Crash of a Piper PA-46R-350T Matrix off Cat Cay

Date & Time: Aug 25, 2013 at 1406 LT
Registration:
N720JF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cat Cay - Kendall-Miami
MSN:
46-92004
YOM:
2008
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12250
Captain / Total hours on type:
210.00
Aircraft flight hours:
1000
Circumstances:
According to the pilot, he applied full power, set the flaps at 10 degrees, released the brakes, and, after reaching 80 knots, he rotated the airplane. The pilot further reported that the engine subsequently lost total power when the airplane was about 150 ft above ground level. The airplane then impacted water in a nose-down, right-wing-low attitude about 300 ft from the end of the runway. The pilot reported that he thought that the runway was 1,900 ft long; however, it was only 1,300 ft long. Review of the takeoff ground roll distance charts contained in the Pilot’s Operating Handbook (POH) revealed that, with flap settings of 0 and 20 degrees, the ground roll would have been 1,700 and 1,150 ft, respectively. Takeoff ground roll distances were not provided for use of 10 degrees of flaps; however, the POH stated that 10 degrees of flaps could be used. Although the distance was not specified, it is likely that the airplane would have required more than 1,300 ft for takeoff with 10 degrees of flaps. Examination of the engine revealed saltwater corrosion throughout it; however, this was likely due to the airplane’s submersion in water after the accident. No other mechanical malfunctions or abnormalities were noted. Examination of data extracted from the multifunction display (MFD) and primary flight display (PFD) revealed that the engine parameters were performing in the normal operating range until the end of the recordings. The data also indicated that, 7 seconds before the end of the recordings, the airplane pitched up from 0 to about 17 degrees and then rolled 17 degrees left wing down while continuing to pitch up to 20 degrees. The airplane then rolled 77 degrees right wing down and pitched down about 50 degrees. The highest airspeed recorded by the MFD and PFD was about 70 knots, which occurred about 1 second before the end of the recordings. The POH stated that, depending on the landing gear position, flap setting, and bank angle, the stall speed for the airplane would be between 65 and 71 knots. Based on the evidence, it is likely that the engine did not lose power as reported by the pilot. As the airplane approached the end of the runway and the pilot realized that it was not long enough for his planned takeoff, he attempted to lift off at an insufficient airspeed and at too high of a pitch angle, which resulted in an aerodynamic stall at a low altitude. If the pilot had known the actual runway length, he might have used a flap setting of 20 degrees, which would have provided sufficient distance for the takeoff.
Probable cause:
The pilot’s attempt to rotate the airplane before obtaining sufficient airspeed and his improper pitch control during takeoff, which resulted in the airplane exceeding its critical angle-of-attack and subsequently experiencing an aerodynamic stall at a low altitude. Contributing to the accident was the pilot’s lack of awareness of the length of the runway, which led to his attempting to take off with the airplane improperly configured.
Final Report:

Crash of a De Havilland DH.60G Moth in Canons Ashby

Date & Time: Aug 12, 2013 at 1130 LT
Type of aircraft:
Operator:
Registration:
G-AAZG
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Turweston - Turweston
MSN:
1253
YOM:
1930
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
512
Captain / Total hours on type:
15.00
Circumstances:
The pilot was carrying out a local flight with a friend. The weather was good (CAVOK), with a westerly wind of about 12 to 15 kt. The passenger occupied the front cockpit and the pilot the rear. The engine started normally and the aircraft departed, climbing to an altitude of 1,200 ft. The pilot carried out two medium banked turns and a gentle wingover manoeuvre before entering another steep turn to the left. When established in the turn, the engine stopped and the aircraft entered a spin to the left. The pilot recovered from the spin but, due to the limited height available, could only pull out of the dive and carry out a forced landing in an isolated grass area, amongst trees and other obstacles. In doing so, the aircraft struck a ridge and furrow, which destroyed the landing gear and much of the forward fuselage. A member of the public witnessed the accident and called the emergency services, who recovered both occupants from the wreckage. The pilot and his passenger had suffered serious injuries and were transferred to hospital. There was no fire.The aircraft had recently been re-weighed. During that process, the fuel tank had been drained and the same fuel was then used to refill the tank. After that, the aircraft had flown some five hours, during which it had been refuelled twice at a licensed aerodrome. The second refuel had taken place prior to positioning the aircraft back to the private site from which the accident flight departed. It was reported that the engine had been consistently reliable. No reason for the engine failure was identified. The pilot considered that he had avoided a serious head injury because he was wearing a protective helmet. Also, he commented that he had since had discussions with others in the historic aircraft community regarding energy absorbing foam in seat pans and its potential for reducing the level of back injuries in the event of an accident.
Probable cause:
Engine failure for undetermined reason.
Final Report:

Crash of a Rockwell 690B Turbo Commander in New Haven: 4 killed

Date & Time: Aug 9, 2013 at 1121 LT
Registration:
N13622
Flight Type:
Survivors:
No
Site:
Schedule:
Teterboro - New Haven
MSN:
11469
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2067
Aircraft flight hours:
8827
Circumstances:
The pilot was attempting a circling approach with a strong gusty tailwind. Radar data and an air traffic controller confirmed that the airplane was circling at or below the minimum descent altitude of 720 feet (708 feet above ground level [agl]) while flying in and out of an overcast ceiling that was varying between 600 feet and 1,100 feet agl. The airplane was flying at 100 knots and was close to the runway threshold on the left downwind leg of the airport traffic pattern, which would have required a 180-degree turn with a 45-degree or greater bank to align with the runway. Assuming a consistent bank of 45 degrees, and a stall speed of 88 to 94 knots, the airplane would have been near stall during that bank. If the bank was increased due to the tailwind, the stall speed would have increased above 100 knots. Additionally, witnesses saw the airplane descend out of the clouds in a nose-down attitude. Thus, it was likely the pilot encountered an aerodynamic stall as he was banking sharply, while flying in and out of clouds, trying to align the airplane with the runway. Toxicological testing revealed the presence of zolpidem, which is a sleep aid marketed under the brand name Ambien; however, the levels were well below the therapeutic range and consistent with the pilot taking the medication the evening before the accident. Therefore, the pilot was not impaired due to the zolpidem. Examination of the wreckage did not reveal any preimpact mechanical malfunctions.
Probable cause:
The pilot's failure to maintain airspeed while banking aggressively in and out of clouds for landing in gusty tailwind conditions, which resulted in an aerodynamic stall and uncontrolled descent.
Final Report:

Crash of a Socata TBM-850 in Clermont-Ferrand: 3 killed

Date & Time: Aug 8, 2013 at 0940 LT
Type of aircraft:
Operator:
Registration:
N850GC
Flight Type:
Survivors:
No
Schedule:
Toussus-le-Noble - Clermont-Ferrand - Biarritz
MSN:
645
YOM:
2013
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
615
Captain / Total hours on type:
51.00
Circumstances:
On an ILS Z approach to Clermont-Ferrand-Auvergne Airport Runway 26 in IMC conditions, the pilot was instructed by ATC to climb to 6,000 feet to TIS VOR via a right turn because he failed to follow the published missed approach procedures. The single engine aircraft departed the approach path and control was lost after it completed several turns on climb and descent. It entered a high nose-down attitude and struck the ground at high speed about 6 km short of runway. The aircraft disintegrated on impact and all three occupants aged respectively 70, 73 and 76 years old were killed. They were completing an intermediate stop at Clermont-Ferrand Airport to pick up two additional passengers before continuing to Biarritz.
Probable cause:
The trace from the radar data shows that the aircraft followed the ILS Z 26 procedure track in the horizontal plane to about 6.4 NM from the runway threshold. This observation is consistent with the autopilot tracking of the ILS Z 26 procedure entered into the FMS in GPS mode. The transition from GPS to LOC occurred after the FAP. Although the APP mode was engaged, the aircraft did not descend as expected by the pilot. It continued in line with the localizer but in level flight at 4000 feet for more than 1 nm. The pilot attempted to catch up with the glide path from above. Unable to stabilize his course, he aborted the approach without following the prescribed go-around path or the heading and altitude instructions provided by the controller. He made a succession of left and right turns and climbs and descents. The track and readbacks show that he lost situational awareness. The airspeed regression following the last climb caused the pilot to lose control of the aircraft, which collided with the ground. The entire approach was flown with no outside visibility.
Contributing factors (may have contributed to the loss of control):
- A coding error in the Garmin 1000 avionics suite database that prevented the automatic transition from GPS mode to LOC mode. Thus the automatic interception of the descent plan did not occur, which probably surprised the pilot and led him to resume manual piloting with excessive corrections.
- The pilot's overconfidence in the aircraft's autopilot system.
- Lack of knowledge of the conditions required for the aircraft autopilot system to capture and track the glide path.
- Lack of consistency verification by the pilot between the coded procedure in the avionics suite and his breakthrough sheet.
- The pilot's lack of total and recent instrument flight experience without external visual reference, which may have contributed to his increased stress, lack of availability, and spatial disorientation.
- Sensory illusions that the pilot may have been confronted with, given the numerous changes in aircraft attitude, without external visual reference.
- The acquisition of additional experience and skills with safety pilots after obtaining the SET class rating, which is ineffective and outside the regulatory training framework, which can lead pilots to free themselves from this support when it is considered to be restrictive.
Final Report:

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

Date & Time: Aug 1, 2013 at 1800 LT
Type of aircraft:
Operator:
Registration:
4X-AKV
Flight Type:
Survivors:
Yes
Schedule:
Herzliya - Eilat
MSN:
31-8112021
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Following an uneventful flight from Herzliya, the pilot started the approach to Eilat Airport in excellent weather conditions. During the last segment, at a height of about 10 feet, the pilot initiated a go-around procedure following a misunderstanding about an ATC transmission that was given to another crew. The pilot mistakenly closed to fuel valve coupled to the right engine while trying to switch fuel tanks, causing the right engine to stop. Due to an asymmetric thrust, the pilot lost control of the airplane that veered to the right and crashed in a drainage ditch, coming to rest upside down. While both passengers were seriously injured, the pilot was killed.

Crash of a Piper PA-46-310P Malibu in Augsburg

Date & Time: Jun 19, 2013 at 0930 LT
Operator:
Registration:
D-ETSI
Flight Type:
Survivors:
Yes
Schedule:
Rottweil – Augsburg
MSN:
46-8508012
YOM:
1985
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2200
Captain / Total hours on type:
1.00
Aircraft flight hours:
2873
Aircraft flight cycles:
2358
Circumstances:
The single engine airplane departed Rottweil-Zepfenhan Airfield at 0847LT bound for Augsburg Airport. En route, the pilot encountered technical problems with the engine, informed ATC about his situation and activated the electrical fuel pump when the engine restarted. On final approach to Ausgburg, he re-encountered engine problems and attempted an emergency landing when the airplane hit power cables and crashed in a garden located 1,123 meters short of runway 07 threshold. The pilot was seriously injured and the aircraft was damaged beyond repair.
Probable cause:
The aircraft accident is due to the fact that, due to incorrect operation of the auxiliary fuel pump, the engine no longer assumed power on the approach and ran out. Due to the low altitude, the pilot initiated an emergency landing. The landing failed because the aircraft collided with an obstacle and fell uncontrollably to the ground.
Final Report:

Crash of a Cessna 340A near Boynton Beach: 1 killed

Date & Time: Jun 8, 2013 at 1002 LT
Type of aircraft:
Registration:
N217JP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Fort Lauderdale – Leesburg
MSN:
340A-0435
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
16561
Captain / Total hours on type:
56.00
Aircraft flight hours:
4209
Circumstances:
Four minutes after taking off on an instrument flight rules flight, during an assigned climb to 4,000 feet, the pilot advised the departure air traffic controller that the airplane was having "instrument problems" and that he wanted to "stay VFR" (visual flight rules), which the controller acknowledged. As directed, the pilot subsequently contacted the next sector departure controller, who instructed him to climb to 8,000 feet. The pilot stated that he would climb the airplane after clearing a cloud and reiterated that the airplane was having "instrument problems." The controller told the pilot to advise when he could climb the airplane. About 30 seconds later, the pilot told the controller that he was climbing the airplane to 8,000 feet, and, shortly thereafter, the controller cleared the airplane to 11,000 feet, which the pilot acknowledged. Per instruction, the pilot later contacted a center controller, who advised him of moderate-to-heavy precipitation along his (northbound) route for the next 10 miles and told him that he could deviate either left or right and, when able, proceed direct to an intersection near his destination. The pilot acknowledged the direct-to-intersection instruction, and the controller told the pilot to climb the airplane to 13,000 feet, which the pilot acknowledged. The pilot did not advise the center controller about the instrument problems. The airplane subsequently began turning east, eventually completing about an 80-degree turn toward heavier precipitation, and the controller told the pilot to climb to 15,000 feet, but the pilot did not respond. After two more queries, the pilot stated that he was trying to maintain "VFR" and that "I have an instrument failure here." The controller then stated that he was showing the airplane turning east, which "looks like a very bad idea." He subsequently advised the pilot to turn to the west but received no further transmissions from the airplane. Radar indicated that, while the airplane was turning east, it climbed to 9,500 feet but that, during the next 24 seconds, it descended to 7,500 feet and, within the following 5 seconds, it descended to just above ground level (the ground-based radar altitude readout was 0 feet). The pilot recovered the airplane and climbed it northeast-bound to 1,500 feet during the next 20 seconds. It then likely stalled and descended northwest-bound into shallow waters of a wildlife refuge. Weather radar returns indicated that the airplane's first descent occurred in an area of moderate-to-heavy rain but that the second descent occurred in light rain. The ceiling at the nearest recording airport, located about 20 nautical miles from the accident site, was 1,500 feet, indicating that the pilot likely climbed the airplane back into instrument meteorological conditions (IMC)before finally losing control. The investigation could not determine the extent to which the pilot had planned the flight. Although a flight plan was on file, the pilot did not receive a formal weather briefing but could have self-briefed via alternative means. The investigation also could not determine when the pilot first lost situational awareness, although the excessive turn to the east toward heavier precipitation raises the possibility that the turn likely wasn't intentional and that the pilot had already lost situational awareness. Earlier in the flight, when the pilot reported an instrument problem, the two departure controllers coordinated between their sectors in accordance with air traffic control procedures, allowing him to remain low and out of IMC. Although the second controller told the pilot to advise when he was able to climb, the pilot commenced a climb without further comment. The controller was likely under the impression that the instrument problem had been corrected; therefore, he communicated no information about a potential instrument problem to the center controller. The center controller then complied with the level of service required by advising the pilot of the weather conditions ahead and by approving deviations. The extent and nature of the deviation was up to the pilot with controller assistance upon pilot request. The pilot did not request further weather information or assistance with deviations and only told the center controller that the airplane was having an instrument problem after the controller pointed out that the airplane was heading into worsening weather. Due to impact forces, only minimal autopsy results could be determined. Federal Aviation Administration medical records indicated that the 16,560-hour former military pilot did not have any significant health issues, and the pilot's wife was unaware of any preexisting significant medical conditions. The wreckage was extremely fractured, which precluded thorough examination. However, evidence indicated that all flight control surfaces were accounted for at the accident scene and that the engines were under power at the time of impact. The airplane was equipped with redundant pilot and copilot flight instruments, redundant instrument air sources, onboard weather radar, and a storm scope. The pilot did not advise any of the air traffic controllers about the extent or type of instrument problem, and the investigation could not determine which instrument(s) might have failed or how redundant systems could have been failed at the same time. Although the pilot stated on several occasions that the airplane was having instrument problems, he opted to continue flight into IMC. By doing so, he eventually lost situational awareness and then control of airplane but regained both when he acquired visual ground contact. Then, for unknown reasons, he climbed the airplane back into IMC where he again lost situational awareness and airplane control but was then unable to regain them before the airplane impacted the water.
Probable cause:
The pilot's loss of situational awareness, which resulted in an inadvertent aerodynamic stall/spin after he climbed the airplane back into instrument meteorological conditions (IMC). Contributing to the accident was the pilot's improper decision to continue flight into IMC with malfunctioning flight instrument(s).
Final Report:

Crash of a Beechcraft B200GT Super King Air in Baker: 1 killed

Date & Time: Jun 7, 2013 at 1310 LT
Operator:
Registration:
N510LD
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Baton Rouge - McComb
MSN:
BY-24
YOM:
2007
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
15925
Captain / Total hours on type:
5200.00
Aircraft flight hours:
974
Circumstances:
The accident pilot and two passengers had just completed a ferry flight on the recently purchased airplane. A review of the airplane’s cockpit voice recorder audio information revealed that, during the ferry flight, one of the passengers, who was also a pilot, was pointing out features of the new airplane, including the avionics suite, to the accident pilot. The pilot had previously flown another similar model airplane, but it was slightly older and had a different avionics package; the new airplane’s avionics and flight management system were new to the pilot. After completing the ferry flight and dropping off the passengers, the pilot departed for a short cross-country flight in the airplane. According to air traffic control recordings, shortly after takeoff, an air traffic controller assigned the pilot a heading and altitude. The pilot acknowledged the transmission and indicated that he would turn to a 045 heading. The radio transmission sounded routine, and no concern was noted in the pilot’s voice. However, an audio tone consistent with the airplane’s stall warning horn was heard in the background of the pilot’s radio transmission. The pilot then made a radio transmission stating that he was going to crash. The audio tone was again heard in the background, and distress was noted in the pilot’s voice. The airplane impacted homes in a residential neighborhood; a postcrash fire ensued. A review of radar data revealed that the airplane made a climbing right turn after departure and then slowed and descended. The final radar return showed the airplane at a ground speed of 102 knots and an altitude of 400 feet. Examination of the engines and propellers indicated that the engines were rotating at the time of impact; however, the amount of power the engines were producing could not be determined. The examination of the airplane did not reveal any abnormalities that would have precluded normal operation. It is likely that the accident pilot failed to maintain adequate airspeed during departure, which resulted in an aerodynamic stall and subsequent impact with terrain, and that his lack of specific knowledge of the airplane’s avionics contributed to the accident.
Probable cause:
The pilot’s failure to maintain adequate airspeed during departure, which resulted in an aerodynamic stall and subsequent impact with terrain. Contributing to the accident was the pilot’s lack of specific knowledge of the airplane’s avionics.
Final Report:

Crash of a Beechcraft D18S off Red Lake: 2 killed

Date & Time: May 30, 2013 at 1727 LT
Type of aircraft:
Registration:
C-FWWV
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Red Lake - Red Lake
MSN:
A-618
YOM:
1951
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The pilot and his wife, a couple from Phoenix, were performing a flight from the Red Lake Seaplane base to a tourist Camp located north of Red Lake. The twin engine aircraft took off at 1727LT in marginal weather conditions consisting of wind and rain showers. Shortly after departure, the aircraft crashed into the Bruce Channel located between Cochenour and McKenzie Island. The aircraft sank and both occupants were killed.

Crash of a Comp Air CA-8 in Sorocaba: 2 killed

Date & Time: May 29, 2013 at 1540 LT
Type of aircraft:
Operator:
Registration:
PP-XLR
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Sorocaba - Jundiaí
MSN:
0204CA8
YOM:
2006
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after take off from Sorocaba Airport, while climbing, the pilot encountered technical problems and elected to return. While trying to land in a wasteland, the single engine aircraft crashed in a street and was destroyed by impact forces and a post impact fire. Both occupants were killed as a house was also destroyed.