Crash of a Fletcher FU-24-954 in Fox Glacier: 9 killed

Date & Time: Sep 4, 2010 at 1327 LT
Type of aircraft:
Registration:
ZK-EUF
Flight Phase:
Survivors:
No
Schedule:
Fox Glacier - Fox Glacier
MSN:
281
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
4554
Captain / Total hours on type:
41.00
Circumstances:
Shortly after take off from Fox Glacier aerodrome, while climbing, aircraft stalled and crashed in flames in a paddock near the airfield. All nine occupants, the pilot and 8 skydivers, were killed. The new owner and operator of the aeroplane had not completed any weight and balance calculations on the aeroplane before it entered service, nor at any time before the accident. As a result the aeroplane was being flown outside its loading limits every time it carried a full load of 8 parachutists. On the accident flight the centre of gravity of the aeroplane was well rear of its aft limit and it became airborne at too low a speed to be controllable. The pilot was unable to regain control and the aeroplane continued to pitch up, then rolled left before striking the ground nearly vertically.
Probable cause:
Findings:
- There were no technical defects identified that may have contributed to the accident and the aeroplane was considered controllable during the take-off roll, with the engine able to deliver power during the short flight.
- The aeroplane’s centre of gravity was at least 0.122m rear of the maximum permissible limit, which created a tendency for the nose to pitch up. The most likely reason for the crash was the aeroplane being excessively out of balance. In addition, the aeroplane probably became airborne early and at too low an airspeed to prevent uncontrollable nose-up pitch.
- The aeroplane reached a pitch angle that would have made it highly improbable for the unrestrained parachutists to prevent themselves sliding back towards the tail. Any shift in weight rearward would have made the aeroplane more unstable.
- The engineering company that modified ZK-EUF for parachuting operations did not follow proper processes required by civil aviation rules and guidance. Two of the modifications had been approved for a different aircraft type, one modification belonged to another design holder and a fourth was not referred to in the aircraft maintenance logbook.
- The flight manual for ZK-EUF had not been updated to reflect the new role of the aeroplane and was limited in its usefulness to the aeroplane owner for calculating weight and balance.
- Regardless of the procedural issues with the project to modify ZK-EUF, the engineering work conducted on ZK-EUF to convert it from agricultural to parachuting operations in the standard category was by all accounts appropriately carried out.
- The weight and balance of the aeroplane, with its centre of gravity at least 0.122m outside the maximum aft limit, would have caused serious handling issues for the pilot and was the most significant factor contributing to the accident.
- ZK-EUF was 17 kg over its maximum permissible weight on the accident flight, but was still 242 kg lighter than the maximum all-up weight for which the aeroplane was certified in its previous agricultural role. Had the aeroplane not been out of balance it is considered the excess weight in itself would have been unlikely to cause the accident. Nevertheless, the pilots should have made a full weight and balance calculation before each flight.
- The aeroplane owner and their pilots did not comply with civil aviation rules and did not follow good, sound aviation practice by failing to conduct weight and balance calculations on the aeroplane. This resulted in the aeroplane being routinely flown overweight and outside the aft centre of gravity allowable limit whenever it carried 8 parachutists.
- The empty weight and balance for ZK-EUF was properly recorded in the flight manual, but the stability information in that manual had not been appropriately amended to reflect its new role of a parachute aeroplane. Nevertheless, it was still possible for the aeroplane operator to initially have calculated the weight and balance of the aeroplane for the predicted operational loads before entering the aeroplane into service.
- The aeroplane owner did not comply with civil aviation rules and did not follow good, sound aviation practice when they: used the incorrect amount of fuel reserves; removed the flight manual from the aeroplane; and did not formulate their own standard operating procedures before using the aeroplane for commercial parachuting operations.
- The Director of Civil Aviation delegated the task of assessing and overseeing major modifications to Rule Part 146 design organisations and individual holders of “inspection authorisations”. The delegations did not absolve the Director of his responsibility to monitor compliance with civil aviation rules and guidance.
Page 38 | Report 10-009
- The delegations increased the risk that unless properly managed the CAA could lose control of 2 safety-critical functions: design and inspection. The Director had not appropriately managed that risk with the current oversight programme.
- The CAA had adhered strictly to its normal practice and was acting in accordance with civil aviation rules when approving the change in airworthiness category from special to standard. However, knowing the scope, size and complexity of the modifications required to change ZK-EUF from an agricultural to a parachuting aeroplane, it should have had greater participation in the process to help ensure there were no safety implications.
- There was a flaw in the regulatory system that allowed an engineering company undertaking major modification work on an aircraft to have little or no CAA involvement by using an internal or contracted design delegation holder and a person with the inspection authorisation to oversee and sign off the work.
- The level of parachuting activity in New Zealand warranted a stronger level of regulatory oversight than had been applied in recent years.
- The CAA’s oversight and surveillance of commercial parachuting were not adequate to ensure that operators were functioning in a safe manner.
- The CAA had mechanisms through the Director’s powers under the Civil Aviation Act and his designated powers under the HSE Act to effectively regulate the parachuting industry pending the introduction of Rule Part 115.
- An alcohol and drug testing regime needs to be initiated for persons performing activities critical to flight safety, to detect and deter the use of performance-impairing substances.
- In this case the impact was not survivable and the passengers wearing safety restraints would not have prevented their deaths, but in other circumstances the wearing of safety restraints might reduce injuries and save lives.
- Safety harnesses or restraints would help to prevent passengers sliding rearward and altering the centre of gravity of the aircraft. It could not be established if this was a factor in this accident.
Final Report:

