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:

Crash of a Beechcraft B200 Super King in Whatì: 2 killed

Date & Time: Jan 30, 2019 at 0915 LT
Operator:
Registration:
C-GTUC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Yellowknife – Whatì – Wekweèti – Ekati
MSN:
BB-268
YOM:
1977
Flight number:
8T503
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2762
Captain / Total hours on type:
1712.00
Copilot / Total flying hours:
566
Copilot / Total hours on type:
330
Aircraft flight hours:
20890
Aircraft flight cycles:
18863
Circumstances:
At 0851 Mountain Standard Time on 30 January 2019, the Air Tindi Ltd. Beechcraft King Air 200 aircraft (registration C-GTUC, serial number BB-268) departed Yellowknife Airport (CYZF), Northwest Territories, as flight TIN503, on an instrument flight rules flight itinerary to Whatì Airport (CEM3), Northwest Territories, with 2 crew members on board. At 0912, as the aircraft began the approach to CEM3, it departed controlled flight during its initial descent from 12 000 feet above sea level, and impacted terrain approximately 21 nautical miles east-southeast of CEM3, at an elevation of 544 feet above sea level. The Canadian Mission Control Centre received a signal from the aircraft’s 406 MHz emergency locator transmitter and notified the Joint Rescue Coordination Centre in Trenton, Ontario. Search and rescue technicians arrived on site approximately 6 hours after the accident. The 2 flight crew members received fatal injuries on impact. The aircraft was destroyed.
Probable cause:
Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
- For undetermined reasons, the left-side attitude indicator failed in flight.
- Although just before take off the crew acknowledged that the right-side attitude indicator was not operative, they expected it to become operative at some point in the flight. As a result, they did not refer to the minimum equipment list, and departed into instrument meteorological conditions with an inoperative attitude indicator.
- The crew’s threat and error management was not effective in mitigating the risk associated with the unserviceable right-side attitude indicator.
- The crew’s crew resource management was not effective, resulting in a breakdown in verbal communication, a loss of situation awareness, and the aircraft entering an unsafe condition.
- The captain did not have recent experience in flying partial panel. As a result, the remaining instruments were not used effectively and the aircraft departed controlled flight and entered a spiral dive.
- The captain and first officer likely experienced spatial disorientation.
- Once the aircraft emerged below the cloud layer at approximately 2000 feet above ground, the crew were unable to recover control of the aircraft in enough time and with enough altitude to avoid an impact with terrain.

Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
- If flight crews do not use the guidance material provided in the minimum equipment list when aircraft systems are unserviceable, there is a risk that the aircraft will be operated without systems that are critical to safe aircraft operation.
- If flight crews do not use all available resources at their disposal, a loss in situation awareness can occur, which can increase the risk of an accident.

Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
- A review of Air Tindi Ltd.'s pilot training program revealed that all regulatory requirements were being met or exceeded.
Final Report:

Crash of a Piper PA-46-310P Malibu off Guernsey: 2 killed

Date & Time: Jan 21, 2019 at 2016 LT
Operator:
Registration:
N264DB
Flight Phase:
Survivors:
No
Schedule:
Nantes - Cardiff
MSN:
46-8408037
YOM:
1984
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3500
Captain / Total hours on type:
30.00
Aircraft flight hours:
6636
Circumstances:
The pilot of N264DB flew the aircraft and the passenger from Cardiff Airport to Nantes Airport on 19 January 2019 with a return flight scheduled for 21 January 2019. The pilot arrived at the airport in Nantes at 1246 hrs on 21 January to refuel and prepare the aircraft for the flight. At 1836 hrs the passenger arrived at airport security, and the aircraft taxied out for departure at 1906 hrs with the passenger sitting in one of the rear, forward-facing passenger seats. Figure 1 shows the aircraft on the ground before departure. The pilot’s planned route would take the aircraft on an almost direct track from Nantes to Cardiff, flying overhead Guernsey en route (Figure 2). The Visual Flight Rules (VFR) flight plan indicated a planned cruise altitude of 6,000 ft amsl and distance of 265 nm. The aircraft took off from Runway 03 at Nantes Airport at 1915 hrs, and the pilot asked Air Traffic Control (ATC) for clearance to climb to 5,500 ft. The climb was approved by Nantes Approach Control and the flight plan was activated. The aircraft flew on its planned route towards Cardiff until it was approximately 13 nm south of Guernsey when the pilot requested and was given a descent clearance to remain in Visual Meteorological Conditions (VMC). Figure 3 shows the aircraft’s subsequent track. The last radio contact with the aircraft was with Jersey ATC at 2012 hrs, when the pilot asked for a further descent. The aircraft’s last recorded secondary radar point was at 2016:34 hrs, although two further primary returns were recorded after this. The pilot made no distress call that was recorded by ATC. On February 4, 2019, the wreckage (relatively intact) was found at a depth of 63 meters few km north of the island of Guernsey. On February 6, a dead body was found in the cabin and recovered. It was later confirmed this was the Argentine footballer Emiliano Sala. The pilot's body was not recovered.
Probable cause:
Causal factors
1. The pilot lost control of the aircraft during a manually-flown turn, which was probably initiated to remain in or regain VMC.
2. The aircraft subsequently suffered an in-flight break-up while manoeuvring at an airspeed significantly in excess of its design manoeuvring speed.
3. The pilot was probably affected by CO poisoning.
Contributory factors
1. A loss of control was made more likely because the flight was not conducted in accordance with safety standards applicable to commercial operations. This manifested itself in the flight being operated under VFR at night in poor weather conditions despite the pilot having no training in night flying and a lack of recent practice in instrument flying.
2. In-service inspections of exhaust systems do not eliminate the risk of CO poisoning.
3. There was no CO detector with an active warning in the aircraft which might have alerted the pilot to the presence of CO in time for him to take mitigating action.
Final Report:

Crash of a Partenavia P.68B Victor near Strausberg: 2 killed

Date & Time: Jan 12, 2019 at 1155 LT
Type of aircraft:
Operator:
Registration:
D-GINA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Strausberg - Strausberg
MSN:
59
YOM:
1975
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2923
Copilot / Total flying hours:
632
Aircraft flight hours:
5750
Circumstances:
The twin engine airplane departed Strausberg Airport at 1100LT on a local training flight, carrying one instructor and one pilot under supervision. About 50 minutes later, while cruising in clouds at an altitude of 1,300 feet, the airplane entered an uncontrolled descent and crashed in a field located 7,5 km northwest of the airport. The airplane disintegrated on impact and both occupants were killed.

Crash of a Piper PA-46-350P Malibu off Mayport: 2 killed

Date & Time: Dec 20, 2018 at 0904 LT
Registration:
N307JM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kissimmee - Princeton
MSN:
46-36253
YOM:
2000
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
390
Captain / Total hours on type:
30.00
Aircraft flight hours:
3785
Circumstances:
The aircraft impacted the Atlantic Ocean near Mayport, Florida. The private pilot and pilot-rated passenger were fatally injured. The airplane was destroyed. The airplane was privately owned and operated under the provisions of Title 14 Code of Federal Regulations Part 91. Instrument meteorological conditions prevailed at the time and the flight was operating on an instrument flight rules (IFR) flight plan. The personal flight originated from Kissimmee Gateway Airport, Orlando, Florida, about 0821, and was destined for Princeton Airport, Princeton/Rocky Hill, NJ. According to preliminary air traffic control radar and voice data provided by the Federal Aviation Administration (FAA), at 0859:02, one of the airplane's occupants contacted the Jacksonville Air Route Traffic Control Center (ZJX ARTCC) R-73 sector controller and reported passing through Flight Level (FL) 220 for FL230. The controller advised the pilot there were moderate and some heavy precipitation along the route of flight extending for 200 nautical miles. The occupant acknowledged the controller and advised they would be watching the weather. FAA radar data indicated at 0900:22 the flight reached FL227. Preliminary review of weather data revealed that this altitude was above the freezing level, and at that time the flight entered an area of weather radar returns with intensities between 10 to 30 dBZ (which equated to light to moderate precipitation). While in the weather radar-indicated precipitation, the flight climbed to FL230. At 0902:14, while at the edge of the precipitation, the airplane started a slight left turn before entering a right turn at 0902:28 at FL226. The turn had not been directed by the controller or announced by either occupant. Between 0902:28 and 0903:10, the airplane descended from FL226 to FL202. At 0903:10, the airplane was descending through FL202 when the controller attempted to contact the flight, but there was no reply. The controller attempted to communicate with the flight several more times, and at 0903:27 in response to one attempt, while at 14,500 feet mean sea level (msl), an occupant advised, "were not ok we need help." The controller asked the pilot if he was declaring an emergency and "whats going on." At 0903:35, while at 12,600 feet msl an occupant stated, "I'm not sure whats happening", followed by, "I have anti-ice and everything." At 0903:40 the controller asked the flight if it could maintain altitude, an occupant responded that they could not maintain altitude. The controller provided vectors to a nearby airport west of their position, but the flight did not reply to that transmission or a subsequent query. At about 0904:32 (which was the last communication from the airplane), while at 3,300 feet msl, an occupant advised the controller that the airplane was inverted and asked for assistance. The last radar recorded position with altitude read-out of the flight was at 0904:40, at an altitude of 1,700 feet msl, and 30.40069° north latitude and -81.3844° west longitude. The U.S. Coast Guard initiated a search for the missing airplane, but the wreckage was not located and the search was suspended on December 22, 2018. A privately-funded search for the airplane was initiated and the wreckage was located and recovered on February 6, 2019. The recovered wreckage was retained for further investigation.
Probable cause:
An in-flight loss of control following an encounter with supercooled large droplet icing conditions, which ultimately resulted in an uncontrolled descent and subsequent inflight breakup. Also causal was the pilot’s failure to maintain an appropriate airspeed for flight in icing conditions.
Final Report:

Crash of a Britten-Norman BN-2A-20 Islander in West Portal: 1 killed

Date & Time: Dec 8, 2018 at 0828 LT
Type of aircraft:
Operator:
Registration:
VH-OBL
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Cambridge – Bathurst Harbour
MSN:
2035
YOM:
1986
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
540
Captain / Total hours on type:
80.00
Aircraft flight hours:
12428
Circumstances:
On 8 December 2018, the pilot of a Pilatus Britten-Norman BN2A-20 Islander, registered VH-OBL and operated by Airlines of Tasmania, was conducting a positioning flight under the visual flight rules from Cambridge Airport to the Bathurst Harbour aeroplane landing area (ALA), Tasmania. The aircraft departed Cambridge at about 0748 Eastern Daylight-saving Time and was scheduled to arrive at Bathurst Harbour about 0830 to pick up five passengers for the return flight. The passengers were part of a conservation project that flew to south-west Tasmania regularly, and it was the pilot’s only flight for that day. Automatic dependent surveillance broadcast (ADS-B) position and altitude data (refer to the section titled Recorded information) showed the aircraft tracked to the south-west towards Bathurst Harbour (Figure 1). At about 0816, the aircraft approached a gap in the Arthur Range known as ‘the portals’. The portals are a saddle (lowest area) between the Eastern and Western Arthur Range, and was an optional route that Airlines of Tasmania used between Cambridge and Bathurst Harbour when the cloud base prevented flight over the mountain range. After passing through the portals, the aircraft proceeded to conduct a number of turns below the height of the surrounding highest terrain. The final data point recorded was at about At about 0829, the Australian Maritime Safety Authority received advice that an emergency locator transmitter allocated to VH-OBL had activated. They subsequently advised the Tasmanian Police and the aircraft operator of the activation, and initiated search and rescue efforts. The rescue efforts included two helicopters and a Challenger 604 search and rescue jet aircraft. The Challenger arrived over the emergency locator transmitter signal location at around 0925, however, due to cloud cover the crew were unable to visually identify the precise location of VH-OBL. A police rescue helicopter arrived at the search area at about 1030. The pilot of that helicopter reported observing cloud covering the eastern side of the Western Arthur Range, and described a wall of cloud with its base sitting on the bottom of the west portal. Multiple attempts were made throughout the day to locate the accident site, however, due to low-level cloud, and fluctuating weather conditions, the search and rescue operation was unable to confirm visual location of the aircraft until about 1900. The aircraft wreckage was found in mountainous terrain of the Western Arthur Range in the Southwest National Park (Figure 2) . The search and rescue crew assessed that the accident was unlikely to have been survivable. The helicopter crew considered winching personnel to the site, however, due to a number of risks, including potential for cloud reforming, the time of day and lighting, and other hazards associated with the mountainous location, the helicopter departed the area. The aircraft wreckage was accessed the following day, when it was confirmed that the pilot was fatally injured.
Probable cause:
From the evidence available, the following findings are made with respect to the controlled flight into terrain involving Pilatus Britten-Norman BN2A, VH-OBL, 101 km west-south-west of Hobart, Tasmania, on 8 December 2018.
Contributing factors:
• The pilot continued descending over the Arthur Range saddle to a lower altitude than previous flights, likely due to marginal weather. This limited the options for exiting the valley surrounded
by high terrain.
• While using a route through the Arthur Range due to low cloud conditions, the pilot likely encountered reduced visual cues in close proximity to the ground, as per the forecast conditions. This led to controlled flight into terrain while attempting to exit the range.
Final Report:

Crash of a Lockheed KC-130J Hercules in the Pacific Ocean: 5 killed

Date & Time: Dec 6, 2018 at 0200 LT
Type of aircraft:
Operator:
Registration:
167981
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Iwakuni - Iwakuni
MSN:
5617
YOM:
2009
Flight number:
Sumo 41
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The crew departed Iwakuni Airport on a refuelling mission over the Pacific Ocean under callsign 'Sumo 41'. Following a night refuelling operation, the four engine airplane collided with a McDonnell Douglas F/A-18 Hornet. Both aircraft went out of control and crashed into the ocean some 200 miles off Muroto Cape, Japan. The United States Marine Corps confirms that two Marines have been found. One is in fair condition and the other has been declared deceased by competent medical personnel. All five crew members from the Hercules are still missing after two days of SAR operations and presumed dead. The KC-130 Hercules was assigned to Marine Aerial Refueler Transport Squadron 152 (the Sumos), 1st Marine Aircraft Wing.
Probable cause:
The CDA-RB’s report determined four interconnected causal factors led to the 6 December 2018 mishap. First, the flight lead (F/A-18 call sign, Profane 11) requested, and received approval for, an un-briefed, non-standard departure from the C-130 tanker (call sign, Sumo 41). This departure placed the mishap pilot (F/A-18 call sign, Profane 12) on the left side of the tanker. A standard departure would have placed both F/A-18s on the right side of the tanker. Second, Profane 11 chose an authorized, but not optimized, lighting configuration. After tanking, Profane 11 placed his external lights in a brightly lit overt setting, while the C-130’s lights remained in a dimly lit covert setting. These circumstances set the conditions for Profane 12 to focus on the overtly lit Profane 11 aircraft, instead of the dimly lit tanker. Third, Profane 12 lost sight of the C-130 and lost situational awareness of his position relative to the tanker resulting in a drift over the top of the C-130 from left to right. Fourth, Profane 12 was unable to overcome these difficult and compounding challenges created by the first three factors. As a result, when Profane 12 maneuvered his aircraft away from Profane 11, he moved from right to left and impacted the right side of the tanker’s tail section. It must be noted, this specific set of circumstances would have been incredibly difficult for any pilot, let alone a junior, or less proficient pilot to overcome.
The CDA-RB determined the previous 2018 mishap command investigation did not capture a completely accurate picture of the event. The CDA-RB determined portions of the investigation contained a number of inaccuracies. Specifically, the 2018 command investigation incorrectly concluded medication may have been a causal factor in the mishap, the mishap pilot was not qualified to fly the mission, AN/AVS-11 night vision devices contributed to the mishap, and the previously mentioned mishap in 2016 had not been properly investigated. These conclusions are not supported by the evidence, and are addressed in detail in the CDA-RB report. While the 2018 CI contains a few inaccuracies, the CDA-RB does confirm the command investigation’s conclusions related to organizational culture and command climate as contributing factors to the mishap.
The CDA-RB made 42 recommendations to address institutional and organizational contributing factors. As a result, the Assistant Commandant directed 11 actions to address manpower management, training, operations, and medical policies. The Director of the Marine Corps Staff will lead the coordination of all required actions to ensure proper tracking and accomplishment.