Flight

The pilot departed on an instrument flight rules cross-country flight with three passengers. While enroute at a cruise altitude about 6,000 ft mean sea level (msl), the pilot discussed routing and weather avoidance with the controller. The controller advised the pilot there was a gap in the line of weather showing light precipitation, and that the pilot could pass through it and then proceed on course. The controller assigned the pilot a heading, which the pilot initially acknowledged, but shortly thereafter, he advised the controller that the airplane was pointed directly at a convective cell. The controller explained that the heading would keep the pilot out of the heavy precipitation and that he would then turn the airplane through an area of light precipitation. The pilot responded, saying that the area seemed to be closing in fast, the controller acknowledged and advised the pilot if he did not want to accept that routing, he could be rerouted. The pilot elected to turn toward a gap that he saw and felt he could fly straight through it. The controller acknowledged and advised the pilot that course would take him through moderate precipitation starting in about one mile extending for about four miles; the pilot acknowledged. Radar information indicated that the airplane entered an area of heavy to very heavy precipitation, likely a rain shower updraft, while in instrument meteorological conditions, then entered a right, descending spiral and broke up in flight. Examination of the wreckage revealed no evidence of a preaccident malfunction or failure that would have prevented normal operation. The airplane was equipped with the capability to display weather radar "mosaic" imagery created from Next Generation Radar (NEXRAD) data and it is likely that the pilot was using this information to navigate around precipitation when the airplane encountered a rain shower updraft with likely severe turbulence. Due to latencies inherent in processes used to detect and deliver the NEXRAD data from the ground site, as well as the frequency of the mosaic-creation process used by the service provider, NEXRAD data can age significantly by the time the mosaic image is created. The pilot elected to navigate the hazardous weather along his route of flight based on the data displayed to him instead of the routing suggested by the controller, which resulted in the penetration of a rain shower updraft, a loss of airplane control, and a subsequent inflight breakup.

The pilot and two passengers departed on an instrument flight rules cross-country flight in night instrument meteorological conditions (IMC). The pilot was instructed by air traffic control to climb to 12,000 ft, and then cleared to climb to FL230. The pilot reported to the controller that the airplane encountered freezing drizzle and light rime icing during the climb from 6,500 ft to 8,000 ft mean sea level (msl). As the airplane climbed through 11,600 ft msl, the pilot reported that they had an issue with faulty deicing equipment and needed to return to the airport. The controller instructed the pilot to descend and cleared the airplane back to the airport. When asked by the controller if there was an emergency, the pilot stated that they “blew a breaker,” and were unable to reset it. As the controller descended the airplane toward the airport, the pilot reported that they were having issues with faulty instruments. At this time, the airplane was at an altitude of about 4,700 ft. The controller instructed the pilot to maintain 5,000 ft, and the pilot responded that he was “pulling up.” There was no further communication with the pilot. Review of the airplane’s radar track showed the airplane’s departure from the airport and the subsequent turn and southeast track toward its destination. The track appeared as a straight line before a descending, right turn was observed. The turn radius decreased before the flight track ended. The airplane impacted terrain in a right-wing-low attitude. The wreckage was scattered and highly fragmented along a path that continued for about 570 ft. Examination of the wreckage noted various pieces of the flight control surfaces and cables in the wreckage path. Control continuity could not be established due the fragmentation of the wreckage; however, no preimpact anomalies were found. Examination of the left and right engines found rotational signatures and did not identify any pre-impact anomalies. A review of maintenance records noted two discrepancies with the propeller deice and surface deice circuit breakers, which were addressed by maintenance personnel. Impact damage and fragmentation prevented determination of which circuit breaker(s) the pilot was having issues with or an examination of any deicing systems on the airplane. The radio transmissions and transponder returns reflected in the radar data indicate that the airplane’s electrical system was operational before the accident. It is likely that the pilot’s communications with the controller and attempted troubleshooting of the circuit breakers introduced distractions from his primary task of monitoring the flight instruments while in IMC. Such interruptions would make him vulnerable to misleading vestibular cues that could adversely affect his ability to effectively interpret the instruments and maintain control of the airplane. The pilot’s report of “faulty instruments” during a decreasing radius turn and his initial distraction with the circuit breakers and radio communications is consistent with the effects of spatial disorientation.

While on an instructional flight in icing and instrument meteorological conditions (IMC), the pilots indicated that they were having instrumentation difficulties to air traffic control. They initially reported a problem with the autopilot, then a navigational issue, which they later indicated were resolved, and finally they reported it was a problem with the left side attitude indicator. After air traffic control cleared them to their destination, the airplane entered a descending left turn, which continued into a 360° descending turn. An inflight breakup resulted, with the wreckage being scattered over 7,000 ft of wooded terrain. Examination of the engines revealed there were no anomalies that would have precluded normal operation prior to the accident. Control cable continuity was established from the flight controls in the cockpit to all flight control surfaces through multiple overload failures. The pitot-static system was examined, and no blockages were noted. Since there was rotational scoring noted on the vertical gyro and the directional gyro, it’s likely they were operating at the time of the accident. Furthermore, the left side attitude indicator examination revealed that there were no anomalies with the instrument. Examination of the deice valves for the deicing boots revealed that the left wing deice valve did not operate. Corrosion was visible in all three valves and it could not be determined if the corrosion was a result of postimpact environmental exposure. Furthermore, since the cockpit switch positions were compromised in the accident, it could not be determined if the pilots were operating the deicing system at the time of the accident. However, most of the pilot reports (PIREPs) in the area indicated light icing and the airplane performed a 6,000 ft per minute climb just before the loss of control. Given this information, it is unlikely the icing conditions made the airplane uncontrollable. A review of the pilots’ flight experience revealed that the pilot in the left seat did not hold a type rating for the accident airplane model but was scheduled to attend flight training to obtain such a type rating. The pilot in the right seat, who also held a flight instructor certificate, did hold a type rating for the airplane. Given that the remarks section of the filed flight plan described the flight as a “training flight” and the left-seat pilot’s plan to obtain a type rating for the accident airplane model, it is likely the pilot in the left seat was the flying pilot for the majority of the flight. Although the right-seat pilot's autopsy noted coronary artery disease, the condition was poorly described. The circumstances of the accident are not consistent with sudden physical impairment or incapacitation; therefore, it is unlikely it contributed to the event. Toxicology testing identified diphenhydramine, which can cause significant sedation, in the right-seat pilot’s blood. However, the level present at the time of the accident was too low to quantify. Therefore, it is unlikely effects from diphenhydramine contributed to the accident. Prior to entering the descending right turn, air traffic control noted that the airplane was not following assigned headings and altitudes and the pilots’ reported having autopilot problems. Subsequently, the pilots’ reported they were using the right attitude indicator as they had difficulties with the left-side indicator. Information was insufficient to evaluate whether the reported difficulties were the result of a malfunction of the autopilot or the pilots’ management of the autopilot system. However, the reported difficulties likely increased the pilots’ workload, may have diverted their attention while operating in IMC and icing conditions, resulting in task saturation, and may have increased their susceptibility to spatial disorientation. It is also possible that the onset of spatial disorientation was the beginning of the pilots’ difficulties maintaining the airplane’s flight track and what they perceived to be an instrumentation problem. Regardless, since the left seat pilot was not rated to fly the airplane, the right seat pilot’s workload would have increased by having to diagnose the issue, assess the situation, and maintain positive airplane control. The airplane’s track data are consistent with the known effects of spatial disorientation, leading to an inflight loss of control and subsequent inflight breakup.

On 27 January 2020, at approximately 1309 hours local time (L), an E-11A, tail number (T/N) 11-9358, was destroyed after touching down in a field in Ghanzi Province, Afghanistan (AFG) following a catastrophic left engine failure. The mishap crew (MC) were deployed and assigned to the 430th Expeditionary Electronic Combat Squadron (EECS), Kandahar Airfield (KAF), AFG. The MC consisted of mishap pilot 1 (MP1) and mishap pilot 2 (MP2). The mission was both a Mission Qualification Training – 3 (MQT-3) sortie for MP2 and a combat sortie for the MC, flown in support of Operation FREEDOM’S SENTINEL. MP1 and MP2 were fatally injured as a result of the accident, and the Mishap Aircraft (MA) was destroyed. At 1105L, the MA departed KAF. The mission proceeded uneventfully until the left engine catastrophically failed one hour and 45 minutes into the flight (1250:52L). Specifically, a fan blade broke free causing the left engine to shutdown. The MC improperly assessed that the operable right engine had failed and initiated shutdown of the right engine leading to a dual engine out emergency. Subsequently, the MC attempted to fly the MA back to KAF, approximately 230 nautical miles (NM) away. Unfortunately, the MC were unable to get either engine airstarted to provide any usable thrust. This resulted in the MA unable to glide the distance remaining to KAF. With few options remaining, the MC maneuvered the MA towards Forward Operating Base (FOB) Sharana, but did not have the altitude and airspeed to glide the remaining distance. The MC unsuccessfully attempted landing in a field approximately 21 NM short of FOB Sharana.

At about 1205, while B137 was overhead the Adaminaby fire-ground, and about the same time the SAD logged the birddog rejection, B134 departed Richmond as initial attack. On board were the PIC, the copilot and flight engineer. In response to the draft report, the RFS provided excerpts from the state operations controller (SOC) log. An entry was written in the log by the SOC following the accident. The SOC noted having been advised that the birddog had indicated it was ‘not safe to fly’ and that B137 was not returning to the area until the conditions had eased. However, B134 would continue with the PIC to make the ‘decision of safety of bombing operations’. The RFS advised the ATSB that the SOC had the authority to cancel B134’s tasking, but instead allowed it to proceed, with the intention of gathering additional intelligence to assist in determining whether further aerial operations would proceed. The RFS further reported that this indicated an ongoing intelligence gathering and assessment process by the SOC. At about 1235, while returning to Richmond, the PIC of B137 heard the PIC of B134 on the Canberra approach frequency, and contacted them via their designated operating frequency. At that time, B134 was about 112 km north-east of Adaminaby, en route to the fire-ground. In this conversation, the PIC of B137 informed them of the actual conditions and that they would not be returning to Adaminaby. The PIC of B137 reported that they could not recall the specific details of the call, but that the conversation included that they were ‘getting crazy winds’ and ‘you can go take a look’ ’but I am not going back’. It was also noted that the PIC of B134 had asked several questions. It was reported by the majority of the operator’s pilots that, despite receiving information from another pilot, they would have also continued with the tasking under these circumstances, to assess the conditions themselves. At about 1242, the crew of B134 contacted air traffic control to advise them of the coordinates they would be working at, provide an ‘ops normal’ call time, and confirm there was no reported instrument flight rules aircraft in the area. About 5 minutes later, the Richmond ABM also attempted to contact the crew of B134 to confirm ‘ops normal’, firstly by radio, and then by text to the PIC’s mobile phone, but did not receive a response. The automatic dependent surveillance broadcast (ADS-B) data showed that, after arriving at the Adaminaby fire-ground at about 1251, the crew of B134 completed several circuits at about 2,000 ft AGL. At about 1255, the crew advised the Cooma ARO that it was too smoky and windy to complete a retardant drop at that location. The Cooma ARO then provided the crew with the approximate coordinates of the Good Good fire, about 58 km to the east of Adaminaby. The ARO further indicated that they had no specific requirements, but they could look for targets of opportunity, with the objective of conducting structure and property protection near Peak View. At about 1259, the crew of B134 contacted air traffic control to advise that they had been re-tasked to the Good Good fire-ground, and provided updated coordinates. At about the same time, the RFS ground firefighters at the Good Good fire-ground, near Feeney’s Road in Peak View, contacted the Cooma FCC and requested additional assets for property protection. They were advised that a LAT would be passing overhead in about 10 minutes. The firefighters acknowledged the intention of a LAT retardant drop and advised the Cooma FCC they would wait in open country on Feeney’s Road, clear of any properties targeted for protection. At about 1307, B134 arrived overhead the drop area. The drop area was located to the east of a ridgeline, with the fire on the western side of the ridgeline. The aircraft’s recorded track data (SkyTrac) showed that the crew conducted 3 left circuits, at about 1,500 ft, 500 ft and 1,000 ft AGL respectively, prior to commencing the drop circuit. At about 1312, after conducting about 2 circuits, they advised the Cooma ARO of their intention to complete multiple drops on the eastern side of the Good Good fire, and that they would advise the coordinates after the first delivery. At 1315:15, a partial retardant drop was conducted on a heading of about 190°, at about 190 ft AGL (3,600 ft above mean sea level). During the drop, about 1,200 US gallons (4,500 L) of fire retardant was released over a period of about 2 seconds. A ground speed of 144 kt was recorded at the time of the drop. A witness video taken by ground fire-fighters captured the drop and showed the aircraft immediately after the drop in an initial left turn with a positive rate of climb, before it became obscured by smoke. While being intermittently obscured by smoke, the aircraft climbed to about 330 ft AGL (3,770 ft above mean sea level). At about this time, ATSB analysis of the video showed that the aircraft was rolling from about 18° left angle of bank to about a 6° right angle of bank. Following this, the aircraft descended and about 17 seconds after the completion of the partial retardant drop, it was seen at a very low height above the ground, in a slight left bank. Video analysis and accident site examination showed there was no further (emergency) drop of retardant. Throughout this period, the recorded groundspeed increased slightly to a maximum of 151 kt. Shortly after, there was a significant left roll just prior to ground impact. At about 1315:37, the aircraft collided with terrain and a post-impact fuel-fed fire ensued. The 3 crew were fatally injured and the aircraft was destroyed. A review of the Airservices Australia audio recording of the applicable air traffic control frequency found no distress calls were received by controllers prior to the impact.

A Cessna S550 Citation S/II of the South African Civil Aviation Authority crashed into the Outeniqua mountains, near the town of Friemersheim. The three occupants were killed and the aircraft was destroyed. The Citation departed Port Elizabeth Airport (FAPE) on a positioning flight to George Airport (FAGG). On approach to FAGG, the flying crew requested to carry out a calibration flight for the very high frequency omnidirectional range (VOR) beacon at FAGG. Due to inclement weather conditions at the time, they were not cleared to conduct VOR calibration. As a result, they decided to land and refuel the aircraft before commencing with the calibration of the Instrument Landing System (ILS) on runway 11 at FAGG. The flying crew requested take-off from runway 11 and an early right turn to intercept radial 250°, 17 nautical miles (nm) DME arc to radial 330° at 3000 feet (ft) climbing to 4,000 feet. The air traffic control (ATC) granted their request. Radar data indicated that at 10:42, the aircraft took off from runway 11 and, once airborne, made a right-hand turn to intercept radial 250° using the George VOR (GRV VOR). The aircraft climbed to 3000ft. Once the aircraft reached 17 nm on the DME from the GRV VOR (DME is co-located with the VOR), it commenced with a right-hand turn to intercept radial 330° while maintaining 17nm DME arc. At 10:46, the ATC at FAGG advised the flying crew that they were now exiting controlled airspace and were advised to broadcast on the special rules frequency. The crew acknowledged the advisory to change frequency and there was no further communication. The aircraft was still being monitored by ATC using secondary surveillance radar. At 10:50, radar data showed the aircraft crossing radial 310° and entered a climb from 3000ft, reaching 3,900 feet. As the aircraft levelled off at 3,900 feet, a rapid descent occurred, and the aircraft lost 1500ft in approximately 9 seconds. Three seconds prior to impact, the aircraft nose pitched up before impacting a ridge at 2,192 feet. The aircraft was destroyed and all three occupants were killed.

The airplane departed Rahim Yar Khan-Sheikh Zayed Airport and was spraying pesticide in the area to tackle another wave of locust attacks, which began in December 2019, on the request of the district administration. In unknown circumstances, the single engine airplane went out of control and crashed in a sandy area located in Sadiqabad, killing both crew members, a pilot and a flight engineer. They were completing a mission on behalf of the Department of Agriculture of Pakistan. Initial investigations suggest the plane crashed due to a technical fault.

Crashed in unknown circumstances in Haputale while completing a survey flight from Wirawila to Colombo-Ratmalana Airport. The aircraft was destroyed by a post crash fire and all four crew members were killed.

The single engine airplane departed Hermosillo-General Ignacio Pesqueira García Airport at 0700LT on a schedule service (CFV872) to Guerrero Negro, Baja California del Sur, with one passenger and one pilot on board. About half an hour into the flight, radio and radar contact were lost with the airplane. Debris were found two days later in an uninhabited area located in the region of Tastiota, about 30 km southwest of Miguel Alemán. The aircraft was totally destroyed upon impact and both occupants were killed.

The airline transport pilot departed on a night cargo flight into conditions that included an overcast cloud ceiling and “hazy” visibility, as reported by another pilot. About one minute after takeoff, the pilot made a series of course changes and large altitude and airspeed deviations. Following several queries from the air traffic controller concerning the airplane’s erratic flight path, the pilot responded that he had “some instrument problems.” The pilot attempted to return to land at the departure airport, but the airplane impacted terrain after entering a near-vertical dive. The airplane was one of two in the operator’s fleet equipped with an inverter system that electrically powered the pilot’s (left side) flight instruments. Examination of the annunciator panel lighting filaments revealed that the inverter system was not powered when the airplane impacted the ground. Without electrical power from an inverter, the pilot’s side attitude indicator and horizontal situation indicator (HSI) would have been inoperative and warning flags would have been displayed over the respective instruments. The pilot had a history of poor procedural knowledge and weak flying skills. It is possible that he either failed to turn on an inverter during ground operations and did not respond to the accompanying warning flags, or he did not switch to the other inverter in the event that an inverter failed inflight. Due to impact damage, the operational status of the two inverters installed in the airplane could not be confirmed. However, the vacuum-powered flight instruments on the copilot’s (right side) were operational, and the pilot could have referenced these instruments to maintain orientation. Based on the available information, the pilot likely lost control of the airplane after experiencing spatial disorientation. The night marginal visual flight rules conditions and instrumentation problems would have been conducive to the development of spatial disorientation, and the airplane’s extensive fragmentation indicative of a high-energy impact was consistent with the known effects of spatial disorientation. Ethanol identified during toxicology testing may have come from postmortem production and based on the low levels recorded, was unlikely to have contributed to this accident. Morphine identified in the pilot’s liver could not be used to extrapolate to antemortem blood levels; therefore, whether or to what extent the pilot’s use of morphine contributed to the accident could not be determined.