Crash of a PZL-Mielec AN-2T in Tuzla: 12 killed

Date & Time: Jul 5, 2010 at 1740 LT
Type of aircraft:
Operator:
Registration:
53
Flight Phase:
Survivors:
Yes
Schedule:
Tuzla - Tuzla
MSN:
1G194-53
YOM:
1982
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
12
Circumstances:
Shortly after takeoff from Tuzla Airport, the single engine aircraft stalled and crashed in an open field, bursting into flames. Two passengers survived while 12 other occupants were killed. The aircraft was carrying 4 crew and 10 members of the Romanian Navy engaged in a paratroopers mission.
Those killed were:
Cdr Nicolae Jianu,
Lt Cdr Cătălin Vicenţiu Antoche,
Lt Lavinia Guită,
Lt Răzvan Rîngheţ,
Lt Liviu Antim,
Florin Claudiu Cişmaşu,
Cătălin Rădoi,
Băduţ Papuc,
Vlăduţ Sărman,
Marius Cătălin Chioveanu,
Cosmin Furtună,
Cosmin Florescu.
The Captain Daniel Bâlsanu and the foreman Marius Nazare were injured.

Crash of an Antonov AN-2 in Astrakhan

Date & Time: May 12, 2010
Type of aircraft:
Operator:
Flight Phase:
Survivors:
Yes
Schedule:
Astrakhan - Astrakhan
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff, while in initial climb, the aircraft suffered an engine failure. The crew attempted an emergency landing when the aircraft stalled and crashed in an open field, bursting into flames. All 12 occupants escaped uninjured while the aircraft was destroyed by a post crash fire.
Probable cause:
Engine failure for unknown reasons.

Crash of a PAC 750XL in Cascais: 1 killed

Date & Time: Feb 12, 2010 at 1700 LT
Operator:
Registration:
D-FGOJ
Survivors:
Yes
Schedule:
Évora - Cascais
MSN:
139
YOM:
2008
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft departed Evora Airport in the afternoon for a local flight with two skydivers, one photographer and a pilot on board. Few minutes after take off, the photographer output a weapon and ordered both skydivers to jump. After they left the cabin, the photographer then threatened the pilot and ordered him to divert to Cascais-Tires Airport. After landing, the aircraft veered off runway, lost its undercarriage and came to rest in a grassy area near the apron. The pilot was able to escape while the photographer shot himself and died. Aircraft was damaged beyond repair, both wings being partially sheared off.
Probable cause:
Aircraft and crew hijacked in flight by a 'photographer'.
Final Report:

Crash of a Technoavia SM-92T Turbo Finist in Kalachevo: 8 killed

Date & Time: Dec 13, 2009 at 1100 LT
Operator:
Registration:
RA-0257G
Flight Phase:
Survivors:
No
Schedule:
Kalachevo - Kalachevo
MSN:
02-005
YOM:
1997
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
4658
Captain / Total hours on type:
98.00
Aircraft flight hours:
536
Aircraft flight cycles:
1378
Circumstances:
The single engine was completing local skydiving sorties at Kalachevo Airport, about 24 kkm south of Chelyabinsk. Shortly after takeoff, while climbing to a height of about 100 metres, the aircraft stalled and crashed in a snow covered field located 1,5 km north of the airfield. The aircraft was totally destroyed upon impact and all 8 occupants were killed.
Probable cause:
The accident was the consequence of a stall during initial climb due to the combination of the following factors:
- Violation of the climb procedures regarding the speed,
- Flight performances were not met as the aircraft was operated for skydiving purposes but not intended for such type of flight,
- The total weight of the aircraft was above the MTOW,
- The aircraft was not equipped with a system that could inform the pilot of the imminence of a stall,
- The aircraft stalled at a relative low altitude that could not allow the pilot to expect recovery.
Final Report:

Crash of a Beechcraft 99 Airliner in Évora: 2 killed

Date & Time: Aug 14, 2009 at 1908 LT
Type of aircraft:
Operator:
Registration:
F-BTME
Survivors:
No
Site:
Schedule:
Évora - Évora
MSN:
U-79
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
22993
Aircraft flight cycles:
17449
Circumstances:
The aircraft, a Beechcraft model BE-99, s/n U79, with French registration F-BTME, belonging to the operator “Avioarte Serviços Aéreos, Lda”, was involved all that day, 14th of August, 2009, flying locally, carrying parachutists for skydiving exercises, in the vicinity of Évora aerodrome (LPEV), working for the enterprise “Skydive”. With twelve full equipped parachutists and one pilot on board, the aircraft took-off on runway 01 at 18:47, intending to climb to an altitude of 13000ft (4000m), at which altitude the jumping would take place. When passing about 9500ft (2900m), left engine (#1) flame-out and respective propeller was automatically feathered. The pilot stop climb at around 10500ft (3200m), informed the parachutists that one engine had stopped and they should jump a little lower than it was expected, while he would proceed for landing at same aerodrome, with one engine inoperative. All parachutists left the aircraft, on sequence, but one, who, after being next to the exit, returned to the cockpit and remained on board, with the pilot. The aircraft started a dive, turning around the field, and the pilot contacted the tower on left base leg for runway 01, but said nothing about the inoperative engine or any assistance required. He was told to report on final, which he never did. He continued the approach for runway 01, with landing gear down and flaps at initial setting (13º), but keeping high speed. The aircraft made a low pass, over all runway length, without the wheels touching the ground. Once passing runway end it continued flying, the pilot increased power on right engine (#2) and the aircraft started deviating to the left, with wings levelled and without showing significant climb tendency. Observers, at the aerodrome, lost the sight of the aircraft for some moments and saw it reappearing close to Almeirim residential quarter (in the outskirts of Évora). One testimony, sited at the aerodrome, referred seeing the aircraft executing a sudden manoeuvre, like a left roll, pointing the wheels up to the sky. Moments later a collision sound was heard, the engine became silent and some flames and a black smoke cloud appeared. The aircraft collided with a residential building, in Maria Auxiliadora street, Almeirim residential quarter, sited about 1160m far from runway end, on track 330º. After the collision with the building, the aircraft fell to the ground, upside-down, a fire sparked immediately and the plane was engulfed by flames. Fire brigades from Évora, Viana do Alentejo, Montemor-o-Novo and Arraiolos arrived at the scene, promptly, but it took some time for the fire to be extinguished (after burning all aircraft fuel) and the burned bodies recovered from the wreckage.
Probable cause:
Primary Cause:
Primary cause for this accident was pilot inability, as he was not qualified to fly this class of aircraft, to carry a single engine landing or maintain directional control during go-around with one engine inoperative.
Contributory Factors:
The following were considered as Contributory factors:
- The pilot was not qualified to operate multi-engine aircrafts and had no knowledge and training to fly this kind of aircraft;
- Unsuitable fuel monitoring and omission on manufacturer recommended procedures accomplishment;
- Inadequate flying technique, without consideration to the airplane special flying characteristics;
- Inadequate supervision, by the competent authorities, on flying activities carried by pilots and aircrafts with foreign licenses and registrations, inside Portuguese territory.
Final Report:

Crash of a Fokker F27 Friendship 400M in Bandung: 24 killed

Date & Time: Apr 6, 2009 at 1230 LT
Type of aircraft:
Operator:
Registration:
A-2703
Survivors:
No
Schedule:
Bandung - Bandung
MSN:
10538
YOM:
1976
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
24
Circumstances:
The aircraft was performing a paratroopers/skydiving mission in the region of Bandung, taking part to a military program with members of the Special Forces on board. While approaching runway 29 with 20 knots crosswind, the aircraft went out of control and crashed onto a hangar, bursting into flames. All 24 occupants were killed, among them 17 paratroopers, one instructor and 6 crew members.

Crash of a PZL-Mielec AN-2T in Volosovo

Date & Time: Mar 7, 2009
Type of aircraft:
Operator:
Registration:
RF-01206
Flight Phase:
Survivors:
Yes
Schedule:
Volosovo - Volosovo
MSN:
1G98-22
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
45 seconds after takeoff, while climbing, the aircraft stalled and crashed in a snow covered field. The pilot and all 10 skydivers escaped uninjured while the aircraft was damaged beyond repair.

Crash of an Antonov AN-2 in Pskov

Date & Time: Feb 11, 2009 at 1030 LT
Type of aircraft:
Operator:
Registration:
10 yellow
Flight Phase:
Survivors:
Yes
Schedule:
Pskov - Pskov
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after take off from Pskov Airport, while climbing to a height of about 50-70 metres, the crew encountered engine problems and elected to make an emergency landing. The aircraft lost height and crashed in a snow covered field located near the airport and came to rest. All 13 occupants escaped uninjured while the aircraft was damaged beyond repair. All passengers were skydivers (paratroopers) from the Marine Corps.
Probable cause:
Engine failure for unknown reasons.

Crash of a Pacific Aerospace PAC 750XL in Pont-en-Ogoz: 2 killed

Date & Time: Sep 21, 2008 at 1328 LT
Operator:
Registration:
ZK-JPP
Flight Phase:
Survivors:
No
Schedule:
Colombier – Ecuvillens
MSN:
106
YOM:
2003
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
645
Captain / Total hours on type:
213.00
Aircraft flight hours:
1471
Aircraft flight cycles:
4214
Circumstances:
Following an uneventful flight from Beromünster, the single engine aircraft landed at Colombier Airport where 17 skydivers boarded the plane on a flight to Ecuvillens. While overflying the region of Gruyere, all 17 skydivers jumped. Few minutes later, while descending to Ecuvillens, the pilot encountered marginale weather conditions with limited visibility due to stratus up to the altitude of 1,060 metres. While flying under VFR mode in IMC conditions, the aircraft collided with trees and crashed the forest of Gibloux, near Pont-en-Ogoz. The aircraft was totally destroyed by impact forces and a post crash fire and both occupants, one pilot and one female passenger, were killed.
Probable cause:
Controlled flight into terrain after the pilot continued under VFR mode in IMC conditions.
Final Report: