Crash of a Gulfstream G650 in Roswell: 4 killed

Date & Time: Apr 2, 2011 at 0934 LT
Type of aircraft:
Operator:
Registration:
N652GD
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Roswell - Roswell
MSN:
6002
YOM:
2010
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
11237
Captain / Total hours on type:
263.00
Aircraft flight hours:
434
Circumstances:
On April 2, 2011, about 0934 mountain daylight time, an experimental Gulfstream Aerospace Corporation GVI (G650), N652GD, crashed during takeoff from runway 21 at Roswell International Air Center, Roswell, New Mexico. The two pilots and the two flight test engineers were fatally injured, and the airplane was substantially damaged by impact forces and a post crash fire. The airplane was registered to and operated by Gulfstream as part of its G650 flight test program. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident. The accident occurred during a planned one-engine-inoperative (OEI) takeoff when a stall on the right outboard wing produced a rolling moment that the flight crew was not able to control, which led to the right wingtip contacting the runway and the airplane departing the runway from the right side. After departing the runway, the airplane impacted a concrete structure and an airport weather station, resulting in extensive structural damage and a post crash fire that completely consumed the fuselage and cabin interior.
Probable cause:
An aerodynamic stall and subsequent uncommanded roll during a one engine-inoperative takeoff flight test, which were the result of (1) Gulfstream’s failure to properly develop and validate takeoff speeds for the flight tests and recognize and correct the takeoff safety speed (V2) error during previous G650 flight tests, (2) the G650 flight test team’s persistent and increasingly aggressive attempts to achieve V2 speeds that were erroneously low, and (3) Gulfstream’s inadequate investigation of previous G650 uncommanded roll events, which indicated that the company’s estimated stall angle of attack while the airplane was in ground effect was too high. Contributing to the accident was Gulfstream’s failure to effectively manage the G650 flight test program by pursuing an aggressive program schedule without ensuring that the roles and responsibilities of team members had been appropriately defined and implemented, engineering processes had received sufficient technical planning and oversight, potential hazards had been fully identified, and appropriate risk controls had been implemented and were functioning as intended.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 100 in Clayton: 2 killed

Date & Time: Mar 8, 2011 at 1140 LT
Operator:
Registration:
N157KM
Flight Type:
Survivors:
No
Schedule:
Clayton - Clayton
MSN:
57
YOM:
1967
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1255
Captain / Total hours on type:
492.00
Aircraft flight hours:
16541
Aircraft flight cycles:
20927
Circumstances:
The airplane had not been flown for about 5 months and the purpose of the accident flight was a maintenance test flight after both engines had been replaced with higher horsepower models. Witnesses observed the airplane depart and complete two uneventful touch-and-go landings. The airplane was then observed to be struggling to gain altitude and airspeed while maneuvering in the traffic pattern. One witness, who was an aircraft mechanic, reported that he observed the airplane yawing to the left and heard noises associated with propeller pitch changes, which he believed were consistent with the "Beta" range. The airplane stalled and impacted trees in a wooded marsh area, about 1 mile from the airport. It came to rest about 80-degrees vertically. Examination of the wreckage did not reveal any preimpact malfunctions; however, the lack of flight recorders and the condition of the wreckage precluded the gathering of additional relevant information. Damage observed to both engines and both propellers revealed they were likely operating at symmetrical power settings and blade angles at the time of the impact, with any differences in scoring signatures likely the result of impact damage. The reason for the yawing and the noise associated with propeller pitch changes that were reported prior to the stall could not be determined.
Probable cause:
The pilot did not maintain airspeed while maneuvering, which resulted in an aerodynamic stall.
Final Report:

Crash of an Antonov AN-148-100E in Garbuzovo: 6 killed

Date & Time: Mar 5, 2011 at 1040 LT
Type of aircraft:
Operator:
Registration:
61708
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Voronezh - Voronezh
MSN:
41-03
YOM:
2010
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The aircraft departed Voronezh-Pridacha Airport in the morning to conduct a test flight with six crew on board, two pilots from the manufacturer, two engineers and two pilots from the Myanmar Air Force to whom the aircraft should be delivered. In flight, the crew decided to perform an emergency descent. During this manoeuvre, the aircraft reached an excessive speed and lost part of its tail, stabilizers and elevators. It entered an uncontrolled descent and crashed in a snow covered field located near Garbuzovo, bursting into flames. The aircraft was totally destroyed and all six occupants were killed. Tail parts, stabilizers and elevators were later found about 3 km from the point of impact. The airplane was operated by the Voronezh Aircraft Production Association. (VASO - Voronezhskoye Aktsionernoye Samoletostroitelnoe Obshestvo). First accident involving an Antonov AN-148.
Probable cause:
The cause of the accident was the inadvertently permitted the aircraft to accelerate 110 km/h above the design limit speed during an emergency descent. This led to low-frequency vibrations on the aircraft in all axes, an increase of alternating accelerations exceeding the margin of safety. The result was the break up of the aircraft in the air, followed by its collision with the earth.
The main factors contributing to the accident were:
- Untimely and inadequate actions of the crew to control the emergency decent,
- Lack of proper coordination among the members of the crew,
- Deviations from recommendations in the flight manual in executing the emergency descent,
- Misleading indications on basic instruments when outside characteristic operating conditions.

Crash of a Casa 212 Aviocar 100 near Tanjung Pinang: 5 killed

Date & Time: Feb 12, 2011 at 1342 LT
Type of aircraft:
Operator:
Registration:
PK-ZAI
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Batam - Tanjung Pinang
MSN:
120/18N
YOM:
1980
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
13027
Captain / Total hours on type:
3311.00
Copilot / Total flying hours:
2577
Copilot / Total hours on type:
152
Aircraft flight hours:
29990
Aircraft flight cycles:
35128
Circumstances:
On 12 February 2011, a CASA C212-100 aircraft, registered PK-ZAI, operated by Sabang Merauke Raya Air Charter (SMAC), departed from Hang Nadim Airport, Batam (BTH/WIDD) at 1318 LT (0618 UTC)1 for a test flight following an engine replacement to the engine number one. The test flight was conducted over Tanjung Pinang Island area. There were five persons on board consisted of two pilots, and three company engineers. At 0628 UTC the aircraft appeared on Tanjung Pinang Approach radar display and was flying toward Tanjung Pinang area. Tanjung Pinang Approach controller informed that the aircraft was identified flying over Tanjung Pinang at 2000 feet. At 0633 UTC the aircraft received clearance to climb to 4000 feet. At 0644 UTC the aircraft disappeared from Tanjung Pinang radar display. The last position of the aircraft identified on the radar display was on 16 miles radial 010º from Tanjung Pinang airport. Tanjung Pinang Approach controller could not communicate with the PK-ZAI. At 0705 UTC, the controller requested relay by another aircraft to search PK-ZAI. The other aircrafts could not communicate with PK-ZAI. At 0706 UTC Tanjung Pinang Approach controller received information from Indonesian Air Force Base at Gunung Bintan that an aircraft had crashed at Gunung Kijang forest, Bintan Island. After receiving the information, Tanjung Pinang Airport staff coordinated with SAR Bureau, local police, and Indonesian Army for search and rescue operation. The aircraft was found at Gunung Kijang forest, Bintan Island at coordinate 1° 10’ 45” N; 104° 34’ 22” E, about 30 km north of Tanjung Pinang Airport. All occupants were fatally injured in this accident. The aircraft was substantially damaged.
Probable cause:
Factors contributed to the accident are as follows:
• The flight test was not properly well prepared; there was no flight test plan.
• The current and applicable CMM is dissimilar the According to the CASA 212-100 and Garrett TPE331-5 Maintenance Manuals related to flight test requirement after the change of only one engine.
• The left engine was shut down using normal/ ground shut down procedure. It used the fuel shut off switches off followed by pulling the Power Lever rearward to reverse, as indicated by the propeller pitch.
• The right engine most likely shut down by wind milling prior the impact, it was indicated the propellers piston distance position to the cylinder was about normal flight range position and no indication of rotating impact on the blades.
• The Casa Service Bulletin No. 212-76-07 Revision 1 issued dated 23 December 1991 (Anti Reverse) that applicable for Casa 212 -100/200, was not incorporated to this aircraft.
• The PIC with pareses or paralysis vestibular organ or system could not response normally to the three dimensional motion or movement. This condition may the subject more sensitive to suffer Spatial Disorientation (SDO). The SDO is the pilot could not perceived rightly his position motion and attitude to the earth horizontal or to his aircraft or other aircraft and could as the dangerous precondition for unsafe action.
• The Director (DGCA) decree No 30/II/200 issued on 20 February 2009 stated that for issuing medical certificate for pilot after 60th birthday require several additional medical examination items. Point 1.b of this decree states the Video Nystagmography examination.(differed the ICAO Doc 8984).
Final Report:

Crash of a Fokker F27 Friendship 500CRF in Nairobi

Date & Time: Jan 27, 2011 at 1335 LT
Type of aircraft:
Operator:
Registration:
5X-FFD
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nairobi - Nairobi
MSN:
10530
YOM:
1976
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft was engaged in a local post maintenance test flight from Nairobi-Wilson Airport. The crew consisted of two pilots and two engineers. During the takeoff roll from runway 07, the captain decided to abort. Unable to stop within the remaining distance, the aircraft overran, went through a fence, lost its nose gear and came to rest in a field. All four occupants escaped with minor injuries while the aircraft was damaged beyond repair.

Crash of a Piper PA-31P-425 Pressurized Navajo in Oxford: 2 killed

Date & Time: Jan 15, 2010 at 1407 LT
Type of aircraft:
Operator:
Registration:
N95RS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Oxford - Oxford
MSN:
31-7400221
YOM:
1974
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
12500
Circumstances:
The aircraft had recently been purchased in Germany and was flown to the United Kingdom on 11 December 2009 by the pilot of the accident flight. The new owner, who accompanied him for the flight from Germany, was a private pilot himself and was the passenger in the accident. The aircraft landed at Oxford on the evening of 11 December. The pilot reported to a maintenance organisation that there had been a problem with the brakes after landing and the aircraft was left parked outside a hangar. Minor maintenance was carried out on 20 December 2009 and on 9 January 2010 the aircraft was refuelled, but it was not flown again until the accident flight. On the morning of 15 January 2010 the pilot and his passenger met at Oxford Airport and prepared the aircraft for flight. The plan was to carry out an air test, although its exact nature was not established. The flight was pre‑notified to Royal Air Force (RAF) Brize Norton as an air test with a requested level of FL190. At 1344 hrs the aircraft taxied out to Holding Point C for Runway 19 at Oxford. The pilot reported ‘READY FOR DEPARTURE’ at 1400 hrs and was given a clearance for a right turn after takeoff with a climb initially to FL80. The pilot then requested the latest weather information and the tower controller provided the following information: ‘........TWO THOUSAND METRES IN MIST AND CLOUD IS BROKEN AT 200 FEET.’ At 1403 hrs the takeoff commenced and shortly after liftoff Oxford ATC suggested that the pilot should contact Brize Radar on 124.275 Megahertz (MHz). The pilot made contact with Brize Radar at 1404 hrs, two-way communication was established and the provision of a Deconfliction Service was agreed. On the radar screen the Brize Norton controller observed the ‘Mode C’ (altitude) return increase to around 1,500 ft and then noticed it decrease, seeing returns of 1,300 ft and 900 ft, before the secondary return disappeared. At 1406 hrs the Brize Norton controller contacted Oxford ATC to ask if the aircraft had landed back there and was advised that it had not done so, but that it could be heard overhead. The Brize Norton controller told Oxford ATC that they had a continuing contact, but no Secondary Surveillance Radar (SSR). The Oxford controller could still hear an aircraft in the vicinity and agreed with the Brize Norton controller to attempt to make contact. At 1407 hrs Oxford ATC made several calls to the aircraft but there was no reply. The Oxford controller told the Brize Norton controller there was no reply and was informed in return that there was no longer any radar contact either. The Brize Norton controller also attempted to call the aircraft at 1407 hrs but without success. At 1410 hrs the Oxford controller advised the Brize Norton controller that there was smoke visible to the west of the airfield and they would alert both the airport and local emergency services. In the meantime several witnesses saw the aircraft crash into a field to the west of Oxford Airport. A severe fire started soon afterwards and bystanders who arrived at the scene were not able to get close to the aircraft. The local emergency services were notified of the accident by witnesses at 1407 hrs.
Probable cause:
The post-mortem examination showed that the pilot had severe coronary heart disease and there was evidence to suggest that he may have been incapacitated, or died, prior to the collision with the ground. The passenger was a qualified private pilot but was not experienced with either the aircraft or flight in IMC.
Final Report:

Crash of a Beechcraft B200 Super King Air in Greenville

Date & Time: Nov 9, 2009 at 1009 LT
Operator:
Registration:
N337MT
Flight Type:
Survivors:
Yes
Schedule:
Greenville - Greenville
MSN:
BB-1628
YOM:
1998
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15717
Aircraft flight hours:
3060
Circumstances:
The pilot flew the airplane to a maintenance facility and turned it in for a phase inspection. The next morning, he arrived at the airport and planned a local flight to evaluate some avionics issues. He performed a preflight inspection and then went inside the maintenance facility to wait for two avionic technicians to arrive. In the meantime, two employees of the maintenance facility test ran the engines on the accident airplane for about 30 to 35 minutes in preparation for the phase inspection. The pilot reported that he was unaware that the engine run had been performed when he returned to the airplane for the local flight. He referred to the flight management system (FMS) fuel totalizer, and not the aircraft fuel gauges, when he returned to the airplane for the flight. He believed that the mechanics who ran the engines did not power up the FMS, which would have activated the fuel totalizer, thus creating a discrepancy between the totalizer and the airplane fuel gauges. The mechanics who performed the engine run reported that each tank contained 200 pounds of fuel at the conclusion of the engine run. The B200 Pilot’s Operating Handbook directed pilots not take off if the fuel quantity gauges indicate in the yellow arc or indicate less than 265 pounds of fuel in each main tank system. While on final approach, about 23 minutes into the flight, the right engine lost power, followed by the left. The pilot attempted to glide to the runway with the landing gear and flaps retracted, however the airplane crashed short of the runway. Only residual fuel was found in the main and auxiliary fuel tanks during the inspection of the wreckage. The tanks were not breached and there was no evidence of fuel leakage at the accident site.
Probable cause:
A loss of engine power due to fuel exhaustion as a result of the pilot’s failure to visually verify that sufficient fuel was on board prior to flight.
Final Report:

Crash of a PZL-Mielec AN-2TP in Managua

Date & Time: Oct 14, 2009 at 1600 LT
Type of aircraft:
Operator:
Registration:
75
Flight Type:
Survivors:
Yes
Schedule:
Managua - Managua
MSN:
1G214-02
YOM:
1985
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft departed Managua-Augusto Cesar Sandino Airport for a local post maintenance check flight following an engine overhaul. On board were five engineers and pilots. On final approach, the engine failed. The pilot-in-command attempted an emergency landing when the aircraft crashed in an open field and came to rest upside down about 800 metres short of runway threshold. All five occupants escaped with minor injuries and the aircraft was damaged beyond repair.
Probable cause:
Engine failure for unknown reasons.

Ground accident of a Learjet 40 in Fort Worth

Date & Time: Jun 18, 2009
Type of aircraft:
Operator:
Registration:
N998AL
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
45-2029
YOM:
2005
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Learjet 40 was being operated by two A&P mechanics for the purpose to taxi out for an engine test run on the n°1 engine. During taxi it was necessary to stop the aircraft for motor vehicle traffic. The mechanic advanced the throttles for taxi and to climb a 15 to 20 foot hill. When the mechanic attempted to reduce the throttles only the n° 2 engine could be retarded. The n°1 engine was at a high power setting and could not be reduced. The aircraft left 4 skid marks as the main tires were locked for approximately the length of a little more than a football field. The mechanics could not shut down the n°1 engine. Control of the aircraft was lost with the n°1 engine at a high power setting. The right wing impacted the corner of a hanger. The nose gear broke and an embankment stopped the aircraft. The mechanics were then able to shut down both engines and exited the aircraft with no injuries.
Probable cause:
The NTSB did not proceed to any investigation on this event.

Crash of a NAL Saras near Bangalore: 3 killed

Date & Time: Mar 6, 2009 at 1534 LT
Type of aircraft:
Operator:
Registration:
VT-XRM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bangalore - Bangalore
MSN:
SP002
YOM:
2007
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2414
Captain / Total hours on type:
310.00
Copilot / Total flying hours:
2080
Copilot / Total hours on type:
315
Aircraft flight hours:
50
Aircraft flight cycles:
49
Circumstances:
On 06.3.2009 Saras Prototype PT2 aircraft VT-XRM manufactured and owned by National Aerospace Laboratories, Bangalore was scheduled for carrying out its test flight n°49. Test flight programme includes general a ir tests/handling checks to ascertain the aircraft flying characteristics after the 50 hrs Scheduled servicing, dummy approach in simulated single engine configuration at 5000' AMSL, go around at 300' AGL in a simulated one engine inoperative condition, landing in a simulated one engine inoperative condition and to carry out in-flight engine shut down and relight procedure at 10000' AMSL within 130 - 150 kts speed. Tests are to be carried out as per existing SOP and test procedures and limitations and pre flight test briefing meeting. Aircraft was cleared by approved inspectors of NAL after carrying out daily inspection on 6.3.2009 for test flight n°49 and was duly accepted by the Chief test pilot. Preflight briefing was taken by the Wg Cdr (22917-S), F(P), chief test pilot was on commander seat , Wg Cdr (23165-H), F(P) - test pilot was on co-pilot seat and Sqn Ldr (24746-M), AE(M) was on Flight test engineer on board. The test team also accepted flight test schedule of flight n°49. Total duration of the tests was estimated to about 45 minutes. Engines were started at 0913 UTC at ASTE, dispersal area . All engine parameters were reported normal. After carrying out post startup and pre taxi checks, aircraft taxied out for Runway 09 at HAL airport. As pe r departure instructions after departure R/W 09 aircraft to climb on R/W heading 5000’, turn right set course to southwest -2 and in coordination with approach radar to operate upto 10 miles and level 100. Aircraft was cleared for takeoff from R/W 09 with surface wind 090º/06kts. Aircraft took-off at 0925 UTC and changed over to radar at 0926 UTC. There was no event. Aircraft was then cleared to level 100, operating up to 10 miles. After completing general handling checks at 9000’ AMSL without any events, Aircraft was stabilized with simulated single engine approach to the landing r/w 09. Single engine simulated approach was carried out. At about 0941 UTC aircraft was cleared for overshoot, wind 090/06 kts. Aircraft made overshoot at 300’ AGL. Aircraft was then changed over to radar again. At 0942 UTC aircraft was cleared to climb level 100 and proceed sector southwest 2. Aircraft right engine was throttled up to match left engine and aircraft climbed out to 9000’ AMSL in sector southwest. At about 0948 UTC aircraft reported 15 miles and FL90 and reported turning around. But HAL radar as well as BIAL radar showing level was 72 for which aircraft replied that it has descended and climbing back to 9000’ AMSL. At about 0955 UTC aircraft reported “OPS NORMAL” at 20 Nm in sector southwest 2. This was the last contact by aircraft with radar. After 0955 UTC Radar contact with the aircraft was completely lost. As per ASTE Telemetry, after turned round to point towards HAL airfield aircraft was observed about 20 miles at 9000’ AMSL with 140 kts speed. Telemetry link was good at this position Left engine was then shut down and secured following the test procedure at about 10:00:40 UTC. Pilot was in touch with Flight test director on R/T at telemetry desk. After about 47 secs, left engine relight procedure was initiated at around 9200’ AMSL. Pilot also reported to Telemetry the start of relight of the engine. Telemetry indications also showed the rise in Ng and ITT. At about 100 secs prior to crash aircraft went into sudden dive from 9200’ to 7300’ for about 13 secs. Meanwhile During the relighting of left engine, FTD desk also lost RT contact with aircraft about 37 secs prior to crash and telemetry link with the aircraft was also intermittent. At 37 secs prior to crash when Telemetry called aircraft “ can you call up. What is going on”, aircraft replied “Standby” this was the last contact of Telemetry with aircraft. After that there was no contact from the pilot. Just before 7 secs of crash when the telemetry data signal was restored aircraft already lost to the height of 4260’ AMSL(1900’AGL) and in continuous loss of height and Ng was about 31%. There was no response from pilots even after repeated calls from FTD desk. Aircraft was rapidly losing the height without any control. Cockpit voice recording clearly showed that on last moments just 10 secs prior to crash ,commander called out “ Aircraft has departed” indicating aircraft completely gone out of control. During the last moment of crash telemetry recorded Ng : about 54% (63% as per FDR), Engine oil pressure 88, fuel flow 94%,ITT 647 deg C, indicating engine relight was successful. But by the time aircraft was almost on ground. Aircraft crashed at about 1004 UTC (10:03:44). All possible communication means including through en -route traffic to contact the aircraft went in vain. Search operation by ALH helicopter (A67) ,Chetak(T45) and T55 was effected. At about 1033 UTC police control room reported that an aircraft had crashed near Bidadi. After extensive search efforts, at about 1100 UTC, A67 found out the crash site having bearing 251° and 17 Nm from HAL airport. Later it was affirmed that the aircraft crashed at a village called Sehsagirihalli (close to wonderland amusement park) near Bidadi and 37 km by road(off Mysore road) Southwest of HAL airport, Bangalore. The crash site was a wide -open residential plot area of uneven hard terrain surrounded by poles and wild plants. It was on a radial of 251° /17 NM from HAL, Bangalore airport having coordinates LAT : N12° 50’56”, LONG: E077° 23’46”). All the three persons on board were charred to death and were on their seats. There was post impact fire. Aircraft fuselage was broken from rear of the main plane and found in an inverted position. The vertical fin leading edge was facing the ground and the respective tail mounted engines by the side of it. The nose portion of the aircraft was facing East direction. Aircraft was completely destroyed due impact and fire.
Probable cause:
Incorrect relight procedure devised by the designer and adopted by the crew at insufficient height leading to rapid loss of altitude and abnormal behavior of aircraft resulted into accident.
Contributory factors:
a) Lack of crew coordination and cockpit procedures,
b) Handling of the controls,
c) Non-aborting of flight by the crew in coordination with the flight test Director after failure of first relight attempt,
d) Devising engine relight procedures by NAL without consulting the propeller manufacturer.
Final Report: