Crash of a Piper PA-31-350 Navajo Chieftain in Sayaxché: 2 killed

Date & Time: Apr 13, 2019
Operator:
Registration:
N2613
Flight Phase:
Flight Type:
Survivors:
No
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
In the morning, the Guatemala Army Forces were informed by ATC that a PA-31 entered the Guatemala Airspace without prior permission. The twin engine airplane crashed in a wooded area located near the farm of Sepens located in the region of Sayaxché, Petén. The aircraft was partially destroyed by impact forces and both occupants were killed. A sticker was set on the fuselage with the registration N2613 which is wrong.

Crash of a Piper PA-31-350 Navajo Chieftain near San Rafael de Yuma

Date & Time: Apr 5, 2019 at 2228 LT
Operator:
Registration:
YV312
Flight Phase:
Flight Type:
Survivors:
Yes
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane departed Venezuela in the evening on a probable drug smuggling flight with an unknown destination. At 2226LT, after it entered the Dominican Airspace, a crew of the Dominican Air Force was dispatched with an Embraer EMB-314 Super Tucano but the PA-31 disappeared from radar screens at 2228LT after crashing in a sugar cane field located in the region of San Rafael de Yuma, between La Romana and Punta Cana. Due to limited visibility caused by night and poor weather conditions, SAR operations were suspended shortly after midnight. The wreckage was found in the next early morning. Nobody was found on site and the aircraft is probably written off. The registration YV312 may be a wrong one.

Crash of a Beechcraft B200 Super King Air in Matsieng: 1 killed

Date & Time: Mar 23, 2019 at 2020 LT
Operator:
Registration:
A2-MBM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Gaborone - Matsieng
MSN:
BB-1489
YOM:
1994
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Earlier in the afternoon the pilot was an uninvited guest at a private function that was held at the Matsieng Flying Club facility at Matsieng Aerodrome. In a statement, the Matsieng Flying Club reported that it was rumored that the pilot was involved in a domestic dispute earlier in the afternoon. At 2015LT the aircraft approached Matsieng Aerodrome from the direction of Sir Seretse Khama Airport and made a number of low level fly passes from different directions past the Club facilities next to the Air Traffic Control tower. An immediate evacuation of the club premises was ordered. The final extreme low level run by the aircraft along runway 36 resulted in an impact with the Matsieng Flying Club facility at ground level. The Club facility and Matsieng ATC tower was destroyed on impact. The post impact fire destroyed 13 parked vehicles. The emergency services of the Kgatleng District Council were on the scene within minutes to attend to the post-impact fire and distress. These response actions are to be commended. It is believed that the pilot had no permission to fly the aircraft involved. Sole on board, he was killed.
Probable cause:
Pilot suicide suspected.

Crash of a Piper PA-31-350 Navajo Chieftain in Madeira: 1 killed

Date & Time: Mar 12, 2019 at 1516 LT
Operator:
Registration:
N400JM
Flight Phase:
Survivors:
No
Site:
Schedule:
Cincinnati - Cincinnati
MSN:
31-8152002
YOM:
1981
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6421
Captain / Total hours on type:
1364.00
Aircraft flight hours:
19094
Circumstances:
The commercial pilot was conducting an aerial observation (surveying) flight in a piston engineequipped multiengine airplane. Several hours into the flight, the pilot advised air traffic control (ATC) that the airplane had a fuel problem and that he needed to return to the departure airport. When the airplane was 8 miles from the airport, and after passing several other airports, the pilot informed ATC that he was unsure if the airplane could reach the airport. The final minutes of radar data depicted the airplane in a descent and tracking toward a golf fairway as the airplane's groundspeed decreased to a speed near the single engine minimum control airspeed. According to witnesses, they heard an engine sputter before making two loud "back-fire" sounds. One witness reported that, after the engine sputtered, the airplane "was on its left side flying crooked." Additional witnesses reported that the airplane turned to the left before it "nose-dived" into a neighborhood, impacting a tree and private residence before coming to rest in the backyard of the residence. A witness approached the wreckage immediately after the accident and observed a small flame rising from the area of the left engine. Video recorded on the witness' mobile phone several minutes later showed the airplane engulfed in flames. Examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions or failures of either engine. The fuel systems feeding both engines were damaged by impact forces but the examined components generally displayed that only trace amounts of fuel remained; with the exception of the left engine nacelle fuel tank. Given the extent of the fire damage to this area of the wreckage, and the witness report that the post impact fire originated in this area, it is likely that this tank contained fuel. By design, this fuel in this tank was not able to supply fuel directly to either engine, but instead relied on an electric pump to transfer fuel into the left main fuel tank. Fire damage precluded a detailed postaccident examination or functional testing of the left nacelle fuel transfer pump. Other pilots who flew similar airplanes for the operator, along with a review of maintenance records for those airplanes, revealed at least three instances of these pumps failing in the months surrounding the accident. The other pilots also reported varying methods of utilizing fuel and monitoring fuel transfers of fuel from the nacelle fuel tanks, since there was no direct indication of the quantity of fuel available in the tank. These methods were not standardized between pilots within the company and relied on their monitoring the quantity of fuel in the main fuel tanks in order to ensure that the fuel transfer was occurring. Had the pilot not activated this pump, or had this pump failed during the flight, it would have rendered the fuel in the tank inaccessible. Given this information it is likely that the fuel supply available to the airplane's left engine was exhausted, and that the engine subsequently lost power due to fuel starvation. The accident pilot, along with another company pilot, identified fuel leaking from the airplane's left wing, about a week before the accident. Maintenance records showed no actions had been completed to the address the fuel leak. Due to damage sustained during the accident, the origin of the fuel leak could not be determined, nor could it be determined whether the fuel leak contributed to the fuel starvation and eventual inflight loss of power to the left engine. Because the left engine stopped producing power, the pilot would have needed to configure the airplane for single-engine flight; however, examination of the left engine's propeller found that it was not feathered. With the propeller in this state, the pilot's ability to maintain control the airplane would have been reduced, and it is likely that the pilot allowed the airplane's airspeed to decrease below the singleengine minimum controllable airspeed, which resulted in a loss of control and led to the airplane's roll to the left and rapid descent toward the terrain. Toxicology results revealed that the pilot had taken doxylamine, an over-the-counter antihistamine that can decrease alertness and impair performance of potentially hazardous tasks. Although the toxicology results indicated that the amount of doxylamine in the pilot's cavity blood was within the lower therapeutic range, review of ATC records revealed that the pilot was alert and that he was making necessary decisions and following instructions. Thus, the pilot's use of doxylamine was not likely a factor in the accident.
Probable cause:
Fuel starvation to the left engine and the resulting loss of engine power to that engine, and a loss of airplane control due to the pilot's failure to maintain the minimum controllable airspeed.
Final Report:

Crash of a BAe 125-600A in San Pedro de Peralta: 1 killed

Date & Time: Mar 10, 2019
Type of aircraft:
Operator:
Registration:
N18BA
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
256046
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft was engaged in an illegal flight, carrying two pilots and a load of 200 kg of cocaine. En route, the crew apparently encountered an unexpected situation and was forced to attempt an emergency landing when the airplane crashed in a wooded area located near San Pedro de Peralta. A pilot was killed while the second was seriously injured. Originally registered N299GS, the aircraft was cancelled from the US registered on 15 February 2018 and exported to Mexico. The registration N18BA is false.

Crash of a Douglas DC-3 in Finca La Bendición: 14 killed

Date & Time: Mar 9, 2019 at 1036 LT
Type of aircraft:
Operator:
Registration:
HK-2494
Flight Phase:
Survivors:
No
Schedule:
San Jose del Guaviare – Villavicencio
MSN:
33105/16357
YOM:
1945
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
14
Captain / Total flying hours:
12710
Captain / Total hours on type:
7044.00
Copilot / Total flying hours:
12710
Copilot / Total hours on type:
7044
Aircraft flight hours:
23000
Circumstances:
The twin engine airplane departed San José del Guaviare on a charter flight to Villavicencio, carrying 11 passengers and three crew members. While cruising at an altitude of 8,500 feet in good weather conditions, the left engine failed due to an important fuel leak. The crew elected to secure the engine but was unable to feather the propeller. The airplane lost speed and height, and while attempting an emergency landing, the crew lost control of the airplane that stalled and crashed in a palm plantation, bursting into flames. The aircraft was totally destroyed by a post crash fire and all 14 occupants were killed.
Probable cause:
The investigation determined that the accident was caused by the following probable causes:
- Loss of control in-flight as a consequence of the decrease in minimum in-flight control speed and drag generated by the impossibility of performing the No. 1 engine propeller feathering in the face of engine failure.
- Malfunction of the lubrication system of engine No. 1, evident in the abundant oil leakage from the engine, in flight, and in the governor of the left propeller; although discrepancies were found in the maintenance of the propeller feathering pressure line, it was not possible to determine the origin of the oil leakage.
- Weaknesses in the aircraft Operator's operational procedures, lacking a standard that would facilitate a crew's decision making to act in the event of critical failures, in matters such as making an emergency landing on unprepared field or the selection of an alternate airfield.

Contributing Factors:
- Deficiencies in standard maintenance practices during repairs performed on the No. 1 engine's propeller propeller feathering oil pressure line.
- Non-compliance with an effective and reliable maintenance program, which did not verify the operating conditions of the aircraft components; it was not possible to determine compliance with the last 50-hour service, Phase A, to engine No. 1 according to the company's maintenance program, since there are no records of that service in the Flight Log.
- Inefficient safety management system of the Operator for not detecting errors in the maintenance processes and in the conduct and control of operations.
Final Report:

Crash of a Pilatus AU-23A Turbo Porter in Wat Bang Sala

Date & Time: Mar 5, 2019 at 1300 LT
Operator:
Registration:
74-2079
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Pattani - Hat Yai
MSN:
2079
YOM:
1974
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine airplane departed Pattani (9th AF Command) at 1156LT bound for the Wing 56 Air Division 4 located at Hat Yai Airport. En route, the crew encountered technical problems with the engine and attempted an emergency landing when the airplane crashed in a banana plantation located in the region of Wat Bang Sala. All three occupants were injured and the aircraft was damaged beyond repair.

Crash of a Boeing 767-375ER off Anahuac: 3 killed

Date & Time: Feb 23, 2019 at 1239 LT
Type of aircraft:
Operator:
Registration:
N1217A
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Miami - Houston
MSN:
25685/430
YOM:
1992
Flight number:
5Y3591
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
11172
Captain / Total hours on type:
1252.00
Copilot / Total flying hours:
5073
Copilot / Total hours on type:
520
Aircraft flight hours:
91063
Aircraft flight cycles:
23316
Circumstances:
On February 23, 2019, at 1239 central standard time, Atlas Air Inc. (Atlas) flight 3591, a Boeing 767-375BCF, N1217A, was destroyed after it rapidly descended from an altitude of about 6,000 ft mean sea level (msl) and crashed into a shallow, muddy marsh area of Trinity Bay, Texas, about 41 miles east-southeast of George Bush Intercontinental/Houston Airport (IAH), Houston, Texas. The captain, first officer (FO), and a nonrevenue pilot riding in the jumpseat died. Atlas operated the airplane as a Title 14 Code of Federal Regulations Part 121 domestic cargo flight for Amazon.com Services LLC, and an instrument flight rules flight plan was filed. The flight departed from Miami International Airport (MIA), Miami, Florida, about 1033 (1133 eastern standard time) and was destined for IAH. The accident flight’s departure from MIA, en route cruise, and initial descent toward IAH were uneventful. As the flight descended toward the airport, the flight crew extended the speedbrakes, lowered the slats, and began setting up the flight management computer for the approach. The FO was the pilot flying, the captain was the pilot monitoring, and the autopilot and autothrottle were engaged and remained engaged for the remainder of the flight. Analysis of the available weather information determined that, about 1238:25, the airplane was beginning to penetrate the leading edge of a cold front, within which associated windshear and instrument meteorological conditions (as the flight continued) were likely. Flight data recorder data indicated that, during the time, aircraft load factors consistent with the airplane encountering light turbulence were recorded and, at 1238:31, the airplane’s go-around mode was activated. At the time, the accident flight was about 40 miles from IAH and descending through about 6,300 ft msl toward the target altitude of 3,000 ft msl. This location and phase of flight were inconsistent with any scenario in which a pilot would intentionally select go-around mode, and neither pilot made a go-around callout to indicate intentional activation. Within seconds of go-around mode activation, manual elevator control inputs overrode the autopilot and eventually forced the airplane into a steep dive from which the crew did not recover. Only 32 seconds elapsed between the go-around mode activation and the airplane’s ground impact.
Probable cause:
The NTSB determines that the probable cause of this accident was the inappropriate response by the first officer as the pilot flying to an inadvertent activation of the go-around mode, which led to his spatial disorientation and nose-down control inputs that placed the airplane in a steep descent from which the crew did not recover. Contributing to the accident was the captain’s failure to adequately monitor the airplane’s flightpath and assume positive control of the airplane to effectively intervene. Also contributing were systemic deficiencies in the aviation industry’s selection and performance measurement practices, which failed to address the first officer’s aptitude-related deficiencies and maladaptive stress response. Also contributing to the accident was the Federal Aviation Administration’s failure to implement the pilot records database in a sufficiently robust and timely manner.
Final Report:

Crash of a Cessna 421C Golden Eagle III near Canadian: 2 killed

Date & Time: Feb 15, 2019 at 1000 LT
Registration:
N421NS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Amarillo – Canadian
MSN:
421C-0874
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5000
Aircraft flight hours:
6227
Circumstances:
The pilot was conducting a personal cross-country flight with one passenger in his twin-engine airplane. There was no record that the pilot received a weather briefing before the accident flight. While en route to the destination, the pilot was in contact with air traffic control and received visual flight rules flightfollowing services. About 18 miles from the destination airport, the radar service was terminated, as is typical in this geographic region due to insufficient radio and radar coverage below 7,000 ft. The airplane was heading northeast at 4,900 ft mean sea level (msl) (about 2,200 ft above ground level [agl]). About 4 minutes later, radar coverage resumed, and the airplane was 6 miles west of the airport at 4,100 ft msl (1,400 ft agl) and climbing to the north. The airplane climbed through 6,000 ft msl (3,300 ft agl), then began a shallow left turn and climbed to 6,600 ft msl (3,800 ft agl), then began to descend while continuing the shallow left turn ; the last radar data point showed the airplane was about 20 nm northwest of the airport, 5,100 ft msl (2,350 ft agl) on a southwest heading. The final recorded data was about 13 miles northwest of the accident site. A witness near the destination airport heard the pilot on the radio. He reported that the pilot asked about the cloud height and the witness responded that the clouds were 800 to 1,000 ft agl. In his final radio call, the pilot told the witness, "Ok, see you in a little bit." The witness did not see the airplane in the air. The airplane impacted terrain in a slightly nose-low and wings-level attitude with no evidence of forward movement, and a postimpact fire destroyed a majority of the wreckage. The damage to the airplane was consistent with a relatively flat spin to the left at the time of impact. A postaccident examination did not reveal any preimpact mechanical malfunctions or anomalies that would have precluded normal operation. A detailed examination of the cockpit instruments and other portions of the wreckage was not possible due to the fire damage. A cold front had advanced from the northeast and instrument meteorological conditions prevailed across the region surrounding the accident site and the destination airport; the cloud ceilings were 400 ft to 900 ft above ground level. The airplane likely experienced wind shear below 3,000 ft, and there was likely icing in the clouds. While moderate icing conditions were forecast for the accident site, about the time of the accident, investigators were unable to determine the amount and severity of icing the flight may have experienced. The weather conditions had deteriorated over the previous 1 to 2 hours. The conditions at the destination airport had been clear about 2 hours before accident, and visual flight rules conditions about 1 hour before accident, when the pilot departed. Based on the available evidence it is likely that the pilot was unable to maintain control of the airplane, which resulted in an aerodynamic stall and spin into terrain.
Probable cause:
The pilot's failure to maintain control of the airplane while in instrument meteorological conditions with icing conditions present, which resulted in an aerodynamic stall and spin into terrain.
Final Report:

Crash of a Convair C-131B Samaritan off Miami: 1 killed

Date & Time: Feb 8, 2019 at 1216 LT
Type of aircraft:
Operator:
Registration:
N145GT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nassau - Miami
MSN:
256
YOM:
1955
Flight number:
QAI504
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
23000
Captain / Total hours on type:
725.00
Copilot / Total flying hours:
650
Copilot / Total hours on type:
305
Aircraft flight hours:
12701
Circumstances:
According to the first officer, during the first cargo flight of the day, the left engine propeller control was not working properly and the captain indicated that they would shut down the airplane and contact maintenance if the left engine propeller control could not be reset before the return flight. For the return flight, the engines started normally, and both propellers were cycled. The captain and the first officer were able to reset the left propeller control, so the airplane departed with the first officer as the pilot flying. The takeoff and initial climb were normal; however, as the airplane climbed through 4,000 ft, the left engine propeller control stopped working and the power was stuck at 2,400 rpm. The captain tried to adjust the propeller control and inadvertently increased power to 2,700 rpm. The captain then took control of the airplane and tried to stabilize the power on both engines. He leveled the airplane at 4,500 ft, canceled the instrument flight rules flight plan, and flew via visual flight rules direct toward the destination airport. The first officer suggested that they return to the departure airport, but the captain elected to continue as planned (The destination airport was located about 160 nautical miles from the departure airport). The first officer's postaccident statements indicated that he did not challenge the captain's decision. When the flight began the descent to 1,500 ft, the right engine began to surge and lose power. The captain and the first officer performed the engine failure checklist, and the captain feathered the propeller and shut down the engine. Shortly afterward, the left engine began to surge and lose power. The captain told the first officer to declare an emergency. The airplane continued to descend, and the airplane impacted the water "violently," about 32 miles east of the destination airport. The captain was unresponsive after the impact and the first officer was unable to lift the captain from his seat. Because the cockpit was filling rapidly with water, the first officer grabbed the life raft and exited the airplane from where the tail section had separated from the empennage. The first officer did not know what caused both engines to lose power. The airplane was not recovered from the ocean, so examination and testing to determine the cause of the engine failures could not be performed. According to the operator, the flight crew should have landed as soon as practical after the first sign of a mechanical issue. Thus, the crew should have diverted to the closest airport when the left engine propeller control stopped working and not continued the flight toward the destination airport.
Probable cause:
The captain's decision to continue with the flight with a malfunctioning left engine propeller control and the subsequent loss of engine power on both engines for undetermined reasons, which resulted in ditching into the ocean. Contributing to the accident was the first officer's failure to challenge the captain's decision to continue with the flight.
Final Report: