Flight

The crew was completing a spraying mission against mosquito in the regon of Jagodina. Following a 50-minutes successful mission, the crew encountered engine problems. The engine started to vibrate, smoke emanated and an oil leak occurred. The crew elected to divert to the nearest airport when oil spread onto the windshield. The crew lost all visual contact with the ground and attempted an emergency landing when the aircraft impacted a tree with its left wing and crashed in a field. All three occupants evacuated uninjured and the aircraft was damaged beyond repair.

The four engine aircraft departed Hmeimim AFB located southeast of Latakia at 2031LT on a maritime patrol and reconnaissance mission over the Mediterranean Sea. About an one hour and a half later, while returning to its base, the airplane was hit by a S-200 surface-to-air missile shot by the Syrian ground forces. At the time of the accident, four Israel F-16 fighters were involved in a ground attack onto several infrastructures located in the region of Latakia. Out of control, the airplane crashed into the Mediterranean Sea some 35 km west of Latakia. The following morning, Russian Authorities confirmed the loss of the aircraft that was inadvertently shot down by the Syrian Army forces and that all 15 crew members were killed.

The pilot departed Florianópolis-Hercílio Luz Airport at 1100LT on a flight to Chapecó. Following an uneventful flight, the pilot initiated the descent to Chapecó-Serafim Enoss Bertasco Airport but encountered marginal weather conditions with limited visibility. While descending under VFR mode, the aircraft collided with trees and crashed in a dense wooded area located in Ipumirim, some 50 km east of Chapecó Airport, bursting into flames. The aircraft was destroyed by impact forces and a post crash fire and the pilot, sole occupant, was killed.

Owned by a construction company and registered under Vancon Holdings LLC (VanCon Inc.), the aircraft was parked at Spanish Fork-Springville Airport when it was stolen at night by a private pilot. After takeoff, hew flew southbound to Payson, reduced his altitude and voluntarily crashed the plane onto his house located in Payson. The airplane disintegrated on impact and was destroyed by impact forces and a post crash fire. The pilot was killed. His wife and daughter who were in the house at the time of the accident were uninjured despite the house was also destroyed by fire. Local Police declared that the pilot intentionally flew the airplane into his own home hours after being booked for domestic assault charges. An examination of the airplane found no anomalies with the flight controls that would have contributed to the accident. Toxicology testing revealed the presence of a medication used to treat depression, obsessive-compulsive disorder, some eating disorders, and panic attacks; the pilot did not report the use of this medication to the Federal Aviation Administration. The pilot had a known history of depression, anxiety, and anger management issues. The circumstances of the accident were consistent with the pilot's intentional flight into his home.

On August 10, 2018, about 2043 Pacific daylight time, a De Havilland DHC-8-402, N449QX, was destroyed when it impacted trees on Ketron Island, near Steilacoom, WA. The noncertificated pilot was fatally injured. The airplane was registered to Horizon Air Industries, Inc,. and was being operated by the noncertificated pilot as an unauthorized flight. Visual meteorological conditions prevailed in the area at the time of the event, and no flight plan was filed. The airplane departed from the Seattle-Tacoma International Airport, Seattle, Washington, about 1932. Horizon Air personnel reported that the noncertificated pilot was employed as a ground service agent and had access to the airplanes on the ramp. The investigation of this event is being conducted under the jurisdiction of the Federal Bureau of Investigation (FBI). The NTSB provided requested technical assistance to the FBI, and any material generated by the NTSB is under the control of the FBI. The NTSB does not plan to issue an investigative report or open a public docket.

The commercial pilot was conducting a 1-hour commercial air tour flight over Denali National Park and Preserve with four passengers on board. About 48 minutes after departure, the Alaska Rescue Coordination Center received an alert from the airplane's emergency locator transmitter. About 7 minutes later, company personnel received a call from the pilot, who reported that the airplane had run "into the side of a mountain." Although a search was initiated almost immediately, due to poor weather conditions in the area, the wreckage was not located until almost 36 hours later in a crevasse on a glacier about 10,920 ft mean sea level. Due to the unique challenges posed by the steepness of terrain, the crevasse, avalanche hazard, and the condition of the airplane, neither the occupants nor the wreckage were recovered from the accident site. A weather model sounding for the area of the accident site estimated broken cloud bases at 700 ft above ground level (agl) with overcast clouds at 1,000 ft agl and cloud tops to 21,000 ft agl and higher clouds above. The freezing level was at 9,866 ft and supported light-to-moderate rime type icing in clouds and precipitation. The on-scene assessment indicated that the right wing impacted snow while the airplane was flying in a wings-level attitude; the right wing had separated from the remainder of the wreckage. Based upon available weather data and forecast models and the impact evidence, it is likely that the pilot entered an area of reduced visibility and was unable to see the terrain before the airplane's right wing impacted the snow. The company's organizational structure was such that one group of management personnel oversaw operations in both Anchorage and Talkeetna. Interviews with company management revealed that they were not always aware of the exact routing a pilot would take for a tour; the route was pilot's discretion based upon the weather at the time of the flight to provide the best tour experience. Regarding risk mitigation, the company did not utilize a formal risk assessment process, but rather relied on conversations between pilots and flight followers. This could lead to an oversight of actual risk associated with a particular flight route and weather conditions. About 8 months after the accident, an assessment flight conducted by the National Park Service determined that during the winter, the hazardous hanging glacier at the accident site calved, releasing an estimated 4,000 to 6,000 tons of ice and debris. There was no evidence of the airplane wreckage near the crash site, in the steep fall line, or on the glacier surface over 3,600 ft below. Although the known circumstances of the accident are consistent with a controlled flight into terrain event, the factual information available was limited because the wreckage was not recovered and no autopsy or toxicology of the pilot could be performed; therefore, whether other circumstances may have contributed to the accident could not be determined.

At 16:14 on 4 August 2018, the historic Junkers Ju 52/3m g4e commercial aircraft, registered as HB-HOT and operated by Ju-Air, took off from Locarno Aerodrome (LSZL) for a commercial VFR flight to Dübendorf (LSMD). On this flight, pilot A was sitting in the left-hand seat in the cockpit and piloting the aircraft as the commander, while pilot B was assisting him as the co-pilot sitting on the right. Following take-off from concrete runway 26R westwards and a 180-degree turn over Lake Maggiore, the flight led into the Blenio valley via Bellinzona and Biasca. HB-HOT steadily gained altitude in the process. North of Olivone, the aircraft turned into the valley of the Lago di Luzzone reservoir and thus into the Adula/Greina/Medels/Vals countryside preservation quiet zone. This zone was crossed at between 120 and 300 m above ground and at times with a minimal lateral separation from the terrain. At 16:45, as the aircraft was flying over Alp Nadels, the ISP sent a text message to a friend in Ruschein (municipality of Ilanz) to say that the Ju 52 was approaching the area. The flight subsequently continued eastwards into the Surselva region at approximately 2,500 m AMSL. At 16:51, the aircraft crossed the Vorderrhein valley in the region of Ilanz on a north-easterly heading and initially made a relatively tight left turn, taking it over Ruschein. The flight path then led generally northwards past the Crap Sogn Gion mountain and towards the basin south-west of Piz Segnas. At first, the aircraft approached this basin on the left-hand, western side of the valley. HB-HOT was climbing at this time, and reached an altitude of 2,833 m AMSL in the Nagens region. The aircraft made a slight right turn when flying past the Berghaus Nagens lodge (see figure 2). During this phase, at 16:55, one of the pilots informed the passengers of the scenery over the speakers in the cabin and through the passengers’ personal headphones. To start with, the aircraft was flying at a ground speed of 165 km/h during this phase. By point F2, the ground speed had decreased to 135 km/h, and roughly remained so until shortly before point F3. Towards point F3, the aircraft’s altitude dropped slightly and the ground speed briefly increased by around 65 km/h to approximately 200 km/h. During this time, its pitch attitude3 was 5 to 7 degrees. Towards the end of this phase, just before point F4, the flight path angle4 changed from -3 degrees to approximately -1 degree and the speed of each of the three engines decreased steadily by approximately 20 revolutions per minute (rpm). At point F4, the aircraft was at an altitude of 2,742 m AMSL. At 16:56:02, shortly after point F4, the speed of each of the three engines increased by approximately 40 rpm. At 16:56:09, HB-HOT entered the basin southwest of Piz Segnas at an altitude of 2,755 m AMSL (point F5, see also figure 14) and was therefore approximately 130 m above the elevation of the Segnes pass. The flight crew then navigated the aircraft on a north-north-easterly heading almost in the centre of the valley. HB-HOT climbed slightly during this phase and its flight path angle was approximately 2 degrees; its pitch angle remained at 5 to 7 degrees. At 16:56:17, the aircraft reached an altitude of 2,767 m AMSL at point F7 and was therefore approximately 140 m above the elevation of the Segnes pass. HB-HOT flew past the Tschingelhörner mountain peaks and began to reduce in altitude, dropping more than 15 m in approximately 6 seconds. During this phase, the power of the engines was rapidly reduced by 30 to 50 rpm, which meant that the engines were increasingly running at a similar speed5 . During this process, the pitch angle increased and the flight path angle continuously became more negative. When the aircraft was approximately abeam the Martinsloch and at an altitude of approximately 2,766 m AMSL (point F8), the flight crew initiated a right turn during their descent and then made a left turn (point F109, see figure 5). The ground speed was approximately 170 km/h and the difference between the aircraft’s pitch and flight path angles increased to approximately 15 degrees during the right turn. When transitioning into the left turn (between points F9 and F10), the pitch angle was approximately 11 degrees and the flight path angle was around -10 degrees. At this time, the aircraft was flying at approximately 125 m above the elevation of the Segnes pass (see figure 3). During roughly the next 4 seconds, the aircraft descended by 25 m and the already negative flight path angle became even more negative, which is clearly apparent when comparing figures 3 and 4 as well as in figure 5. After point F13, the roll to the left increased steadily and did not decrease even when a significant aileron deflection to the right was made. The ailerons were then brought into a neutral position and temporarily deflected into a position for a left turn. At the same time, the pitch attitude began to decrease and the flight path ran increasingly steeper downwards whilst the left bank attitude constantly increased (see figure 6). During this last flight phase, the aircraft experienced low-frequency vibrations. Ultimately, when the aircraft was 108 m above ground (point F16, see figures 6 and 7), its longitudinal axis was pointing downwards by 68 degrees from horizontal. By this time, the elevator had deflected upwards by approximately 13 degrees and the rudder was pointing 2 degrees to the right. The speeds of the three engines had increased slightly compared to the beginning of the downward spiral trajectory and were between 1,720 and 1,750 rpm shortly before impact. The roll to the left accelerated significantly during this phase. Shortly after 16:57, the aircraft hit the ground in a vertical flight attitude with an almost vertical flight path and at a speed of approximately 200 km/h (see figure 8). All 20 people on board the aircraft lost their lives in the accident. The aircraft was destroyed. Fire did not break out. Reconstructions revealed that, at the time of the accident, HB-HOT’s centre of gravity was at 2.071 m behind the wing’s leading edge (see annex A1.6). In the images and video footage available that had been captured from inside HB-HOT, there was no evidence of anyone moving within the aircraft or not sitting in their seat between the period when the aeroplane entered the basin south-west of Piz Segnas and up to the beginning of its downward spiral trajectory. A detailed description of the reconstruction of the flight path and an illustration of the relevant parameters between position F1 and the site of the accident can be found in section 1.11.2. More information regarding the background and history of the flight can be found in annex A1.1.

On 01 August 2018, after completing 2 hours of survey work near Penticton, British Columbia (BC), an Aries Aviation International Piper PA-31 aircraft (registration C-FNCI, serial number 31-8112007) proceeded on an instrument flight rules flight plan from Penticton Airport (CYYF), BC, to Calgary/Springbank Airport (CYBW), Alberta, at 15 000 feet above sea level. The pilot and a survey technician were on board. When the aircraft was approximately 40 nautical miles southwest of CYBW, air traffic control began sequencing the aircraft for arrival into the Calgary airspace and requested that the pilot slow the aircraft to 150 knots indicated airspeed and descend to 13 000 feet above sea level. At this time, the right engine began operating at a lower power setting than the left engine. About 90 seconds later, at approximately 13 500 feet above sea level, the aircraft departed controlled flight. It collided with terrain near the summit of Mount Rae at 1336 Mountain Daylight Time. A brief impact explosion and fire occurred during the collision with terrain. The pilot and survey technician both received fatal injuries. The Canadian Mission Control Centre received a 406 MHz emergency locator transmitter signal from the occurrence aircraft and notified the Trenton Joint Rescue Coordination Centre. Search and rescue arrived on site approximately 1 hour after the accident.

The crew was completing a positioning flight from Kiev to Khartoum with an intermediate stop in El Alamein, Egypt. While cruising by night, the crew informed ATC that he was short of fuel and attempted an emergency landing in a desert area located about 50 km east of El Alamein Airport. The aircraft belly landed, slid for few dozen metres and came to rest, broken in two. There was no fire. All six crew members escaped uninjured while the aircraft was damaged beyond repair. It is reported that the crew was forced to make an emergency landing due to fuel shortage, probably caused by strong headwinds all along the flight.

The airline transport pilot was conducting a commercial visual flight rules (VFR) flight transporting 10 passengers from a remote fishing lodge. According to the pilot, while in level cruise flight about 1,100 ft mean sea level (msl) and as the flight progressed into a mountain pass, visibility decreased rapidly. In an attempt to turn around and return to VFR conditions, the pilot initiated a climbing right turn. Before completing the 180° right turn, he saw what he believed to be a body of water and became momentarily disoriented, so he leveled the wings. Shortly thereafter, he realized that the airplane was approaching an area of snow-covered mountainous terrain, so he applied full power and initiated a steep climb; the airspeed decayed, and the airplane collided with an area of rocky, rising terrain, which resulted in substantial damage to the wings and fuselage. The pilot reported no mechanical malfunctions or anomalies that would have precluded normal operation, and the examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The weather forecast at the accident time included scattered clouds at 2,500 ft msl, overcast clouds at 5,000 ft msl with cloud tops to 14,000 ft and clouds layered above that to flight level 250, and isolated broken clouds at 2,500 ft with light rain. AIRMET advisory SIERRA for "mountains obscured in clouds/precipitation" was valid at the time of the accident. Conditions were expected to deteriorate. Passenger interviews revealed that through the course of the flight, the airplane was operating in marginal visual meteorological conditions and occasional instrument meteorological conditions (IMC) with areas of precipitation, reduced visibility, obscuration, and, at times, little to no forward visibility. Thus, based on weather reports and forecasts, and the pilot's and passengers' statements, it is likely that the flight encountered IMC as it approached mountainous terrain and that the pilot then lost situational awareness. The airplane was equipped with a terrain awareness and warning system (TAWS); however, the alerts were inhibited at the time of the accident. Although the TAWS was required to be installed per Federal Aviation Administration (FAA) regulations, there is no requirement for it to be used. All company pilots interviewed stated that the TAWS inhibit switch remained in the inhibit position unless a controlled flight into terrain (CFIT) escape maneuver was being accomplished. However, the check airman who last administered the accident pilot's competency check stated that the TAWS inhibit switch was never moved, even during a CFIT escape maneuver. The unwritten company policy to leave the TAWS in the inhibit mode and the failure of the pilot to move the TAWS out of the inhibit mode when weather conditions began to deteriorate were inconsistent with the goal of providing the highest level of safety. However, if the pilot had been using TAWS, due to the fact that he was operating at a lower altitude and thus would have likely received numerous nuisance alerts, the investigation could not determine the extent to which TAWS would have impacted the pilot's actions. At the time of the accident, the director of operations (DO) for the company resided in another city and served as DO for another air carrier as well. He traveled to the company's main base of operation about once per month but was available via telephone. According to the chief pilot, he had assumed a large percentage of the DO's duties. The president of the company said that the chief pilot had taken over "officer of the deck" and "we're just basically using him [the DO] for his recordkeeping." The FAA was aware that the company's DO was also DO for another commuter operation. FAA Flight Standards District Office management and principal operations inspectors allowed him to continue to hold those positions, although it was contrary to the guidance provided in FAA Order 8900.1. The company's General Operations Manual (GOM) only listed the DO, the chief pilot, and the president by name as having the authority to exercise operational control. However, numerous company personnel stated that operational control could be and was routinely delegated to senior pilots. The GOM stated that the DO "routinely" delegated the duty of operational control to flight coordinators, but the flight coordinator on duty at the time of the accident stated that she did not have operational control. In addition, the investigation revealed numerous inadequate and missing operational control procedures and processes in company manuals and operations specifications. Based on the FAA's inappropriate approval of the DO, the insufficient company onsite management, the inadequate operational control procedures, and the exercise of operational control by unapproved persons likely resulted in a lack of oversight of flight operations, inattentive and distracted management personnel, and a loss of operational control within the air carrier. However, the investigation could not determine the extent to which any changes to operational control, company management, and FAA oversight would have influenced the pilot's decision to continue the VFR flight into IMC.