Crash of a Piper PA-61P Aerostar (Ted Smith 601) near Carrollton

Date & Time: Oct 20, 2016 at 1110 LT
Operator:
Registration:
N601UK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Hampton – Carrollton
MSN:
61-0183-012
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1338
Captain / Total hours on type:
36.00
Aircraft flight hours:
2236
Circumstances:
The pilot reported that the purpose of the flight was to reposition the airplane to another airport for refuel. During preflight, he reported that the airplane's two fuel gauges read "low," but the supplemental electronic fuel totalizer displayed 55 total gallons. He further reported that it is not feasible to visual check the fuel quantity, because the fueling ports are located near the wingtips and the fuel quantity cannot be measured with any "external measuring device." According to the pilot, his planned flight was 20 minutes and the fuel quantity, as indicated by the fuel totalizer, was sufficient. The pilot reported that about 12 nautical miles from the destination airport, both engines began to "surge" and subsequently lost power. During the forced landing, the pilot deviated to land in grass between a highway, the airplane touched down hard, and the landing gear collapsed. The fuselage and both wings sustained substantial damage. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The pilot reported in the National Transportation Safety Board Pilot/ Operator Aircraft Accident Report that there was a "disparity" between the actual fuel quantity and the fuel quantity set in the electronic fuel totalizer. He further reported that a few days before the accident, he set the total fuel totalizer quantity to full after refueling, but in hindsight, he did not believe the fuel tanks were actually full because the wings may not have been level during the fueling. The "Preflight" chapter within the operating manual for the fuel totalizer in part states: "Digiflo-L is a fuel flow measuring system and NOT a quantity-sensing device. A visual inspection and positive determination of the usable fuel in the fuel tanks is a necessity. Therefore, it is imperative that the determined available usable fuel be manually entered into the system."
Probable cause:
The pilot's failure to verify the usable fuel in the fuel tanks, which resulted in an inaccurate fuel totalizer setting during preflight, fuel exhaustion, and a total loss of engine power.
Final Report:

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

Date & Time: Oct 17, 2016 at 1243 LT
Operator:
Registration:
N20NR
Flight Type:
Survivors:
Yes
Schedule:
Bitburg - Karlsruhe
MSN:
61-0445-169
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1446
Captain / Total hours on type:
362.00
Aircraft flight hours:
2635
Circumstances:
Following an uneventful flight from Bitburg, the pilot was cleared for an approach to Karlsruhe-Baden Baden Airport Runway 21. On final approach, while completing a sharp turn to the left to join the runway, the twin engine airplane stalled and crashed in an open field, bursting into flames. The pilot was seriously injured and the aircraft was destroyed by a post crash fire. The wreckage was found about 500 metres from the runway threshold and 350 metres to the left of the runway extended centerline.
Probable cause:
The aircraft stalled on final approach while completing a sharp turn to the left at an insufficient speed with an insufficient distance with the ground, following an unstabilized approach. The limited visibility was considered as a contributing factor.
Final Report:

Crash of a Socata TBM-900 in Fairoaks

Date & Time: Oct 15, 2016 at 0732 LT
Type of aircraft:
Registration:
M-VNTR
Flight Type:
Survivors:
Yes
Schedule:
Douglas - Fairoaks
MSN:
1097
YOM:
2016
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5272
Captain / Total hours on type:
1585.00
Circumstances:
The accident occurred as the aircraft was preparing to land at Fairoaks Airport at the end of a private flight from Ronaldsway Airport on the Isle of Man. On board were the aircraft commander and a passenger who occupied the front right seat. As the aircraft neared Fairoaks, the pilot listened to the Farnborough ATIS broadcast, which reported a visibility of 4,000 m in mist. He and the passenger discussed the visibility, and agreed that they would proceed to Fairoaks while retaining the option to divert to Farnborough Airport (9 nm to the south-west) if a landing was not possible. The visibility at Fairoaks was recorded as 4,500 m, with ‘few’ clouds at 4,000 ft and a surface wind of 3 kt from 240°. Runway 24 was in use with a left-hand circuit. The circuit height, based on the Fairoaks QNH was 1,100 ft (the elevation of Fairoaks Airport is 80 ft amsl). Runway 24 is a hard runway, 813 m long and 27 m wide. The pilot identified the airfield visually, although there was low lying mist in the area. In order to maintain visual contact with the landing area he joined the circuit and flew a downwind leg that was closer to the runway than usual. He recalled carrying out the pre-landing checks while downwind, including lowering the landing gear and extending the flaps to the takeoff position2 . Based on a final approach with flaps at the landing setting, the pilot planned for an initial approach speed of 90 kt, reducing to a final approach speed of 80 kt. The pilot recalled the aircraft being slightly low as it turned from the downwind leg onto its final approach track. He believed he had selected flaps to the landing position, and recalled seeing the airspeed just below 90 kt, which prompted him to increase power slightly. The aircraft flew through the extended runway centreline and the pilot increased the bank angle to regain it. The pilot’s next recollection was of being in a right bank and seeing only sky ahead. He pushed forward on the control column and attempted to correct the bank with aileron. The aircraft then rolled quickly in the opposite direction and he again applied a correction. He became aware of being in an approximately wings-level attitude and seeing the ground approaching rapidly. He responded by pulling back hard on the control column, but was unable to prevent the aircraft striking the ground. He did not recall hearing a stall warning, or any other audio warning, before the loss of control occurred. The aircraft struck flat ground and slid for about 85 m before coming to rest against a treeline, about 500 m from Runway 24 and approximately on the extended centreline. The propeller was destroyed in the accident sequence and the landing gear legs detached, causing damage to the wings which included a ruptured fuel tank. In the latter stages of the slide the aircraft yawed right, coming to rest heading approximately in the direction from which it had come. The pilot and passenger remained conscious but had both suffered injury. The passenger saw flames from the region of the engine and warned the pilot that they needed to evacuate. He went to the rear of the cabin, opened the main door and left the aircraft. The pilot initially attempted to open his side door, but his right arm was injured and he was unable to open the door with only his left. He therefore followed the passenger out of the rear door.
Probable cause:
There were no indications that the aircraft had been subject to any defects or malfunctions that may have contributed to the accident. Reports from the two occupants, eye witness accounts and radar data all confirm that the aircraft commenced its final turn from a position closer to the runway than usual. This would have required a sustained moderate angle of bank through about 180° of turn. The radar data indicates that the turn onto the final approach was initially flown with less angle of bank than required. The pilot therefore either lost visual contact with the runway or did not fully appreciate the turn requirements. An explanation for the latter might be that the low height on the downwind leg combined with the relatively poor visibility to produce a runway visual aspect that gave a false impression that the aircraft spacing was not abnormal. As the finals turn progressed, there was a need to increase the angle of bank to a relatively high value. With the flaps remaining at the takeoff setting, and maintaining level flight, this placed the aircraft close to its stalling speed. Any increase in angle of bank or ‘g’ loading (as may have occurred when it became evident that the aircraft would fly through the extended centreline) risked a stall. The available evidence indicates that the aircraft stalled during the turn onto the final approach. Recovery actions taken by the occupants appear to have been partially successful, but there was evidently insufficient height in which to effect a full recovery.
Final Report:

Crash of a Cessna 500 Citation I in Winfield: 4 killed

Date & Time: Oct 13, 2016 at 2136 LT
Type of aircraft:
Operator:
Registration:
C-GTNG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kelowna – Calgary
MSN:
500-0169
YOM:
1974
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3912
Captain / Total hours on type:
525.00
Aircraft flight hours:
8649
Circumstances:
The pilot and 3 passengers boarded the aircraft. At 2126, the pilot obtained an IFR clearance from the CYLW ground controller for the KELOWNA SEVEN DEP standard instrument departure (SID) procedure for Runway 34. The instructions for the runway 34 KELOWNA SEVEN DEP SID were to climb to 9000 feet ASL, or to an altitude assigned by air traffic control (ATC), and to contact the Vancouver Area Control Centre (ACC) after passing through 4000 feet ASL. The aircraft was then to climb and track 330° magnetic (M) inbound to the Kelowna non-directional beacon (LW). From LW, the aircraft was to climb and track 330°M outbound for vectors to the filed or assigned route. At 2127, C-GTNG began to taxi toward Runway 34. At 2131, the CYLW tower controller cleared the aircraft to take off from the intersection of Runway 34 and Taxiway D. The pilot acknowledged the clearance and began the take-off roll on Runway 34 about 1 minute later. Radar data showed that, at 2133:41, the aircraft was 0.5 nautical miles (nm) beyond the departure end of the runway and was climbing at more than 4000 feet per minute (fpm) through 2800 feet ASL, at a climb angle of approximately 16°. In that time, it had deviated laterally by about 3° to the right of the 330°M track associated with the SID. At 2134:01, when the aircraft was 1.2 nm beyond the runway, it had climbed through 3800 feet ASL and deviated further to the right of the intended routing. The aircraft’s rate of climb decreased to about 1600 fpm, and its ground speed was 150 knots. A short time later, the aircraft’s rate of climb decreased to 600 fpm, its climb angle decreased to 2°, and its ground speed had increased to 160 knots. At 2134:22, the aircraft was 2.1 nm beyond the departure end of the runway, and it was climbing through approximately 4800 feet ASL. The aircraft had deviated about 13° to the right of the intended track, and its rate of climb reached its maximum value of approximately 000 fpm, 3 with a climb angle of about 22°. The ground speed was roughly 145 knots. At 2134:39, the aircraft was 2.7 nm beyond the departure end of the runway, passing through 5800 feet ASL, and had deviated about 20° to the right of the intended routing. The rate of climb was approximately 2000 fpm, with a climb angle of about 7°. According to the SID, the pilot was to make initial contact with the ACC after the aircraft had passed through 4000 feet ASL.Initial contact was made when the aircraft was passing through 6000 feet ASL, at 2134:42. At 2134:46, the ACC acknowledged the communication and indicated that the aircraft had been identified on radar. The aircraft was then cleared for a right turn direct to the MENBO waypoint once it was at a safe altitude, or once it was climbing through 8000 feet ASL. The aircraft was also cleared to follow the flight-planned route and climb to 10 000 feet ASL. At 2134:55, the pilot read back the clearance as the aircraft climbed through 6400 feet ASL, with a rate of climb of approximately 2400 fpm. The aircraft was tracking about 348°M at a ground speed of about 170 knots. At 2135:34, the aircraft began a turn to the right, which was consistent with the instruction from the ACC. Flying directly to the MENBO waypoint required the aircraft to be on a heading of 066°M, requiring a right turn of about 50°. At this point, the aircraft was still climbing and was passing through 8300 feet ASL. The rate of climb was about 3000 fpm. The aircraft continued the right turn and was tracking through 085°M. After reaching a peak altitude of approximately 8600 feet ASL, the aircraft entered a steep descending turn to the right, consistent with the characteristics of a spiral dive. At 2135:47, the ACC controller cleared C-GTNG to climb to FL 250. The lack of radar returns and radio communications from the aircraft prompted the controller to initiate search activities. At 2151, NAV CANADA notified first responders, who located the accident site in forested terrain at about midnight. The aircraft had been destroyed, and all of the occupants had been fatally injured.
Probable cause:
The aircraft departed controlled flight, for reasons that could not be determined, and collided with terrain.
Final Report:

Crash of a De Havilland DHC-2 Beaver I near Laidman Lake: 1 killed

Date & Time: Oct 10, 2016 at 0844 LT
Type of aircraft:
Registration:
C-GEWG
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Vanderhoof - Laidman Lake
MSN:
842
YOM:
1955
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
280
Captain / Total hours on type:
23.00
Circumstances:
On 10 October 2016, at approximately 0820 Pacific Daylight Time, a privately operated de Havilland DHC-2 Beaver aircraft on amphibious floats (registration C-GEWG, serial number 842), departed from Vanderhoof Airport, British Columbia, for a day visual flight rules flight to Laidman Lake, British Columbia. The pilot and 4 passengers were on board. Approximately 24 minutes into the flight, the aircraft struck terrain about 11 nautical miles east of Laidman Lake. The 406 MHz emergency locator transmitter (ELT) activated on impact. The ELT's distress signal was detected by the Cospas-Sarsat satellite system, and a search-and-rescue operation was initiated by the Joint Rescue Coordination Centre Victoria. One of the passengers was able to call 911 using a cell phone. The pilot was fatally injured, and 2 passengers were seriously injured. The other 2 passengers sustained minor injuries. The aircraft was substantially damaged. There was no post-impact fire.
Probable cause:
Findings as to causes and contributing factors:
1. As the aircraft approached the mountain ridge, the high overcast ceiling and uniform snow-covered vegetation were conducive to optical illusions associated with flight in mountainous terrain. These illusions likely contributed to the pilot’s misjudgment of the proximity of the terrain, inadvertent adoption of an increasingly nose-up attitude, and non-detection of the declining airspeed before banking the aircraft to turn away from the hillside.
2. As the angle of bank increased during the turn, the stall speed also increased and the aircraft entered an accelerated stall.
3. The aircraft’s out-of-limit weight-and-balance condition increased its stall speed and degraded its climb performance, stability, and slow-flight characteristics. As a result, its condition, combined with the aircraft’s low altitude, likely prevented the pilot from regaining control of the aircraft before the collision with the terrain.
4. The absence of a stall warning system deprived the pilot of the last line of defence against an aerodynamic stall and the subsequent loss of control of the aircraft.
5. The forward shifting of the unsecured cargo and the partial detachment of the rear seats during the impact resulted in injuries to the passengers.
6. During the impact sequence, the load imposed on the pilot’s lap-belt attachment points was transferred to the seat-attachment points, which then failed in overload. As a result, the seat moved forward during the impact and the pilot was fatally injured.

Findings as to risk:
1. If pilots do not obtain quality sleep during the rest period prior to flying, there is a risk that they will operate an aircraft while fatigued, which could degrade pilot performance.
2. If cargo is not secured, there is a risk that it will shift forward during an impact or turbulence and injure passengers or crew.

Other findings:
1. Because the aircraft was equipped with a 406 MHz emergency locator transmitter that transmitted an alert message to the Cospas-Sarsat satellites system in combination with the homing signal transmitted on 121.5 MHz, the Joint Rescue Coordination Centre aircraft was able to locate the wreckage and occupants in a timely manner.
Final Report:

Crash of a Beechcraft 200 Super King Air in Orlando

Date & Time: Sep 10, 2016 at 1530 LT
Registration:
N369CD
Flight Type:
Survivors:
Yes
Schedule:
Marathon – Orlando
MSN:
BB-110
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5000
Captain / Total hours on type:
50.00
Aircraft flight hours:
10321
Circumstances:
The pilot of a multi-engine turboprop airplane reported that during the landing flare he encountered a crosswind gust, which pushed the airplane to the right of the runway centerline. The pilot further reported that he applied power to abort the landing, but the airplane touched down in the grass to the right of the runway. After the wheels touched down in the grass, he reported that the power added "caught up with the aircraft," but the airplane was rolling toward trees and hangars. Subsequently, the pilot pulled the power to idle, but the right wing impacted a tree and the right main landing gear and nose wheel collapsed. A post-crash fire ensued after the collision and the right wing sustained substantial damage. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. There was no record of the observed weather at the airport during the accident. An automated weather observing system about 14 nautical miles from the accident airport, near the time of the accident, recorded the wind variable at 5 knots.
Probable cause:
The pilot's failure to maintain directional control during an attempted aborted landing in gusty crosswind conditions, which resulted in a runway excursion and an impact with a tree.
Final Report:

Crash of a Piper PA-46-310P Malibu in Chariton: 1 killed

Date & Time: Sep 7, 2016 at 1219 LT
Registration:
N465JM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Olathe - Ankeny
MSN:
46-8408042
YOM:
1984
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
242
Captain / Total hours on type:
118.00
Circumstances:
The noninstrument-rated private pilot was conducting a visual flight rules (VFR) cross-country flight while receiving VFR flight following services from air traffic control. Radar data and voice
communication information indicated that the airplane was in cruise flight as the pilot deviated around convective weather near his destination. The controller issued a weather advisory to the pilot concerning areas of moderate to extreme precipitation along his route; the pilot responded that he saw the weather on the airplane's NEXRAD weather display system and planned to deviate around it before resuming course. About 3 minutes later, the pilot stated that he was around the weather and requested to start his descent direct toward his destination. The controller advised the pilot to descend at his discretion. Radar showed the airplane in a descending right turn before radar contact was lost at 2,900 ft mean sea level. There were no eyewitnesses, and search personnel reported rain and thunderstorms in the area about the time of the accident. The distribution of the wreckage was consistent with an in-flight breakup. Examination of the airframe revealed overload failures of the empennage and wings. No pre-impact airframe structural anomalies were found, and the propeller showed evidence of rotation at the time of impact. Further, there was no evidence of pilot impairment or incapacitation. Review of weather information indicated that the pilot most likely encountered instrument meteorological conditions as the airplane descended during the last several minutes of flight. During this time, it is likely that the pilot became disoriented while attempting to maneuver in convective, restricted visibility conditions, and lost control of the airplane. The transition from visual to instrument flight conditions would have been conducive to the development of spatial disorientation; the turning descent before the loss of radar contact and the in-flight breakup are also consistent with a loss of control due to spatial disorientation.
Probable cause:
The non-instrument-rated pilot's loss of control due to spatial disorientation in instrument meteorological conditions, which resulted in an exceedance of the airplane's design stress limitations and a subsequent in-flight breakup. Contributing to the accident was the pilot's decision to continue visual flight into convective instrument meteorological conditions.
Final Report:

Crash of a Beechcraft B60 Duke in Loma Plata

Date & Time: Sep 1, 2016 at 1655 LT
Type of aircraft:
Operator:
Registration:
ZP-BID
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
P-326
YOM:
1975
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane was completing a flight to Asunción, carrying one passenger and one pilot. En route, the pilot encountered an unexpected situation and was forced to attempt an emergency landing. Upon landing on a dirt road, the aircraft lost its undercarriage and slid for few dozen metres before coming to rest with its right wing torn off. Both occupants were injured and the aircraft was destroyed.

Crash of a Piper PA-31-325 Navajo C/R in Tuscaloosa: 6 killed

Date & Time: Aug 14, 2016 at 1115 LT
Type of aircraft:
Registration:
N447SA
Flight Type:
Survivors:
No
Schedule:
Kissimmee – Oxford
MSN:
31-8312016
YOM:
1983
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
749
Captain / Total hours on type:
48.00
Aircraft flight hours:
3447
Circumstances:
The private pilot and five passengers departed on a day instrument flight rules cross-country flight in the multiengine airplane. Before departure, the airplane was serviced to capacity with fuel, which corresponded to an endurance of about 5 hours. About 1 hour 45 minutes after reaching the flight's cruise altitude of 12,000 ft mean sea level, the pilot reported a failure of the right engine fuel pump and requested to divert to the nearest airport. About 7 minutes later, the pilot reported that he "lost both fuel pumps" and stated that the airplane had no engine power. The pilot continued toward the diversion airport and the airplane descended until it impacted trees about 1,650 ft short of the approach end of the runway; a postimpact fire ensued. Postaccident examination of the airframe and engines revealed no preimpact failures or malfunctions that would have precluded normal operation. The propellers of both engines were found in the unfeathered position. All six of the fuel pumps on the airplane were functionally tested or disassembled, and none exhibited any anomalies that would have precluded normal operation before the accident. Corrosion was noted in the right fuel boost pump, which was likely the result of water contamination during firefighting efforts by first responders. The airplane was equipped with 4 fuel tanks, comprising an outboard and an inboard fuel tank in each wing. The left and right engine fuel selector valves and corresponding fuel selector handles were found in the outboard tank positions. Given the airplane's fuel state upon departure and review of fuel consumption notes in the flight log from the day of the accident, the airplane's outboard tanks contained sufficient fuel for about 1 hour 45 minutes of flight, which corresponds to when the pilot first reported a fuel pump anomaly to air traffic control. The data downloaded from the engine data monitor was consistent with both engines losing fuel pressure due to fuel starvation. According to the pilot's operating handbook, after reaching cruise flight, fuel should be consumed from the outboard tanks before switching to the inboard tanks. Two fuel quantity gauges were located in the cockpit overhead switch panel to help identify when the pilot should return the fuel selectors from the outboard fuel tanks to the inboard fuel tanks. A flight instructor who previously flew with the pilot stated that this was their normal practice. He also stated that the pilot had not received any training in the accident airplane to include single engine operations and emergency procedures. It is likely that the pilot failed to return the fuel selectors from the outboard to the inboard tank positions once the outboard tanks were exhausted of fuel; however, the pilot misdiagnosed the situation as a fuel pump anomaly.
Probable cause:
A total loss of power in both engines due to fuel starvation as a result of the pilot's fuel mismanagement, and his subsequent failure to follow the emergency checklist. Contributing to the pilot's failure to follow the emergency checklist was his lack of emergency procedures training in the accident airplane.
Final Report:

Crash of a Cessna 414A Chancellor off Destin: 1 killed

Date & Time: Aug 2, 2016 at 2030 LT
Type of aircraft:
Operator:
Registration:
N2735A
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Destin – Abbeville
MSN:
414A-0463
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
15000
Aircraft flight hours:
6202
Circumstances:
The instrument-rated commercial pilot departed from an airport adjacent to the Gulf of Mexico with an instrument flight rules clearance for a cross-country flight in dark night, visual
meteorological conditions. The flight continued in a south-southwesterly direction, climbing to about 900 ft over the gulf, where it entered a steep right turn. The airplane then descended at a steep rate and impacted the water in a nose-low attitude. Post accident examination of the recovered wreckage, including flight controls, engines, and propellers revealed no evidence of preimpact failure or malfunction. While the outlet fuel line from the left auxiliary fuel pump was found separated and there was evidence that the B-nut was loose and had been only secured by the first 2 threads, recorded data from the engine monitor for the flight revealed no loss of power from either engine. Therefore, the final separation likely occurred during the impact sequence. Although the accident pilot was instrument rated and had recently completed instrument currency training, the dark night conditions present at the time of the accident combined with a further lack of visual references due to the airplane's location over a large body of water, presented a situation conducive to the development of spatial disorientation. The pilot had been instructed by air traffic control to turn southwest after takeoff; however, the continuation of the turn past the intended course and the airplane's steep bank angle and excessive rate of descent are consistent with a loss of control due to spatial disorientation.
Probable cause:
The pilot's loss of control due to spatial disorientation shortly after takeoff, while maneuvering over water during dark night conditions.
Final Report: