Crash of a Cessna 402B in Nantucket

Date & Time: Sep 13, 2017 at 0723 LT
Type of aircraft:
Registration:
N836GW
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nantucket – Hyannis
MSN:
402B-1242
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1500
Captain / Total hours on type:
1100.00
Aircraft flight hours:
4928
Circumstances:
The commercial pilot stated that, shortly after taking off for a cross-country, personal flight and while accelerating, he noticed high airplane nose-down control forces and that the airplane became increasingly difficult to control. He used manual trim to attempt to trim out the control forces and verified that the autopilot was not engaged; however, the nose-down tendency continued, and the pilot had trouble maintaining altitude. During the subsequent emergency landing, the airframe sustained substantial damage. Postaccident examination of the airplane revealed that the elevator trim push rod assembly was separated from the elevator trim tab actuator, and the end of the elevator trim push rod assembly was found wedged against the elevator's main spar. The elevator trim indicator in the cockpit was found in the nose-up stop position; however, the elevator trim tab was deflected 24° trailing edge up/airplane nose down (the maximum airplane nose-down setting is 6°). A drilled bolt was recovered from inside the right elevator; however, the associated washer, castellated nut, and cotter pin were not found. Examination of the bolt revealed that the threads were damaged and that the bolt hole on one of the clevis yoke halves exhibited deformation, consistent with the bolt separating. About 2 weeks before the accident, the pilot flew the airplane to a maintenance facility for an annual inspection. At that time, Airworthiness Directive (AD) 2016-07-24, which required installation of new hardware at both ends of the pushrod for the elevator trim tab, was overdue. While the airplane was in for the annual inspection, AD 2016-07-24 was superseded by AD 2016-17-08, which also required the installation of new hardware. The ADs were issued to prevent jamming of the elevator trim tab in a position outside the normal limits of travel due to the loss of the attachment hardware connecting the elevator trim tab actuator to the elevator trim tab push-pull rod, which could result in loss of airplane control. While in for the annual inspection, the airplane was stripped and painted, which would have required removal of the right elevator. Although the repair station personnel indicated that they did not disconnect the elevator trim pushrod from the elevator trim tab actuator when they painted the airplane, photographs taken of the airplane while it was undergoing inspection and painting revealed that the pushrod likely had been disconnected. The repair station owner reported that he reinstalled the right elevator and the elevator trim pushrod after the airplane was painted; however, he did not replace the hardware at either end of the pushrod as required by the ADs. Subsequently, the airplane was approved for return to service. After the annual inspection, no work, repairs, or adjustments were made to the elevator trim system. The airplane had accrued about 58 hours since the annual inspection at the time of the accident. Although reusing the self-locking nut might have resulted in it coming off by itself, the cotter pin should have prevented this from happening. Therefore, although the castellated self-locking nut, washer, and cotter pin normally used to secure the elevator trim pushrod at the elevator trim tab actuator were not found, given the evidence it is likely that the hardware, which was not the required hardware, was not properly secured at installation, which allowed it to separate in flight. It is also likely that the pushrod assembly then moved aft and jammed in a position well past the maximum nose-down trim setting, which rendered controlled flight impossible.
Probable cause:
The separation of the pushrod from the elevator trim tab actuator, which rendered controlled flight impossible. Contributing to the separation of the pushrod was the failure of maintenance personnel to properly secure it to the elevator trim tab actuator.
Final Report:

Crash of a Piper PA-31-310 Navajo in Caernarfon: 1 killed

Date & Time: Sep 6, 2017 at 1723 LT
Type of aircraft:
Registration:
N250AC
Flight Type:
Survivors:
No
MSN:
31-7612040
YOM:
1976
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4000
Aircraft flight hours:
9243
Circumstances:
Approximately 20 minutes after takeoff from a private airstrip in Cheshire the pilot reported pitch control problems and stated his intention to divert to Caernarfon Airport. Approximately 5 minutes later, the aircraft struck Runway 25 at Caernarfon Airport, with landing gear and flaps retracted, at high speed, and with no noticeable flare manoeuvre. The aircraft was destroyed. The elevator trim was found in a significantly nose-down position, and whilst the reason for this could not be determined, it is likely it would have caused the pilot considerable difficulty in maintaining control of the aircraft. The extensive fire damage to the wreckage and the limited recorded information made it difficult to determine the cause of this accident with a high level of confidence. A possible scenario is a trim runaway, and both the CAA and the EASA are taking safety action to promote awareness for trim runaways as a result of this accident.
Probable cause:
After reporting pitch control problems, N250AC made a direct diversion with a significantly unstable approach, in a clean configuration, to Runway 25 at Caernarfon Airport. The elevator trim was found in a nose-down position and, whilst the reason for this could not be determined, it is likely that it caused the pilot considerable difficulty in controlling the aircraft. The aircraft struck Runway 25 at Caernarfon Airport, with landing gear and flaps retracted, at high speed, and with no noticeable flare manoeuvre. The extensive fire damage to the wreckage and the limited recorded information made it difficult to determine the cause of this accident with a high level of confidence. It is possible there was a nose-down trim runaway that the pilot was unable to stop.
Final Report:

Crash of a Piper PA-61P Aerostar (Ted Smith 601P) in Donegal Springs

Date & Time: Aug 19, 2017 at 1642 LT
Operator:
Registration:
N7108
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Donegal Springs - Donegal Springs
MSN:
61-0405-142
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
400
Captain / Total hours on type:
1.00
Aircraft flight hours:
3957
Circumstances:
The commercial pilot stated that, during the takeoff roll, the airplane swerved to the right, and he corrected to the left and aborted the takeoff; however, the airplane departed the left side of the runway and collided with an embankment. At the time of the accident, a quartering tailwind was present. The pilot had no previous experience in the accident airplane make and model or in any other multiengine airplane equipped with engines capable of producing 300 horsepower. During a postaccident conversation with a mechanic, the pilot stated that the airplane "got away from him" during the attempted takeoff. Because a postaccident examination of the airplane did not reveal any evidence of a preimpact mechanical malfunction or failure of the airplane's flight controls or nosewheel steering system that would have precluded normal operation and the pilot did not have any previous experience operating this make and model of airplane, it is likely that the pilot lost directional control during takeoff with a quartering tailwind.
Probable cause:
The pilot's failure to maintain directional control during takeoff with a quartering tailwind. Contributing to the accident was the pilot's lack of experience in the accident airplane make and model.
Final Report:

Crash of a Socata TBM-700 in Yamazoe: 2 killed

Date & Time: Aug 14, 2017 at 1215 LT
Type of aircraft:
Registration:
N702AV
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Yao – Fukushima
MSN:
182
YOM:
2001
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3750
Captain / Total hours on type:
7.00
Aircraft flight hours:
2094
Circumstances:
The single engine aircraft departed Yao Airport at 1157LT on a leisure flight to Fukushima, carrying one passenger and one pilot. Few minutes later, the pilot reported an unexpected situation to ATC and was cleared to return to Yao. At an altitude of 17,200 feet and a speed of 150 knots, the aircraft entered an uncontrolled descent, partially disintegrated in the air and eventually crashed in a hilly and wooded terrain near the village of Yamazoe, bursting into flames. Both occupants were killed.
Probable cause:
In the accident, it is highly probable that the Aircraft lost control during flight, nose-dived while turning, and disintegrated in mid-air, resulting in the crash. It is somewhat likely that the Aircraft lost control during flight, because the captain did not have pilot skills and knowledge necessary for the operation of the Aircraft, and was not able to perform proper flight operations.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage off Mainau Island: 2 killed

Date & Time: Aug 8, 2017 at 1152 LT
Operator:
Registration:
HB-PPH
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Zurich – Hamburg
MSN:
46-36045
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2236
Aircraft flight hours:
2408
Circumstances:
The single engine airplane departed Zurich Airport Runway 28 at 1134LT bound for Hamburg-Helmut Schmidt Airport, carrying one passenger and one pilot. After passing over the city of Konstanz at an altitude of 16,750 feet in IFR conditions, the airplane entered an uncontrolled descent and eventually crashed in the Konstanz Lake, about 200 metres off Mainau Island. The wreckage was found at a depth of 60 metres and both occupants were killed.
Probable cause:
Loss of control while cruising in IMC conditions with strong atmospheric turbulences associated with icing conditions.
Final Report:

Crash of a Mitsubishi MU-2B-26A Marquise near San Fernando: 3 killed

Date & Time: Jul 24, 2017 at 1430 LT
Type of aircraft:
Operator:
Registration:
LV-MCV
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
San Fernando – Las Lomitas
MSN:
361
YOM:
1977
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
682
Captain / Total hours on type:
58.00
Aircraft flight hours:
5804
Aircraft flight cycles:
4670
Circumstances:
Shortly after takeoff from San Fernando Airport in Buenos Aires, while in initial climb, the pilot was contacted by ATC about an apparent transponder issue. The crew did not respond when, few seconds later, the twin engine airplane entered an uncontrolled descent and crashed in a marshy area located in the delta of Paraná de la Palmas. The wreckage was found on August 19 about 17 km north of San Fernando Airport. The aircraft disintegrated on impact and all three occupants were killed.
Crew:
Matías Ronzano,
Passengers:
Emanuel Vega,
Matías Aristi.
Probable cause:
Loss of control during climb due to the combination of the following factors:
- The particular characteristics of the aircraft;
- The attention required by the transponder as it is not displayed by air traffic control;
- The detour of the planned flight at the request of the inspection department of air traffic;
- Aircraft trajectory management with autopilot switched off;
- The pilot's limited experience in instrument flight conditions. In addition, the absence of additional instruction in the aircraft type (due to the lack of specific regulations) can be considered a contributing factor, according to the probable scenario described above. In addition, the research identified the following elements with potential impact in operational safety:
- Absence of the TAWS system on the aircraft in non-conformity with the established RAAC 91;
- Lack of effective means to enable the flight plan office to quickly determine whether an aircraft has operating restrictions;
- Shortcomings in the training of staff in the units ATS and SAR in search and rescue.
Final Report:

Crash of a Cessna 207 Skywagon near Hope

Date & Time: Jul 3, 2017 at 1032 LT
Operator:
Registration:
N9620M
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Seldovia – Anchorage
MSN:
207-0711
YOM:
1981
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5365
Captain / Total hours on type:
3.00
Aircraft flight hours:
23833
Circumstances:
According to the pilot, he was flying the second airplane in a flight of two about 1 mile behind the lead airplane. The lead airplane pilot reported to him, via the airplane's radio, that he had encountered decreasing visibility and that he was making a 180° left turn to exit the area. The pilot recalled that, after losing sight of the lead airplane, he made a shallow climbing right turn and noticed that the terrain was rising. He recalled that he entered the clouds for a few seconds and "at that moment I ran into the trees which I never saw coming." The airplane sustained substantial damage to both wings. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The pilot reported that the temperature was 60°F with 8 miles visibility and 1,500-eeft ceilings. The nearest METAR was about 1 mile away and reported that the temperature was 54°F, dew point was 52°F, visibility was 8 statute miles with light rain, and ceiling was broken at 500 feet and overcast at 1,500 feet.
Probable cause:
The pilot's inadvertent flight into instrument meteorological conditions and subsequent controlled flight into terrain.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Catawba: 6 killed

Date & Time: Jul 1, 2017 at 0153 LT
Registration:
N2655B
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Waukegan – Winnipeg
MSN:
421C-0698
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
2335
Captain / Total hours on type:
70.00
Circumstances:
The commercial pilot of the multi-engine airplane was conducting an instrument flight rules cross-country flight at night. The pilot checked in with air traffic control at a cruise altitude about 10,000 ft mean sea level (msl). About 31 minutes later, the pilot reported that he saw lightning off the airplane's left wing. The controller advised the pilot that the weather appeared to be about 35 to 40 miles away and that the airplane should be well clear of it. The pilot responded to the controller that he had onboard weather radar and agreed that they would fly clear of the weather. There were no further communications from the pilot. About 4 minutes later, radar information showed the airplane at 10,400 ft msl. About 1 minute later, radar showed the airplane in a descending right turn at 9,400 ft. Radar contact was lost shortly thereafter. The distribution of the wreckage, which was scattered in an area with about a 1/4-mile radius, was consistent with an in-flight breakup. The left horizontal stabilizer and significant portions of both left and right elevators and their respective trim tabs were not found. Of the available components for examination, no pre-impact airframe structural anomalies were found. Examination of the engines and turbochargers did not reveal any pre-impact anomalies. Examination of the propellers showed evidence of rotation at impact and no pre-impact anomalies. Review of weather information indicated that no convection or thunderstorms were coincident with or near the airplane's route of flight, and the nearest convective activity was located about 25 miles west of the accident site. Autopsy and toxicology testing revealed no evidence of pilot impairment or incapacitation. Given the lack of radar information after the airplane passed through 9,400 ft, it is likely that it entered a rapid descent during which it exceeded its design stress limitations, which resulted in the in-flight breakup; however, based on the available information, the event that precipitated the descent and loss of control could not be determined.
Probable cause:
A loss of control and subsequent in-flight breakup for reasons that could not be determined
based on the available information.
Final Report:

Crash of a Beechcraft E90 King Air in Ruidoso: 2 killed

Date & Time: Jun 13, 2017 at 2210 LT
Type of aircraft:
Operator:
Registration:
N48TA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ruidoso – Abilene
MSN:
LW-283
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1073
Captain / Total hours on type:
25.00
Aircraft flight hours:
12621
Circumstances:
The commercial pilot had filed an instrument flight rules flight plan and was departing in dark night visual meteorological conditions on a cross-country personal flight. A witness at the departure airport stated that during takeoff, the airplane sounded and looked normal. The witness said that the airplane lifted off about halfway down runway 24, and there was "plenty" of runway remaining for the airplane to land. The witness lost sight of the airplane and did not see the accident because the airport hangars blocked her view. The wreckage was located about 2,400 ft southeast of the departure end of runway 24. Examination of the accident site indicated that the airplane impacted in a nose-down attitude with a left bank of about 20°. A left turn during departure was consistent with the airport's published instrument departure procedures for obstacle avoidance, which required an immediate climbing left turn while proceeding to a navigational beacon located about 7 miles east-northeast of the airport. Examination of the wreckage did not reveal any evidence of preimpact mechanical malfunctions that would have precluded normal operation. The pilot had reportedly been awake for about 15 hours and was conducting the departure about the time he normally went to sleep and, therefore, may have been fatigued about the time of the event; however, given the available evidence, it was impossible to determine the role of fatigue in this event. Although the circumstances of the accident are consistent with spatial disorientation, there was insufficient evidence to determine whether it may have played a role in the sequence of events.
Probable cause:
The pilot's failure to maintain clearance from terrain after takeoff during dark night conditions.
Final Report: