Crash of a Beechcraft A90 King Air in Pitt Meadows

Date & Time: Aug 3, 2008 at 1524 LT
Type of aircraft:
Registration:
N17SA
Survivors:
Yes
Schedule:
Pitt Meadows - Pitt Meadows
MSN:
LJ-164
YOM:
1966
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4800
Captain / Total hours on type:
1290.00
Aircraft flight hours:
13257
Circumstances:
The Bill Dause Beech 65-A90 King Air (United States registration N17SA, aircraft serial number LJ-164) took off from Pitt Meadows Airport, British Columbia, with the pilot and seven parachutists for a local sky diving flight. At 1521 Pacific daylight time, as the aircraft was climbing through 3900 feet above sea level, the pilot reported an engine failure and turned back towards Pitt Meadows Airport for a landing on Runway 08R. The airport could not be reached and a forced landing was carried out in a cranberry field, 400 metres west of the airport. On touchdown, the aircraft struck an earthen berm, bounced, and struck the terrain again. On its second impact, the left wing dug into the soft peat, spinning the aircraft 180 degrees. Four of the parachutists received serious injuries and the aircraft was substantially damaged. There was no fire and the occupants were evacuated. The emergency locator transmitter functioned at impact and was turned off by first responders.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The general condition of the aircraft, the engine time before overhaul (TBO) over-run and the missed inspection items demonstrated inadequate maintenance that was not detected by regulatory oversight.
2. The TBO over-run and missed inspections resulted in excessive spline wear in the left engine-driven fuel pump going undetected.
3. The left engine lost power due to mechanical failure of the engine fuel pump drive splines.
4. The horizontal engine instrument arrangement and the lack of recent emergency training made quick engine malfunction identification difficult. This resulted in the pilot shutting down the wrong engine, causing a dual-engine power loss and a forced landing.
5. Not using the restraint devices contributed to the seriousness of injuries to some passengers.
Finding as to Risk:
1. There is a risk to passengers if Transport Canada does not verify that holders of Canadian Foreign Air Operator Certificates-Free Trade Agreement meet airworthiness and operational requirements.
Final Report:

Crash of a Pilatus PC-6/B2-H4 Turbo Porter in Lillo: 2 killed

Date & Time: May 30, 2008 at 1545 LT
Operator:
Registration:
EC-JXH
Flight Phase:
Survivors:
Yes
Schedule:
Lillo - Lillo
MSN:
700
YOM:
1969
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1100
Captain / Total hours on type:
150.00
Aircraft flight hours:
15833
Aircraft flight cycles:
26931
Circumstances:
The airplane had taken off from runway 30 at the Lillo (Toledo) Aerodrome for a local parachute drop. On board were the pilot and 10 skydivers, six of whom consisted of instructor-student pairs doing tandem jumps. When at an altitude of approximately 14,000 feet and having sounded the acoustic signal indicating two minutes to go before the jump, the airplane was subjected to an instantaneous and sharp negative acceleration that pushed two occupants against the ceiling of the aircraft. As soon as the airplane regained a normal attitude, the left wing fractured and detached. As a result, the airplane started to fall to the ground. Nine of the parachutists were ejected out and were able to open their parachutes at a sufficient enough altitude to land normally. The airplane eventually impacted the ground and burst into flames at a site located 4.5 km north of the aerodrome. The fire destroyed the area between the firewall and the aft end of the passenger cabin. The pilot and one parachutist were unable to exit the aircraft and died on impact. Several components, including the detached wing and its control surfaces, as well as part of the horizontal stabilizer, were thrown off and found between 1.5 km and 2.5 km to the northeast of the main crash site.
Probable cause:
The accident took place as the aircraft was entering an area of strong turbulence inside a storm. The aircraft was turning left to align with the heading used for the parachuting run, and as a result of the turn both the wing and the tail were subjected to loads in excess of design loads. This caused several of their components to fracture, resulting in the detachment of the left wing and the horizontal stabilizer. Contributing significantly to the accident is the fact that neither the company that operated the aircraft nor the jump supervisors were aware of the violent storm present to the north of the aerodrome, exactly over the area where the flight and the skydiving activity were going to take place.
Final Report:

Crash of a Cessna 208B Grand Caravan near Naches: 10 killed

Date & Time: Oct 7, 2007 at 1959 LT
Type of aircraft:
Operator:
Registration:
N430A
Flight Phase:
Survivors:
No
Site:
Schedule:
Star - Shelton
MSN:
208B-0415
YOM:
1995
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
2054
Captain / Total hours on type:
296.00
Aircraft flight hours:
9604
Circumstances:
The pilot was returning a group of skydivers to their home base after a weekend of skydiving. He flew several jump flights, and then stopped early in the afternoon to prepare the airplane for the flight home. The flight was planned into an area of clouds, turbulence, and icing, which the pilot had researched. He delayed the departure until he decided that he could complete the planned flight under visual flight rules (VFR). The accident occurred at night with little illumination of the moon, and the airplane was in an area of layered clouds. A detailed analysis of the weather conditions revealed that the flight probably encountered broken to overcast layers both below and above its flight altitude. The satellite and sounding images suggested that it was possibly in an area of mountain wave conditions, which can enhance icing. The recorded radar data indicated that the pilot was likely maneuvering to go around, above, or below rain showers or clouds while attempting to maintain VFR. The airplane likely entered clouds during the last 3 minutes of flight, and possibly icing and turbulence. It was turning when it departed from controlled flight, and a performance study showed that the angle-of-attack at this point in the flight was increasing rapidly. The study determined that the
departure from controlled flight was consistent with an aerodynamic stall. The unpressurized airplane was flying at over 14,000 feet mean sea level for more than 1 hour during the flight. It reached 15,000 feet just prior to the accident in sequential 360-degree turns while climbing and descending. Supplemental oxygen was not being used. At these altitudes, the pilot would be substantially impaired by hypoxia, but would have virtually no subjective symptoms, and would likely be unaware of his impairment. The pilot had logged over 2,000 hours of total flight time, with nearly 300 hours in this make and model of airplane. He was instrument rated, but had only logged a total of 2 hours of actual instrument flight time. Company policy was to fly under visual flight rules only, and they had not flight-checked the pilot for instrument flight.
Probable cause:
The pilot's failure to maintain an adequate airspeed to avoid an aerodynamic stall while maneuvering. Contributing to the accident were the pilot's impaired physiological state due to hypoxia, the pilot's inadequate preflight weather evaluation, and his attempted flight into areas of known adverse weather. Also contributing were the pilot's inadvertent flight into instrument meteorological conditions that included clouds, turbulence, and dark night conditions.
Final Report:

Crash of a Pilatus PC-6/B1-H2 Turbo Porter in Casas de Los Pinos

Date & Time: Apr 14, 2007 at 1015 LT
Operator:
Registration:
EC-JOE
Survivors:
Yes
Schedule:
Casas de Los Pinos - Casas de Los Pinos
MSN:
705
YOM:
1969
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
650
Captain / Total hours on type:
138.00
Aircraft flight hours:
9046
Circumstances:
The aircraft ran off runway 30 at the Casas de los Pinos aerodrome while landing. The aircraft, used for parachuting operations, was making a reconnaissance flight before the parachuting flights, which were scheduled for later. According to the pilot's statement, during the flare, and before touching down, a gust of wind lifted the left wing. The pilot used left rudder and tilt to try to level the aircraft, but could not keep it from exiting the runway. As stated by the pilot, the approach was performed without flaps, at a speed of 70 knots and with the aft gear locked. The aircraft ended up 25 metres from the edge of the runway on a heading of 190°, resting on its lower fuselage, which was damaged along its underside, as were the left aileron and the horizontal stabilizer. The right main landing gear was bent outward, the left gear had detached and was 30 metres away from the aircraft, and the propeller had detached at the reduction gearbox and was next to the aft landing gear to the left of the aircraft. Both occupants were able to exit the aircraft under their own power. The pilot received a slight injury to his chin and the passenger was unhurt.
Probable cause:
It is not known why aircraft EC-JOE left runway 30 during the landing, though it seems obvious that the aircraft's path was altered while it was flying at a low altitude. The possibility that a technical problem with the aircraft caused the accident has been ruled out. It has not been possible to confirm if the wind was gusting at the aerodrome at the time of the accident, though even gusty conditions should not have affected control of the aircraft since its airspeed was high enough with respect to the stall speed.
Final Report:

Crash of a De Havilland DHC-2 Beaver III in Headcorn: 1 killed

Date & Time: Mar 11, 2007 at 1600 LT
Type of aircraft:
Operator:
Registration:
OY-JRR
Flight Phase:
Survivors:
Yes
Schedule:
Headcorn - Headcorn
MSN:
1632
YOM:
1966
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
932
Captain / Total hours on type:
27.00
Circumstances:
The pilot was conducting flights for the purpose of parachute operations; these flights are known colloquially as ‘lifts’. On the previous day, he had conducted 13 lifts, of which eleven were to an altitude of 12,000 ft and two to an altitude of 5,500 ft or less. On the day of the accident the pilot recorded that he took off for the first lift at 0927 hrs. The aircraft, with nine parachutists aboard, climbed to 12,000 ft and landed at 0946 hrs. There followed three flights of an average 18 minute duration, between each of which the aircraft was on the ground for no more than 7 minutes. The last of these flights landed at 1100 hrs, after which the aircraft uplifted 230 ltr of Jet A1 fuel. The aircraft utilised the main runway, Runway 29, for each of these flights. The surface wind had freshened from the south and the pilot requested the use of the shorter Runway 21. The air/ground radio operator refused this request because he believed that the pilot had not been checked out to use this runway, as required by the Headcorn Aerodrome Manual. Accordingly, the pilot approached a nominated check pilot who agreed to observe his next flight. The check pilot briefed the pilot of OY-JRR on the procedures for using the short runway, emphasising the need to make an early decision to abort the takeoff if necessary. The check pilot stated that the pilot of OY-JRR performed a thorough pre-takeoff check using the full checklist available in the cockpit and that the subsequent flight was entirely satisfactory. Following the check flight the aircraft took off again at 1148 hrs and flew a further five flights, each separated by periods that ranged between 7 and 36 minutes. The check pilot observed several of these flights, all of which were from Runway 21, and most appeared to proceed normally. He and another witness noticed that on one occasion the climb gradient after takeoff appeared shallower than normal, but they believed that the wind speed had decreased at this time. The pilot recorded that the aircraft was refuelled again after landing at 1443 hrs, this time uplifting 266 ltr of fuel. The next takeoff was at 1447 hrs and having climbed to 12,000 ft again the aircraft landed at 1521 hrs. The accident occurred on the pilot’s eleventh flight of the day. Prior to the flight the aircraft was refuelled with a further 100 ltr at 1555 hrs. Shortly before 1605 hrs the aircraft taxied to Runway 21. It appeared to accelerate normally but at no time was the tail seen to rise in its usual manner prior to becoming airborne. Onboard, the experienced jump-master noticed that the aircraft was passing the aerodrome refuelling installation and several aircraft parked close to the runway, beyond the intersection of Runway 21 with Runway 29. He was aware that the aircraft had now passed the point where it would normally become airborne. Almost simultaneously, he heard the pilot shout “Abort”. One of the parachutists shouted to the other occupants “Brace - Brace, everyone on the floor”. The aircraft stopped abruptly when its left wing and cockpit collided with a camouflaged F100 fighter aircraft which was parked as a museum exhibit to the left of the southern edge of Runway 21. The occupants of the cabin were able to vacate the aircraft with mutual assistance. Members of the aerodrome fire service extinguished a small fire, which had started in the area of the engine, and other witnesses helped the occupants to move away from the aircraft. The pilot, however, remained unconscious in the cockpit. He was attended subsequently by paramedics and taken to hospital, where he succumbed to his injuries.
Probable cause:
The pilot’s training was probably adequate for the normal and abnormal circumstances envisaged by his instructor. However, the pilot was not familiar with the handling or performance characteristics of the aircraft during takeoff with the flaps in the UP position and consequently he may not have identified that the aircraft was in the wrong configuration for takeoff. The design authority for this type considered that this configuration was “outside the normal flight envelope” and had produced no performance charts or procedures for its use. In such circumstances, it is essential that the pilot follows the published procedures and positively ensures that the aircraft is correctly configured for takeoff.
Final Report:

Crash of a PZL-Mielec AN-2TP in Aranchi: 15 killed

Date & Time: Oct 19, 2006 at 0730 LT
Type of aircraft:
Operator:
Registration:
UK-70152
Survivors:
No
Schedule:
Aranchi - Aranchi
MSN:
1G137-26
YOM:
1972
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
15
Circumstances:
The single engine aircraft was engaged in a military training exercise with 2 pilots and 13 soldiers (paratroopers from the Special Forces) for a routine local paratroop flight. Few minutes after takeoff, the crew decided to return to Aranchi Airport because weather conditions deteriorated. On final approach, the crew encountered local patches of fog and in a reduced visibility, the aircraft descended too low and impacted ground few hundred metres short of runway. The aircraft was destroyed and all 15 occupants were killed.

Crash of a De Havilland DHC-6 Twin Otter 100 in Sullivan: 6 killed

Date & Time: Jul 29, 2006 at 1345 LT
Operator:
Registration:
N203E
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Sullivan - Sullivan
MSN:
53
YOM:
1967
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
6000
Aircraft flight hours:
37434
Circumstances:
On July 29, 2006, about 1345 central daylight time, a de Havilland DHC-6-100, N203E, registered to Adventure Aviation, LLC, and operated by Skydive Quantum Leap as a local parachute operations flight, crashed into trees and terrain after takeoff from Sullivan Regional Airport (UUV), near Sullivan, Missouri. The pilot and five parachutists were killed, and two parachutists were seriously injured. The flight was operated under 14 Code of Federal Regulations (CFR) Part 91 with no flight plan filed. Visual meteorological conditions prevailed. According to photographic evidence provided by a witness, the pilot taxied the airplane onto runway 24 from the intersecting taxiway, which is about 1,700 feet from the runway’s west end, and began a takeoff roll to the west from that location, rather than using the runway’s entire 4,500-foot length. Photographic evidence depicting the airport windsock shows that the airplane departed into a moderate headwind. Witnesses at the airport reported seeing the airplane take off and climb to about treetop height. Several witnesses reported hearing a “poof” or “bang” noise and seeing flames and smoke coming from the right engine. One witness reported that, after the noise and the emergence of flames, the right propeller was “just barely turning.” Photographic evidence shows that, at one point after the flames occurred, the airplane was about one wingspan (about 65 feet) above the runway. One witness estimated that the airplane climbed to about 150 feet. Witnesses reported that the airplane lost some altitude, regained it, and then continued to fly low above the treetops before turning to the right and disappearing from their view behind the tree line. Another witness in the backyard of a residence northwest of the airport reported that she saw the airplane flying straight and level but very low over the trees before it dived nose first to the ground. She and her father called 911, and she said that local emergency medical service personnel arrived within minutes. The airplane impacted trees and terrain and came to rest vertically, nose down against a tree behind a residence about 1/2 mile northwest of the end of runway 24.
Probable cause:
The pilot’s failure to maintain airspeed following a loss of power in the right engine due to the fracturing of compressor turbine blades for undetermined reasons. Contributing to some parachutists’ injuries was the lack of a more effective restraint system on the airplane.
Final Report:

Crash of a Pilatus PC-6/B2-H2 Turbo Porter in DeLand

Date & Time: Oct 3, 2005 at 1505 LT
Operator:
Registration:
N7895J
Flight Phase:
Survivors:
Yes
Schedule:
DeLand - DeLand
MSN:
767
YOM:
1976
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5233
Captain / Total hours on type:
43.00
Aircraft flight hours:
6517
Circumstances:
The airline transport certificated pilot with 10 skydiving passengers began a takeoff in a tailwheel-equipped and turboprop powered airplane on a CFR Part 91 skydiving flight. As the airplane started its climb, the pitch angle of the nose of the airplane increased until the airplane appeared to stall about 50 to 100 feet agl. It descended and impacted the runway in a left wing, nose low attitude. Several FAA inspectors responded to the accident site and documented the accident scene and the airplane systems. The inspectors reported that flight control continuity was established, and they noted that the stabilizer appeared to be in a nose up trim position. Measurement of the stabilizer trim position equated to a 56.5 percent nose up trim condition. The airplane's horizontal stabilizer trim system is electrical. An electric trim indicator, and a trim warning light were installed in the upper left portion of the instrument panel. The light will illuminate if "full-up" trim is set, and the engine is producing over 80 percent power. A placard stating, "Set Correct Trim for Takeoff," was installed on the lower instrument panel in front of the pilot position. The airplane's flight manual contains a "Before Takeoff" warning, which states, in part: "Warning - An extreme out-of-trim stabilizer can, in combination with loading, flaps position and power influence, result in an uncontrollable aircraft after the aircraft leaves the ground." In addition, a caution states, in part: "Caution - Failure to set correct trim settings will result in large control forces and/or unrequested pitching/yawing." Pilot actions listed in the "Before Takeoff" checklist include stabilizer trim settings. The airplane contained seat belts for all passengers, but the pilot's shoulder harness was not used, as it was folded and tie-wrapped near its upper attach point.
Probable cause:
The pilot's incorrect setting of the stabilizer trim and his failure to maintain adequate airspeed during takeoff initial climb, which resulted in a stall. A factor contributing to the accident was an inadvertent stall. A factor contributing to the severity of the pilot's injuries was his failure to utilize his shoulder harness.
Final Report:

Crash of a Cessna 207 Skywagon in Barradas: 4 killed

Date & Time: May 8, 2005 at 1100 LT
Operator:
Registration:
RP-C3216
Flight Phase:
Survivors:
Yes
Schedule:
Barradas - Barradas
MSN:
207-0333
YOM:
1976
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
Shortly after takeoff from Barradas Airport located near Tanauan (Batangas), while in initial climb, the aircraft suffered an engine failure. It stalled and crashed in a coconut grove located in the village of Santor, near the airfield. The pilot and three passengers were killed while two others were seriously injured. All occupants were completing a local skydiving mission. Witnesses reported that the engine emitted white smoke shortly after rotation.
Probable cause:
Engine failure for unknown reasons.

Crash of a PZL-Mielec AN-28 in Østre Æra

Date & Time: Jul 16, 2004 at 1324 LT
Type of aircraft:
Registration:
YL-KAB
Survivors:
Yes
Schedule:
Østre Æra - Østre Æra
MSN:
1AJ009-15
YOM:
1991
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14000
Captain / Total hours on type:
400.00
Copilot / Total flying hours:
18000
Copilot / Total hours on type:
1000
Circumstances:
Two aircraft of type AN-28, operated by Rigas Aeroklubs Latvia, were dropping parachutists at the National Parachute Sport Centre, Østre Æra airstrip in Østerdalen. The company had had a great deal of experience with this type of operations, and had been carrying out parachute drops in Norway each summer for the last 9 years. They had brought their own licensed aircraft technicians with them to Østre Æra. On Friday morning, 16 July 2004, the weather conditions were good when the flights started. The crew of YL-KAB, which comprised two experienced pilots, were rested after a normal night's sleep. They first performed six routine drop flights. After stopping to fill up with fuel, normal preparations were made for the next flight with 20 parachutists who were to jump in two groups of 10. The seventh departure was carried out at time 1305. The Commander asked for and was given clearance by the air traffic control service to climb to flight level FL150 (15,000 ft equivalent to approx. 4,500 metres). The parachutists were then dropped from that altitude. The first drop of 10 parachutists was made on a southerly course above the airstrip, and the aircraft continued on that course for a short time before turning through 180° and getting ready for the next drop at the same location on a northerly course. A large cumulonimbus cloud (CB), with precipitation, had approached the airfield from the north at this time. To reach the drop zone above the runway, the aircraft had to fly close to this cloud. The aircraft was not equipped with weather radar. The last parachutists to leave the aircraft were in a tandem jump that was being filmed on video. The film showed that the parachutists became covered in a layer of white ice within 2-3 seconds of leaving the aircraft. The ice on the parachutists only thawed once they had descended to lower altitudes where the air temperature was above zero. Once the parachutists had jumped, the aircraft was positioned close to the CB cloud at a low cruising speed. They were exposed to moderate turbulence from the cloud. The Commander, who was the PF (pilot flying), started a sudden 90° turn to the left while also reducing engine power to flight idle in order to avoid the CB cloud and return to Østre Æra to land. At this point, the First Officer who was PNF (pilot not flying) observed that ice had formed on the front windshield, and he chose to switch on the anti-icing system. He did this without informing the PF. A few seconds later both engines stopped, and both propellers automatically adopted the feathered position. The pilots had not noticed any technical problems with the aircraft engines before they failed. During the descent, the PNF, on the PF's orders, carried out a series of start-up attempts with reference to the checklist/procedure they had available in the cockpit. The engines would not start and the PF made a decision and prepared to carry out an emergency landing at Østre Æra without engines. The runway at Østre Æra is 600 m long and 10 m wide. The surrounding area is covered by dense coniferous forest and they had no alternative landing areas within reach. Because they were without engine power, there was no hydraulic power to operate the aircraft's flaps. This meant that the speed of the aircraft had to be kept relatively high, approx. 160-180 km/h. The final approach was further complicated because the PF had to avoid the last 10 parachutists who were still in the air and who were steering towards a landing area just beside the airstrip. The PF first positioned the aircraft on downwind on a southerly course west of the airfield, in order then to make a left turn to final on runway 01. The landing took place around halfway down the runway, at a faster speed than normal - according to the Commander's explanation approximately 160-170 km/h. The PF braked using the wheel brakes, but when he realized that he would not be able to stop on the length of runway remaining, he ceased braking. He knew that the terrain directly on the extension to the runway was rough, and chose to use the aircraft's remaining speed to lift it off the ground and to alter course a little to the right. The aircraft passed over the approx. 2.5 m high embankment in the transition between the runway level and the higher marshy plateau surrounding the northern runway area, see Figure 1. The aircraft ran approx. 230 m in ground effect before landing on its heels in the flat marshy area north of the airfield. After around 60 m of roll-out, the nose wheel and the aircraft's nose struck a ditch and the aircraft turned over lengthways. It came to rest upside down with its nose section pointing towards the landing strip.
Probable cause:
The experienced Commander assessed the distance to the cumulonimbus cloud as sufficient to allow the drop to be carried out, and expected that they would then rapidly make their way out of the exposed area. It appeared, however, that problems arose when the aircraft was exposed to turbulence and icing from the cloud. The AIBN believes the limits of the engines' operational range were exceeded since the anti-icing system was switched on while the power output from the engines was low, in combination with low airspeed, turbulence and sudden manoeuvring. At that, both engines stopped, and the propellers were automatically feathered. The AIBN believes the engines would not restart because the Feathering Levers were not moved from the forward to the rear position and forward again, as is required after automatic feathering. The manufacturer has pointed out that, according to the procedures, the crew should have refrained from restart attempts and prioritized preparing for the emergency landing. AIBN acknowledges this view, taken into consideration that the crew had not received necessary training and that no suitable checklists existed. On the other hand, it is the AIBN’s opinion that this strategy may appear too passive in a real emergency. If the flight is over rugged mountain terrain or over water, an emergency landing may have fatal outcome. Provided there is sufficient time, and that crew cooperation is organised in such a way that it does not jeopardise the conduct of safe flight, a successful restart may prevent an accident. The AIBN cannot rule out the possibility that the crew's ability to make a correct assessment of the situation was reduced due to oxygen deficiency. Low oxygen-saturation in the brain would first lead to generally reduced mental capacity. In particular, this applies to the capacity to do several things simultaneously and the ability to remember. These are factors that are crucial when a pilot in a stressful situation has to choose the best solution to a problem, and the negative effects will appear more rapidly the older a person is. The fact that the First Officer switched on the anti-icing system without asking the Commander first, indicates that crew collaboration was not functioning at its best. The AIBN believes that the crew, after having entered this difficult situation, carried out a satisfactory emergency landing under very demanding conditions. The fact of the parachutists being within the approach sector made the scenario more complex, and a landing ahead of the threshold had to be avoided. With the flaps non-functional, it is understandable that the speed was high and the touchdown point not optimal. The fact that the Commander got the aircraft into the air again and landed on the higher marshy plateau, was probably crucial to the outcome. Continued braking would have resulted in the aircraft running into the earth embankment at relatively high residual speed, and it is doubtful whether the crew would have survived. A safety recommendation is being put forward in connection with this. Even if allowances are made for parachuting being a special type of operation that often takes place under the direction of a club, the AIBN believes that this investigation has uncovered several issues that cannot be considered to be satisfactory when compared to the safety standard on which they ought to be based. A user-friendly checklist system in the cockpit which is used during normal operations, in emergency situations and during flight training would increase the probability of the aircraft being operated in accordance with the manufacturer's recommendations. It is of great importance that pilots are sufficiently trained and experienced to carry out appropriate emergency procedures. It is assumed, however, that the new regulation concerning civil parachute jumping will contribute to increased levels of safety, and the AIBN sees no need to recommend any further measures.
Final Report: