequency, which activated the pilot-controlled lighting. It is possible that the pilot did not see this note or inadvertently selected an incorrect frequency, which resulted in his inability to activate the runway lighting system. In addition, the published instrument approach procedure for the approach that the pilot was conducting indicated that the runway was not authorized for night landings. It is possible that the pilot did not see this note since he gave no indication that he was going to circle to land on an authorized runway. Given that the airplane's landing gear and flaps were extended, it is likely that the pilot intended to land but elected to go-around when he was unable to activate the runway lights and see the runway environment. However, the pilot failed to reconfigure the airplane for climb by retracting the landing gear and flaps. The pilot had previously failed to secure the inoperative right engine following the loss of power, even though these procedures were designated in the airplane's operating handbook as "immediate action" items that should be committed to memory. It is likely that the airplane was unable to climb in this configuration, and during the attempted go-around, the pilot exceeded the airplane's critical angle of attack, which resulted in an aerodynamic stall. Additionally, the pilot had the option to climb to altitude using singleengine procedures and fly to a tower-controlled airport that did not have any landing restrictions, but instead, he decided to attempt a go-around and land at his destination airport.
Probable cause:
The pilot's improper fuel management, which resulted in a total loss of right engine power due to fuel starvation; the pilot's inadequate flight planning; the pilot's failure to secure the right engine following the loss of power; and his failure to properly configure the airplane for the go-around, which resulted in the airplane's failure to climb, an exceedance of the critical angle of attack, and an aerodynamic stall.
Final Report:

Crash of a Beechcraft C90GTi King Air in Vila Rica

Date & Time: Sep 5, 2018 at 1120 LT
Type of aircraft:
Registration:
PR-GVJ
Flight Type:
Survivors:
Yes
Schedule:
Belo Horizonte – Confresa
MSN:
LJ-2145
YOM:
2017
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane departed Belo Horizonte-Pampulha-Carlos Drummond de Andrade Airport at 0820LT on a private flight to Confresa, carrying five passenger and one pilot. While descending to Confresa, the pilot decided to fly directly to the farm of the owner (Fazenda Angola) located in Vila Rica, about 80 km northeast of Confresa Airport. On final approach, the aircraft was too low when it struck the surface of a lake then its bank. On impact, the undercarriage were torn off and the aircraft crash landed and came to rest on its belly. There was no fire. All six occupants were injured, one seriously. The aircraft was damaged beyond repair.
Probable cause:
The pilot descended too low on approach to an umprepared terrain.
Contributing Factors:
- Attitude,
- Command application,
- Pilot judgment,
- Decision making process,
- Lack of adherence to regulations established by the authority of Brazilian civil aviation.
Final Report:

Crash of a Beechcraft 60 Duke in Destin: 4 killed

Date & Time: Aug 30, 2018 at 1030 LT
Type of aircraft:
Registration:
N1876L
Flight Type:
Survivors:
No
Schedule:
Toledo - Destin
MSN:
P-386
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2427
Captain / Total hours on type:
100.00
Aircraft flight hours:
4167
Circumstances:
The commercial pilot and three passengers departed on a cross-country flight in a twin-engine airplane. As the flight neared the destination airport, the pilot canceled his instrument flight rules (IFR) clearance. The approach controller transferred the flight to the tower controller, and the pilot reported to the tower controller that the airplane was about 2 miles from the airport. However, the approach controller contacted the tower controller to report that the airplane was 200 ft over a nearby joint military airport at the time. GPS data revealed that, when pilot reported that the airplane was 2 miles from the destination airport, the airplane's actual location was about 10 miles from the destination airport and 2 miles from the joint military airport. The airplane impacted a remote wooded area about 8 miles northwest of the destination airport. At the time of the accident, thunderstorm cells were in the area. A review of the weather information revealed that the pilot's view of the airport was likely obscured because the airplane was in an area of light precipitation, restricting the pilot's visibility. A review of airport information noted that the IFR approach course for the destination airport passes over the joint military airport. The Federal Aviation Administration chart supplement for the destination airport noted the airport's proximity to the other airport. However, it is likely that the pilot mistook the other airport for the destination airport due to reduced visibility because of weather. The accident circumstances were consistent with controlled flight into terrain. The ethanol detected in the pilot's blood specimens but not in his urine specimens was consistent with postmortem bacteria production. The carbon monoxide and cyanide detected in the pilot's blood specimens were consistent with inhalation after the postimpact fire.
Probable cause:
The pilot's controlled flight into terrain after misidentifying the destination airport during a period of restricted visibility due to weather.
Final Report:

Crash of a Cessna 414 Chancellor in Santa Ana: 5 killed

Date & Time: Aug 5, 2018 at 1229 LT
Type of aircraft:
Registration:
N727RP
Flight Type:
Survivors:
No
Site:
Schedule:
Concord – Santa Ana
MSN:
414-0385
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
980
Captain / Total hours on type:
120.00
Aircraft flight hours:
3963
Circumstances:
The pilot and four passengers were nearing the completion of a cross-county business flight. While maneuvering in the traffic pattern at the destination airport, the controller asked the pilot if he could accept a shorter runway. The pilot said he could not, so he was instructed to enter a holding pattern for sequencing; less than a minute later, the pilot said he could accept the shorter runway. He was instructed to conduct a left 270° turn to enter the traffic pattern. The pilot initiated a left bank turn and then several seconds later the bank increased, and the airplane subsequently entered a steep nose-down descent. The airplane impacted a shopping center parking lot about 1.6 miles from the destination airport. A review of the airplane's flight data revealed that, shortly after entering the left turn, and as the airplane’s bank increased, its airspeed decreased to about 59 knots, which was well below the manufacturer’s published stall speed in any configuration. Postaccident examination of the airframe and engines revealed no anomalies that would have precluded normal operation. It is likely that the pilot failed to maintain airspeed during the turn, which resulted in an exceedance of the aircraft's critical angle of attack and an aerodynamic stall.
Probable cause:
The pilot’s failure to maintain adequate airspeed while maneuvering in the traffic pattern which resulted in an aerodynamic stall and subsequent spin at a low altitude, which the pilot was unable to recover from.
Final Report: