Crash of a Swearingen SA226TC Metro II in Querétaro: 5 killed

Date & Time: Jun 2, 2015 at 1425 LT
Type of aircraft:
Swearingen SA226 Metro II
Operator:
Registration:
XA-UKP
Flight Phase:
Takeoff (climb)
Flight Type:
Test
Survivors:
No
Site:
Plain, Valley
Schedule:
Santiago de Querétaro - Santiago de Querétaro
MSN:
TC-376
YOM:
1980
Location:
Santiago de Querétaro
Querétaro
Country:
Mexico
Region:
Central America
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
19172
Captain / Total hours on type:
3731.00
Copilot / Total flying hours:
364
Copilot / Total hours on type:
117
Aircraft flight hours:
26985
Aircraft flight cycles:
37207
Circumstances:
The twin engine aircraft was engaged in a post-maintenance test flight out from Santiago de Querétaro Airport, carrying three engineers and two pilots. It departed runway 09 at 1421LT and the crew was cleared to climb to FL125. While approaching the altitude of 12,000 feet, the aircraft entered an uncontrolled descent and crashed on a motorway located 11 km southwest of the airport, bursting into flames. The aircraft was totally destroyed by impact forces and a post crash fire and all five occupants were killed.
Probable cause:
Loss of control of the aircraft in flight for undetermined reasons. No mechanical failure was found on the aircraft and its components that could affect the normal operation of the airplane.
The following findings were identified:
- Lack of coordination and effective communication between ground staff and flight crew,
- Lack of adequate supervision of operations by the operator,
- Lack of a safety culture of the operator.
Final Report:

Crash of a Cessna 207 Skywagon near Bethel: 1 killed

Date & Time: May 30, 2015 at 1130 LT
Type of aircraft:
Cessna 207 Skywagon/Stationair
Operator:
Registration:
N1653U
Flight Phase:
Flight
Flight Type:
Test
Survivors:
No
Site:
Lake, Sea, Ocean, River
Schedule:
Bethel - Bethel
MSN:
207-0253
YOM:
1974
Location:
Bethel
Alaska
Country:
United States of America
Region:
North America
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7175
Captain / Total hours on type:
6600.00
Aircraft flight hours:
28211
Circumstances:
The pilot departed on a postmaintenance test flight during day visual meteorological conditions. According to the operator, the purpose of the flight was to break in six recently installed engine cylinders, and the flight was expected to last 3.5 hours. Recorded automatic dependent surveillance-broadcast data showed that the airplane was operating at altitudes of less than 500 ft mean sea level for the majority of the flight. The data ended about 3 hours after takeoff with the airplane located about 23 miles from the accident site. There were no witnesses to the accident, which occurred in a remote area. When the airplane did not return, the operator reported to the Federal Aviation Administration that the airplane was overdue. Searchers subsequently discovered the fragmented wreckage submerged in a swift moving river, about 40 miles southeast of the departure/destination airport. Postmortem toxicology tests identified 21% carboxyhemoglobin (carbon monoxide) in the pilot's blood. The pilot was a nonsmoker, and nonsmokers normally have no more than 3% carboxyhemoglobin. There was no evidence of postimpact fire; therefore, it is likely that the pilot's elevated carboxyhemoglobin level was from acute exposure to carbon monoxide during the 3 hours of flight time before the accident. As the pilot did not notify air traffic control or the operator's home base of any problems during the flight, it is unlikely that he was aware that there was carbon monoxide present. Early symptoms of carbon monoxide exposure may include headache, malaise, nausea, and dizziness. Carboxyhemoglobin levels between 10% and 20% can result in confusion, impaired judgment, and difficulty concentrating. While it is not possible to determine the exact symptoms the pilot experienced, it is likely that the pilot had symptoms that may have been distracting as well as some degree of impairment in his judgment and concentration. Given the low altitudes at which he was operating the airplane, he had little margin for error. Thus, it is likely that the carbon monoxide exposure adversely affected the pilot's performance and contributed to his failure to maintain clearance from the terrain. According to the operator, the airplane had a "winter heat kit" installed, which modified the airplane's original cabin heat system. The modification incorporated an additional exhaust/heat shroud system designed to provide increased cabin heat during wintertime operations. Review of maintenance records revealed that the modification had not been installed in accordance with Federal Aviation Administration field approval procedures. Examination of the recovered wreckage did not reveal evidence of any preexisting mechanical anomalies that would have precluded normal operation of the airplane. Examination of the airplane's right side exhaust/heat exchanger did not reveal any leaks or fractures that would have led to carbon monoxide in the cabin. Because the left side exhaust/heat exchanger was
not recovered, it was not possible to determine whether it was the source of the carbon monoxide.
Probable cause:
The pilot's failure to maintain altitude, which resulted in collision with the terrain. Contributing to the accident was the pilot's impairment from carbon monoxide exposure in flight. The source of the carbon monoxide could not be determined because the wreckage could not be completely recovered.
Final Report:

Crash of an Airbus A400M in Seville: 4 killed

Date & Time: May 9, 2015 at 1257 LT
Type of aircraft:
Airbus A400M
Operator:
Registration:
EC-403
Flight Phase:
Takeoff (climb)
Flight Type:
Test
Survivors:
Yes
Site:
Airport (less than 10 km from airport)
Schedule:
Seville - Seville
MSN:
023
YOM:
2015
Flight number:
Casa423
Location:
Seville-San Pablo
Andalusia
Country:
Spain
Region:
Europe
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Aircraft flight hours:
0
Aircraft flight cycles:
0
Circumstances:
Brand new, the aircraft just came out from the manufacturer in Seville and was engaged in its first post assembly test flight. After take off from Seville-San Pablo Airport Runway 09 at 1254LT, the crew completed a 90° turn to the left bound to the north. Shortly later, three of the four engines (engines n°1, 2 and 3) got stuck at high power. The crew attempted to control the power setting to the normal mode but those three engines failed to respond. The crew reduced the engine power after selecting the thrust levers to idle. The regime of those three engines remained blocked in idle so the crew decided to return to the airport for an emergency landing. On approach, the aircraft collided with power lines, stalled and crashed in an open field located 1,6 km north of the airport, bursting into flames. Two crew members were rescued while four others were killed. The aircraft was totally destroyed by a post crash fire. The aircraft was following a test program prior to its delivery to the Turkish Air Force (Türk Hava Kuvvetleri).
Probable cause:
An Airbus official after the accident stated that engine control software was incorrectly installed during final assembly of the aircraft. This led to engine failure and the resulting crash.

Crash of a Piper PA-46-350P Malibu Mirage in Spokane: 2 killed

Date & Time: May 7, 2015 at 1604 LT
Type of aircraft:
Piper PA-46 (Malibu/Meridian/Mirage/Matrix/M-Class)
Operator:
Registration:
N962DA
Flight Phase:
Takeoff (climb)
Flight Type:
Test
Survivors:
No
Site:
Lake, Sea, Ocean, River
Schedule:
Spokane - Spokane
MSN:
46-36031
YOM:
1996
Location:
Spokane-Felts Field
Washington
Country:
United States of America
Region:
North America
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5800
Captain / Total hours on type:
950.00
Circumstances:
The commercial pilot was departing on a local post-maintenance test flight in the single-engine airplane; Four aileron cables had been replaced during the maintenance. Shortly after takeoff, the airplane began to roll right. As the climb progressed, the roll became more pronounced, and the airplane entered a spiraling dive. The pilot was able to maintain partial control after losing about 700 ft of altitude; he guided the airplane away from the airport and then gradually back for a landing approach. During this period, he reported to air traffic control personnel that the airplane had a "heavy right aileron." As the airplane passed over the runway threshold, it rolled right and crashed into a river adjacent to the runway. The aircraft was destroyed and both occupants were killed.
Probable cause:
The mechanic's incorrect installation of two aileron cables and the subsequent inadequate functional checks of the aileron system before flight by both the mechanic and the pilot, which prevented proper roll control from the cockpit, resulting in the pilot's subsequent loss of control during flight. Contributing to the accident was the mechanic's and the pilot's self-induced pressure to complete the work that day.
Final Report:

Crash of a Cessna 208B Grand Caravan in Verdigris

Date & Time: Mar 24, 2015 at 1507 LT
Type of aircraft:
Cessna 208B Grand Caravan
Operator:
Registration:
N106BZ
Flight Phase:
Flight
Flight Type:
Test
Survivors:
Yes
Site:
Plain, Valley
Schedule:
Tulsa - Tulsa
MSN:
208B-0106
YOM:
1988
Location:
Verdigris
Oklahoma
Country:
United States of America
Region:
North America
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6500
Captain / Total hours on type:
970.00
Aircraft flight hours:
11443
Circumstances:
The pilot reported that, during the postmaintenance test flight, the turboprop engine lost power. The airplane was unable to maintain altitude, and the pilot conducted a forced landing, during which the airplane was substantially damaged. The engine had about 9 total flight hours at the time of the accident. A teardown of the fuel pump revealed that the high-pressure drive gear teeth exhibited wear and that material was missing from them, whereas the driven gear exhibited little to no visible wear. A metallurgical examination of the gears revealed that the damaged drive gear was made of a material similar to 300-series stainless steel instead of the harder specified M50 steel, whereas the driven gear was made of a material similar to the specified M50 steel. Subsequent to these findings, the airplane manufacturer determined that the gear manufacturer allowed three set-up gears made from 300-series stainless steel to become part of the production inventory during the manufacturing process. One of those gears was installed in the fuel pump on the accident airplane, and the location of the two other gears could not be determined. Based on the evidence, it is likely that the nonconforming gear installed in the fuel pump failed because it was manufactured from a softer material than specified, which resulted in a loss of fuel flow to the engine and the subsequent loss of engine power. The manufacturer subsequently inspected its stock of gears and issued notices to customers that had engines with fuel pumps installed with the same part number gear set as the one installed on the accident airplane. The manufacturer also issued a service information letter and service bulletins regarding the fuel pump gear set for engines used in civilian and military applications. As of the date of this report, the two remaining gears have not been located.
Probable cause:
The fuel pump gear manufacturer’s allowance of set-up gears made from a nonconforming material to be put in the production inventory system, the installation of a nonconforming gear in the accident airplane’s production fuel pump, and the gear’s failure, which resulted in a loss of fuel flow to the engine and the subsequent loss of engine power.
Final Report:

Ground accident of a Dornier DO328-110 in Hamburg

Date & Time: Jan 12, 2015
Type of aircraft:
Dornier DO328
Operator:
Registration:
D-CIRD
Flight Phase:
Parking
Flight Type:
Test
Survivors:
Yes
Site:
Airport (less than 10 km from airport)
MSN:
3011
YOM:
1994
Location:
Hamburg-Helmut-Schmidt (Fuhlsbüttel)
Hamburg
Country:
Germany
Region:
Europe
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was parked on the ramp and subject to engine test run with one or two engineers on board. During the test, the aircraft jumped over the chocks then collided with obstacles and came to rest. There were no injuries while the aircraft was damaged beyond repair. It was operated by Sun-Air of Scandinavia on behalf of British Airways.

Crash of an Antonov AN-2 in Sevryukovo

Date & Time: Oct 6, 2013 at 1425 LT
Type of aircraft:
Antonov AN-2
Operator:
Sputnik
Registration:
RA-31505
Flight Phase:
Flight
Flight Type:
Test
Survivors:
Yes
Site:
Plain, Valley
Schedule:
Sevryukovo - Sevryukovo
Location:
Sevryukovo
Belgorod oblast
Country:
Russia
Region:
Asia
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Bought in 2000 and stored since, the airplane was under restoration since August 2013. The crew (one pilot and one engineer), decided to perform a test flight in the region of Sevryukovo (Korocha District of the Belgorod region). En route, the engine failed, forcing the crew to attempt an emergency landing. The aircraft impacted ground and crashed, coming to rest upside down and bursting into flames. Both occupants escaped uninjured while the aircraft was partially destroyed by fire.
Probable cause:
An investigation by the Interstate Aviation Committee revealed that the airplane carried a false registration and was flown without a certificate of airworthiness. Since the airplane was not officially registered, the IAC terminated their investigation.

Crash of a PZL-Mielec AN-2P in Shakhty

Date & Time: Jul 28, 2013
Type of aircraft:
PZL-Mielec AN-2
Operator:
Registration:
FLA-3618K
Flight Phase:
Takeoff (climb)
Flight Type:
Test
Survivors:
Yes
Site:
Airport (less than 10 km from airport)
Schedule:
Shakhty - Shakhty
MSN:
1G151-37
YOM:
1973
Location:
Shakhty
Rostov oblast
Country:
Russia
Region:
Asia
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Shakhty Airport, Rostov oblast, the pilot encountered engine problem. He elected to make an emergency landing in an open field located 500 metres from the airport. On touchdown, the aircraft lost its undercarriage, wings and tail before coming to rest in bushes. The pilot, uninjured, fled the scene but was arrested by police few hours later. Technician by a Plant at the Shakhty Airport, he was the owner of this aircraft since seven months and was performing a local test flight despite he was not in possession of any valid pilot licence according to Russian authorities.

Crash of a Canadair CL-601-3A Challenger in Chino

Date & Time: Jun 13, 2013 at 1817 LT
Type of aircraft:
Canadair CL-601 Challenger
Operator:
Grady International
Registration:
N613SB
Flight Phase:
Parking
Flight Type:
Test
Survivors:
Yes
Site:
Airport (less than 10 km from airport)
MSN:
5088
YOM:
1991
Location:
Chino
California
Country:
United States of America
Region:
North America
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Two technicians were performing engine tests on apron at Chino Airport. While facing a hangar, the aircraft jumped over the chocks and collided with the metallic door of the hangar before coming to rest half inside. Both occupants escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
No investigation has been conducted by the NTSB about this event.

Crash of a Beechcraft A100 King Air in Saint-Mathieu-de-Beloeil

Date & Time: Jun 10, 2013 at 1725 LT
Type of aircraft:
Beechcraft 100 King Air
Operator:
Registration:
C-GJSU
Flight Phase:
Landing (descent or approach)
Flight Type:
Test
Survivors:
Yes
Site:
Airport (less than 10 km from airport)
Schedule:
Montreal - Montreal
MSN:
B-88
YOM:
1971
Location:
Saint-Mathieu-de-Beloeil
Quebec
Country:
Canada
Region:
North America
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4301
Captain / Total hours on type:
1500.00
Aircraft flight hours:
13616
Aircraft flight cycles:
10999
Circumstances:
The aircraft took off from the Montréal/St-Hubert Airport, Quebec, on a local flight under visual flight rules with 1 pilot and 3 passengers on board. The purpose of the flight was to check the rudder trim indicator and to confirm a potential synchronization problem between the autopilot and the global positioning system (GPS). As the aircraft approached Runway 24R at the Montréal/St-Hubert Airport, both engines (Pratt & Whitney Canada, PT6A-28) stopped due to fuel exhaustion. The pilot diverted to the St-Mathieu-de-Beloeil Airport, Quebec, and then attempted a forced landing in a field 0.5 nautical mile west of the St-Mathieu-de-Beloeil Airport. The aircraft struck the ground 30 feet short of the selected field, at 1725 Eastern Daylight Time. The aircraft was extensively damaged, and the 4 occupants sustained minor injuries. The emergency locator transmitter activated during the occurrence. The flight took place during daylight hours, and there was no fire.
Probable cause:
Findings as to causes and contributing factors:
- The pilot relied exclusively on the gauge readings to determine the quantity of fuel on board, without cross-checking the fuel consumption since the last fueling to validate those gauge readings.
- The pilot misread the fuel gauges and assumed that the aircraft had enough fuel on board to meet the minimum fuel requirements of the Canadian Aviation Regulations for this visual flight rules flight, rather than adding more fuel to meet the greater reserves required by the company operations manual.
- The pilot did not monitor the fuel gauges while in flight and decided to extend the flight to carry out a practice instrument approach with insufficient fuel to complete the approach.
- The right engine stopped due to fuel exhaustion.
- The pilot did not carry out the approved engine failure procedure when the first engine stopped, and the propeller was not feathered, resulting in significant drag which reduced the aircraft's gliding range after the second engine stopped.
- The pilot continued flying toward Montréal/St-Hubert Airport (CYHU), Quebec, despite having advised air traffic control of the intention to divert to the St-Mathieu-de-Beloeil Airport (CSB3), Quebec, and without communicating the emergency. The priority given to communications resulted in the aircraft moving farther away from the intended diversion airport.
- The left engine stopped due to fuel exhaustion 36 seconds after the right engine stopped, when the aircraft was 7.4 nautical miles from Runway 24R at Montréal/St-Hubert Airport (CYHU), Quebec, and 2400 feet above sea level.
- The pilot's decision to lower the landing gear while the aircraft was still at 1600 feet above sea level further increased the drag, reducing the aircraft's gliding range. As a result, the aircraft was not able to reach the runway at St-Mathieu-de-Beloeil Airport (CSB3), Quebec.
- The operations manager was unable to perform the duties and responsibilities of the position related to monitoring and supervision of flight operations. As a result, the safety of more than half of the flights was compromised.
Findings as to risk:
- If the total fuel quantity required for a flight is not calculated and clearly displayed on the operational flight plan, there is an increased risk that aircraft will depart without the fuel reserves required by the Canadian Aviation Regulations.
- If flights are planned and carried out without the fuel reserves required by the Canadian Aviation Regulations, there is an increased risk of fuel exhaustion resulting from unanticipated situations that extend the duration of the flight.
- If pilots elect to extend flight without first determining whether sufficient fuel reserves are available to do so, there is an increased risk of fuel exhaustion.
- If pilots do not regularly check the quantity of fuel on board, there is an increased risk of fuel exhaustion.
- If pilots do not rule out a fuel leak before opening the crossfeed valve, they risk losing all of the remaining fuel on board.
- If a pilot does not maintain control of an aircraft until landing, the force of an impact following an aerodynamic stall is likely to be far greater, increasing the risk of injury or death during a forced landing.
- If a pilot does not declare an emergency to air traffic control in a timely manner, the pilot may be deprived of assistance and resources that could help deal with the emergency, increasing the risk of an accident.
- If pilots do not receive training in dealing with complex emergencies that require prioritizing tasks, there is a risk that they will not react effectively to emergencies, increasing the risk of an accident.
- If companies do not establish a process to monitor the performance of their pilots during training and testing, there is a risk that those companies will inadvertently assign pilots to carry out flights for which they are not proficient.
- If a flight is planned and authorized solely by the pilot, with no cross-check for compliance with existing regulations, there is a risk that deviations will continue undetected, reducing the safety of the flight.
- If pilots operate without regular supervision to ensure compliance with regulations and company procedures, coupled with effective training, there is a risk of procedural adaptations that result in reduced safety margins.
- If companies assign inexperienced personnel to key flight operations management positions, there is a risk that deviations in performance or from regulations will not be detected, reducing the safety of flight operations.
- If the pilot proficiency check requirements for a chief pilot are not more stringent than those for other pilots, there is a risk that the chief pilot will be unable to perform the duties required to ensure the safety of company training and operations.
- If the approval process for appointment of operations management personnel by companies is reduced to a compliance checklist based on the minimum standards in the Commercial Air Service Standards and on pilot proficiency checks that may be repeated an unlimited number of times, there is a risk that candidates who are unfit to perform the duties and responsibilities of their positions will be appointed.
- If Transport Canada does not take into consideration the combined knowledge and experience of a new operator's management team, there is a risk that the operator will lack the skills necessary to ensure the safety of flight operations.
- If process inspections carried out by Transport Canada do not examine factors related to a recent occurrence, there is a risk that those hazardous conditions will go undetected and will persist.
If process inspections carried by TC on newly certificated operators do not closely examine the outcomes of company processes, there is a risk that hazardous conditions will not be identified and will persist.
- If the inability of appointed individuals to perform their duties and responsibilities does not constitute grounds for suspending or revoking the ministerial approval of such appointments, there is a risk that operations management personnel who are not competent will remain in their positions, increasing the risk to flight safety.
Other findings:
- The chief pilot did not meet the requirements of the Canadian Aviation Regulations at the time of appointment.
- There was no indication that the aircraft's fuel gauges were not functioning properly at the time of the occurrence flight, and it is unlikely that a deviation of the fuel gauge indicator was a factor in the pilot's decision to take off.
- C-GJSU had approximately 260 pounds of fuel on board when it took off from Montréal/St-Hubert Airport (CYHU), Quebec, and did not experience a fuel leak during the occurrence flight.
Final Report:
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