Crash of a Cessna 525 CJ1 in Crozet: 1 killed

Date & Time: Apr 15, 2018 at 2054 LT
Type of aircraft:
Registration:
N525P
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Rchmond - Weyers Cave
MSN:
525-0165
YOM:
1996
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
737
Captain / Total hours on type:
165.00
Aircraft flight hours:
3311
Circumstances:
The instrument rated private pilot was drinking alcohol before he arrived at the airport. Before the flight, he did not obtain a weather briefing or file an instrument flight rules flight plan for the flight that was conducted in instrument meteorological conditions. The pilot performed a 3-minute preflight inspection of the airplane and departed with a tailwind (even though he had initially taxied the airplane to the runway that favored the wind) and without communicating on the airport Unicom frequency. After departure, the airplane climbed to a maximum altitude of 11,500 feet mean sea level (msl), and then the airplane descended to 4,300 ft msl (which was 1,400 ft below the minimum safe altitude for the destination airport) and remained at that altitude for 9 minutes. Afterward, the airplane began a descending left turn, and radar contact was lost at 2054. The pilot did not talk to air traffic control during the flight and while operating in night instrument meteorological conditions. During the flight, the airplane flew through a line of severe thunderstorms with heavy rain, tornados, hail, and multiple lightning strikes. Before the airplane's descending left turn began, it encountered moderate-to-heavy rain. The airplane's high descent rate of at least 6,000 ft per minute and impact with a mountain that was about 450 ft from the last radar return, the damage to the airplane, and the distribution of the wreckage were consistent with a loss of control and a high-velocity impact. Examination of the airplane revealed no evidence of any preimpact mechanical anomalies. Based on the reported weather conditions at the time the flight, the pilot likely completed the entire flight in night instrument meteorological conditions. His decision to operate at night in an area with widespread thunderstorms and reduced visibility were conducive to the development of spatial disorientation. The airplane's descending left turn and its high-energy impact were consistent with the known effects of spatial disorientation. The pilot was not aware of the conditions near and at the destination airport because he failed to obtain a weather briefing and was not communicating with air traffic control. Also, the pilot's decision to operate an airplane within 8 hours of consuming alcohol was inconsistent with the Federal Aviation Administration's regulation prohibiting such operations, and the level of ethanol in the pilot's toxicology exceeded the level allowed by the regulation. Overall, the pilot's intoxication, combined with the impairing effects of cetirizine, affected his judgment; contributed to his unsafe decision-making; and increased his susceptibility to spatial disorientation, which resulted in the loss of control of the airplane.
Probable cause:
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's loss of control while operating in night instrument meteorological conditions as a result of spatial disorientation. Contributing to the accident was the pilot's decision to operate
an airplane after consuming alcohol and his resulting intoxication, which degraded the pilot's judgment and decision-making.
Final Report:

Crash of a Cessna 401 in Pelagiada

Date & Time: Apr 1, 2018 at 1415 LT
Type of aircraft:
Operator:
Registration:
RA-1272G
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Pelagiada - Pelagiada
MSN:
401-0112
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5672
Captain / Total hours on type:
150.00
Aircraft flight hours:
5100
Circumstances:
Few minutes after takeoff from Pelagiada, the pilot informed ATC about the failure of the right engine while the left engine lost power. The pilot completed an emergency belly landing in an open field located near Pelagiada, about 20 km north of Stavropol. The aircraft was damaged beyond repair and the pilot escaped uninjured.
Probable cause:
The failure of the right engine is most likely due to an interruption in the fuel supply due to the presence of dirt in the fuel filter. The left engine lost power presumably due to wear on the cylinders and pistons that had exceeded their life limit. A lack of an effective check of the fuel filters and the life of the various components of the left engines remains contributing factors.
Final Report:

Crash of a Canadair CL-600-2B16 Challenger 604 near Shahr-e-Kord: 11 killed

Date & Time: Mar 11, 2018 at 1840 LT
Type of aircraft:
Operator:
Registration:
TC-TRB
Flight Phase:
Survivors:
No
Site:
Schedule:
Sharjah – Istanbul
MSN:
5494
YOM:
2001
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
11
Captain / Total flying hours:
4880
Captain / Total hours on type:
1600.00
Copilot / Total flying hours:
1132
Copilot / Total hours on type:
114
Aircraft flight hours:
7935
Aircraft flight cycles:
3807
Circumstances:
A Turkish Challenger 604 corporate jet impacted a mountain near Shahr-e Kurd in Iran, killing all 11 on board. The aircraft departed Sharjah, UAE at 13:11 UTC on a flight to Istanbul, Turkey. The aircraft entered Tehran FIR fifteen minutes later and the Tehran ACC controller cleared the flight to climb to FL360 according to its flight plan. About 14:32, the pilot requested FL380, which was approved. Before reaching that altitude, the left and right airspeeds began to diverge by more than 10 knots. The left (captain's) airspeed indicator showed an increase while the right hand (copilot's) airspeed indicator showed a decrease. A caution aural alert notified the flight crew of the difference. Remarks by the flight crew suggested that an 'EFIS COMP MON' caution message appeared on the EICAS. As the aircraft was climbing, the crew reduced thrust to idle. Approximately 63 seconds later, while approaching FL380, the overspeed aural warning (clacker) began to sound, indicating that the indicated Mach had exceeded M 0.85. Based on the Quick Reference Handbook (QRH) of the aircraft, the pilot flying should validate the IAS based on the aircraft flight manual and define the reliable Air Data Computer (ADC) and select the reliable Air Data source. The pilot did not follow this procedure and directly reduced engine power to decrease the IAS after hearing the clacker. The actual airspeed thus reached a stall condition. The copilot tried to begin reading of the 'EFIS COMP MON' abnormal procedure for three times but due to pilot interruption, she could not complete it. Due to decreasing speed, the stall aural warning began to sound, in addition to stick shaker and stick pusher activating repeatedly. The crew then should have referred to another emergency procedure to recover from the stall condition. While the stick pusher acted to pitch down the aircraft to prevent a stall condition, the captain was mistakenly assumed an overspeed situation due to the previous erroneous overspeed warning and pulled on the control column. The aircraft entered a series of pitch and roll oscillations. The autopilot was disengaged by the crew before stall warning, which ended the oscillations. Engine power began to decrease on both sides until both engines flamed out in a stall condition. From that point on FDR data was lost because the electric bus did not continue to receive power from the engine generators. The CVR recording continued for a further approximately 1 minute and 20 seconds on emergency battery power. Stall warnings, stick shaker and stick pusher activations continued until the end of the recording. The aircraft then impacted mountainous terrain. Unstable weather conditions were present along the flight route over Iran, which included moderate up to severe turbulence and icing conditions up to 45000ft. These conditions could have caused ice crystals to block the left-hand pitot tube. It was also reported that the aircraft was parked at Sharjah Airport for three days in dusty weather condition. Initially the pitot covers had not been applied. The formation of dust inside the pitot tube was considered another possibility.
Probable cause:
The accident was caused by insufficient operational prerequisites for the management of erratic airspeed indication failure by the cockpit crew. The following contributing factors were identified:
- The aircraft designer/manufacturer provided insufficient technical and operational guidance about airspeed malfunctions that previously occurred.
- Lack of effective CRM.
Final Report:

Crash of a Beechcraft B60 Duke near Ferris

Date & Time: Mar 1, 2018 at 1100 LT
Type of aircraft:
Registration:
N77MM
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Addison – Mexia
MSN:
P-587
YOM:
1982
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6400
Captain / Total hours on type:
2200.00
Aircraft flight hours:
2210
Circumstances:
The pilot in the multi-engine, retractable landing gear airplane reported that, during an instrument flight rules cross-country flight, about 5,000 ft above mean sea level, the left engine surged several times and he performed an emergency engine shutdown. Shortly afterward, the right engine lost power. During the emergency descent, the airplane struck treetops, and landed hard in a field with the landing gear retracted. The airplane sustained substantial damage to both wings, the engine mounts, and the lower fuselage. The pilot reported that he had requested 200 gallons of fuel from his home airport fixed base operator, but they did not fuel the airplane. The pilot did not check the fuel quantity during his preflight inspection. According to the Federal Aviation Administration Airplane Flying Handbook, Chapter 2, page 2-7, pilots must always positively confirm the fuel quantity by visually inspecting the fuel level in each tank. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause:
The pilot's improper preflight inspection of the fuel level, which resulted in a loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot's failure to lower the landing gear before the emergency landing.
Final Report:

Crash of a Cessna 441 Conquest II in Rossville: 3 killed

Date & Time: Feb 22, 2018 at 1939 LT
Type of aircraft:
Operator:
Registration:
N771XW
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Eagle Creek Airpark - Green Bay
MSN:
441-0065
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2248
Captain / Total hours on type:
454.00
Aircraft flight hours:
6907
Circumstances:
The airline transport pilot and two passengers departed in the twin-engine, pressurized airplane on a business flight in night instrument meteorological conditions. Shortly after takeoff, the airplane began to deviate from its assigned altitude and course. The controller queried the pilot, who responded that the airplane was "… a little out of control." After regaining control of the airplane, the pilot reported that he had experienced a "trim issue." The airplane continued on course and, about 13 minutes later, the pilot again reported a trim malfunction and said that he was having difficulty controlling the airplane. The flight's heading and altitude began to deviate from the course for the last 8 minutes of radar data and became more erratic for the last 2 minutes of radar data; radar and radio communication were subsequently lost at an altitude of about 18,300 ft in the vicinity of the accident site. Several witnesses reported hearing the airplane flying overhead. They all described the airplane as being very loud and that the engine sound was continuous up until they heard the impact. The airplane impacted a field in a relatively level attitude at high speed. The wreckage was significantly fragmented and the wreckage path extended about 1/4 mile over several fields. Examination of the available airframe and engine components revealed no anomalies that would have precluded normal operation of the airplane. The accident airplane was equipped with elevator, rudder, and aileron trim systems; however, not all components of the trim system and avionics were located or in a condition allowing examination. Although the airplane was equipped with an electric elevator trim and autopilot that could both be turned off in an emergency, the investigation could not determine which trim system the pilot was reportedly experiencing difficulties with. It is likely that the pilot was unable to maintain control of the airplane as he attempted to address the trim issues that he reported to air traffic control.
Probable cause:
An in-flight loss of control for reasons that could not be determined based on the available evidence.
Final Report:

Crash of an ATR72-212 on Mt Dena: 66 killed

Date & Time: Feb 18, 2018 at 0931 LT
Type of aircraft:
Operator:
Registration:
EP-ATS
Flight Phase:
Survivors:
No
Site:
Schedule:
Tehran – Yasuj
MSN:
391
YOM:
1993
Flight number:
EP3704
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
60
Pax fatalities:
Other fatalities:
Total fatalities:
66
Captain / Total flying hours:
17926
Captain / Total hours on type:
12519.00
Copilot / Total flying hours:
1880
Copilot / Total hours on type:
197
Aircraft flight hours:
28857
Aircraft flight cycles:
28497
Circumstances:
Iranian ATR72 aircraft registered EP-ATS operated by Iran Aseman Airlines was assigned to perform a domestic scheduled passenger flight from Tehran to Yasuj on 07:55 local time. The aircraft took off from Tehran Mehrabad International Airport (0III) at 04:35 UTC. (08:05 LMT) and the flight was the first flight of the day for aircraft and the crew. The cruise flight was conducted at FL210 on airway W144 and no abnormal situation was reported by the crew and the flight was continued on Tehran ACC frequency till the time the first officer requested latest weather information of the destination by contact to Yasuj tower then requested to leave FL210 to FL170 from Tehran ACC. When the aircraft was descending to FL170 and crew calling YSJ tower the aircraft descending was continued to altitude of 15000 ft. The aircraft was approved to join overhead of the airport and perform “circling NDB approach “to land on RWY 31 at the destination aerodrome. Finally the aircraft collided with a peak lee of DENA Mountains about 8.5 miles at North far from the airport and involved accident on 06:01 UTC. The aircraft was completely destroyed as a result of collision with the mountain at the altitude of approximately 13,300 ft.
Probable cause:
The accident was happened due to many chains of considered causes but the “Human Factor” had main roll for the conclusion of the scenario. The Cockpit Crew action which has caused dangerous conditions for the flight is considered as main cause. Based on provided evidences, the errors of cockpit crew were as follows:
- Continuing to the Yasouj airport for landing against Operation manual of the Company, due to low altitude ceiling of the cloud and related cloud mass. They should divert to alternate airport,
- Descending to unauthorized altitude below minimum of the route and MSA,
- Lack of enough CRM during flight,
- Failure to complete the stall recovery (flap setting, max RPM),
- Inappropriate use of Autopilot after Stall condition,
- Inadequate anticipation for bad weather based on OM (Clouds, Turbulence, and Icing ...),
- Quick action to switch off anti-ice system and AOA,
- Failure to follow the Check lists and standard call out by both pilots.
Contributing Factors:
The contributive factors to this accident include but are not limited to the following:
- The airline was not capable to detect systematic defectives about :
- Effectiveness of crew training about Meteorology, OM, SOP,
- Enough operational supervision on pilot behaviors,
- The lack of SIGMET about Mountain Wave or Severe Mountain wave,
- Unclear procedure for stall recovery in FCOM,
- Lack of warning in aircraft manuals by manufacturer for flight crew awareness about mountain wave.
- Lack of APM System to alert crew about performance degradation.
Other Deficiencies and Short Comes:
In the process of the accident investigation, some detailed deficiencies and short comes were found and should be considered as latent conditions by related authorities:
- AD accomplishment and related monitoring,
- Sanction on aviation industries and effect on Flight safety,
- Non-standard communication between ATC and crew,
- Unclear definition of the Fully Qualified Pilot and qualified copilot in Aircrew regulation.
- Weather forecast (TAF) in the airports based on annex 3 procedure in the Civil Aviation Organization for approving alternative method of compliance for aircraft AD,s
- Search and rescue Coordination with local authorities for aviation accidents,
- Time setting of aircraft flight data recording(FDR) either by technician or pilots.
Final Report:

Crash of a Shaanxi Y-8GX-3 near Zhengchang: 12 killed

Date & Time: Jan 29, 2018
Type of aircraft:
Operator:
Registration:
30513
Flight Phase:
Flight Type:
Survivors:
No
Site:
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
12
Circumstances:
While completing a training mission, the airplane crashed in unknown circumstances near the Zhengchang village, in the Guizhou Province. The PLA Air Force Y-8GX4 Electronic Intelligence (ELINT) aircraft, registered 30513, was assigned to the PLAAF 20th Special Missions Division. The Y-8G fleet of the division is reportedly based close to the crash site. The airplane was totally destroyed by impact forces and a post crash fire and all 12 occupants were killed.

Crash of a Casa-Nurtanio CN-235M-100 near Yalvaç: 3 killed

Date & Time: Jan 17, 2018 at 1250 LT
Operator:
Registration:
98-148
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Eskişehir - Eskişehir
MSN:
C-148
YOM:
1998
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine aircraft departed Eskişehir Airport at 1103LT on a training flight, carrying one technician and two pilots. While flying in good weather conditions, the airplane struck the top of a snow covered mountain located in the region of Yalvaç, some 80 km northeast of Isparta. The wreckage was found at 1430LT. All three crew members were killed.

Crash of a De Havilland DHC-2 Beaver off Cottage Point: 6 killed

Date & Time: Dec 31, 2017 at 1515 LT
Type of aircraft:
Operator:
Registration:
VH-NOO
Flight Phase:
Survivors:
No
Schedule:
Cottage Point - Sydney
MSN:
1535
YOM:
1963
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
10762
Aircraft flight hours:
21872
Circumstances:
On 31 December 2017, at about 1045 Eastern Daylight-saving Time, five passengers arrived via water-taxi at the Sydney Seaplanes terminal, Rose Bay, New South Wales (NSW) for a charter fly-and-dine experience to a restaurant at Cottage Point on the Hawkesbury River. Cottage Point is about 26 km north of Sydney Harbour in the Ku-ring-gai Chase National Park, a 20 minute floatplane flight from Rose Bay. At about 1130, prior to boarding the aircraft, the passengers received a pre-flight safety briefing. At about 1135, the pilot and five passengers departed the Rose Bay terminal for the flight to Cottage Point via the northern beaches coastal route, in a de Havilland Canada DHC-2 Beaver floatplane, registered VH-NOO and operated by Sydney Seaplanes. The flight arrived at Cottage Point just before midday and the passengers disembarked. The pilot then conducted another four flights in VH-NOO between Cottage Point and Rose Bay. The pilot arrived at Cottage Point at about 1353. After securing the aircraft at the pontoon and disembarking passengers from that flight, the pilot walked to a kiosk at Cottage Point for a drink and food. At about 1415, the pilot received a phone call from the operator via the kiosk, asking the pilot to move the aircraft off the pontoon, which could only accommodate one aircraft at a time. This was to allow the pilot of the operator’s other DHC-2 aircraft (VH-AAM) to pick-up other restaurant passengers. The pilot of VH-NOO immediately returned to the aircraft and taxied away from the pontoon into Cowan Creek. The operator’s records indicated that VH-AAM arrived at the pontoon and shut down the engine at about 1419, and subsequently departed at about 1446. The pilot of VH-NOO returned to the pontoon after having taxied in Cowan Creek with the engine running for up to 27 minutes, while waiting for the other aircraft. During the taxi, closed-circuit television footage from a private residence at Cottage Point showed VH-NOO at 1444, with the pilot’s door ajar. After shutting down the aircraft, the pilot briefly went into the restaurant to see if the passengers were ready to leave, and then returned to the aircraft. The return flight to Rose Bay, scheduled to depart at 1500, provided sufficient time for the passengers to meet a previously booked water-taxi to transport them from Rose Bay to their hotel at 1545. At about 1457, the passengers commenced boarding the aircraft and at around 1504, the aircraft had commenced taxiing toward the designated take-off area in Cowan Creek. At about 1511, the aircraft took off towards the north-north-east in Cowan Creek, becoming airborne shortly before passing Cowan Point. The aircraft climbed straight ahead before commencing a right turn into Cowan Water. A witness, who was travelling east in a boat on the northern side of Cowan Water, photographed the aircraft passing over a location known as ‘Hole in the wall’. These photographs indicated that the aircraft was turning to the right with a bank angle of 15-20°. Witnesses observed the right turn continue above Little Shark Rock Point and Cowan Water. The last photograph taken by the passenger was when the aircraft was heading in a southerly direction towards Cowan Bay. At that time, the aircraft was estimated to be at an altitude of about 30 m (98 ft).Shortly after the turn in Cowan Water, several witnesses observed the aircraft heading directly towards and entering Jerusalem Bay flying level or slightly descending, below the height of the surrounding terrain. Witnesses also reported hearing the aircraft’s engine and stated that the sound was constant and appeared normal. About 1.1 km after entering Jerusalem Bay, near the entrance to Pinta Bay, multiple witnesses reported seeing the aircraft flying along the southern shoreline before it suddenly entered a steep right turn at low-level. Part-way through the turn, the aircraft’s nose suddenly dropped before the aircraft collided with the water, about 95 m from the northern shore and 1.2 km from the end of Jerusalem Bay. The aircraft came to rest inverted and with the cabin submerged. A number of people on watercraft who heard or observed the impact, responded to render assistance. Those people could not access the (underwater) aircraft cabin. The entire tail section and parts of both floats were initially above the waterline, but about 10 minutes later had completely submerged. The pilot and five passengers received fatal injuries.
Probable cause:
Contributing factors:
- The aircraft entered Jerusalem Bay, a known confined area, below terrain height with a level or slightly descending flight path. There was no known operational need for the aircraft to be
operating in the bay.
- While conducting a steep turn in Jerusalem Bay, it was likely that the aircraft aerodynamically stalled at an altitude too low to effect a recovery before colliding with the water.
- It was almost certain that there was elevated levels of carbon monoxide in the aircraft cabin, which resulted in the pilot and passengers having higher than normal levels of carboxyhaemoglobin in their blood.
- Several pre-existing cracks in the exhaust collector ring, very likely released exhaust gas into the engine/accessory bay, which then very likely entered the cabin through holes in the main
firewall where three bolts were missing.
- A 27 minute taxi before the passengers boarded, with the pilot’s door ajar likely exacerbated the pilot’s elevated carboxyhaemoglobin level.
- It was likely that the pilot's ability to safely operate the aircraft was significantly degraded by carbon monoxide exposure.
- Disposable chemical spot detectors, commonly used in general aviation, can be unreliable at detecting carbon monoxide in the aircraft cabin. Further, they do not draw a pilot's attention to a hazardous condition, instead they rely on the pilot noticing the changing colour of the sensor.
- There was no regulatory requirement from the Civil Aviation Safety Authority for piston-engine aircraft to carry a carbon monoxide detector with an active warning to alert pilots to the presence of elevated levels of carbon monoxide in the cabin. (Safety issue)

Other factors that increased risk:
- It was likely that the effectiveness of the disposable carbon monoxide chemical spot detector fitted to the aircraft was reduced due to sun bleaching.
- Although detectors were not required to be fitted to their aircraft, Sydney Seaplanes had no mechanism for monitoring the serviceability of the carbon monoxide detectors. (Safety issue)
- The in situ bolts used by the maintenance organisation to secure the magneto access panels on the main firewall were worn, and were a combination of modified AN3-3A bolts and non-specific bolts. This increased the risk of the bolts either not tightening securely on installation and/or coming loose during operations.
- The operator relied on volunteered passenger weights without allowances for variability, rather than actual passenger weights obtained just prior to a flight. This increased the risk of underestimating passenger weights and potentially overloading an aircraft.
- The standard passenger weights specified in Civil Aviation Advisory Publication (CAAP) 235-1(1) Standard passenger and baggage weights did not accurately reflect the average weights of the current Australian population. Further, the CAAP did not provide guidance on the use of volunteered passenger weights as an alternative to weights derived just prior to a flight.
- Australian civil aviation regulations did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and other accidents, have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in the non-identification of safety issues, which continue to present a hazard to current and future passengercarrying operations. (Safety issue)
- Annex 6 to the Convention of International Civil Aviation did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and numerous other accidents have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in important safety issues not being identified, which may remain a hazard to current and future passenger carrying operations. (Safety issue)

Other findings:
- It was very likely that the middle row right passenger did not have his seatbelt fastened at the time of impact, however, the reason for this could not be determined.
- The accident was not survivable due to the combination of the impact forces and the submersion of the aircraft.
- The pilot had no known pre-existing medical conditions that could explain the accident.
Final Report:

Crash of a Britten-Norman BN-2A Islander in Saidor Gap: 1 killed

Date & Time: Dec 23, 2017 at 1010 LT
Type of aircraft:
Operator:
Registration:
P2-ISM
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Derim - Lae
MSN:
227
YOM:
1970
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1982
Captain / Total hours on type:
139.00
Aircraft flight hours:
32232
Circumstances:
On 23 December 2017, at 00:10 UTC (10:10 local), a Britten Norman BN-2A Islander aircraft, registered P2-ISM (ISM), owned and operated by North Coast Aviation, impacted a ridge, at about 9,500 ft (6°11'29"S, 146°46'11"E) that runs down towards the Sapmanga Valley from the Sarawaget Ranges, Morobe Province. The pilot elected to track across the Sarawaget ranges (See figure 1), from Derim Airstrip to Nadzab Airport, Morobe Province, not above 10,000 ft. The track flown from Derim was to the northwest 6.5 nm (12 km) to a point 0.8 nm (1.5 km) westsouthwest of Yalumet Airstrip where the aircraft turned southwest to track to the Saidor Gap. GPS recorded track data immediately prior to the last GPS fix showed that the aircraft was on a shallow descent towards the ridge. The aircraft impacted the ridge about 150 m beyond the last fix. There were no reports of a transmission of an ELT distress signal. During the search for the aircraft, what appeared to be the right aileron was found hanging from a tree near the top of the heavily-timbered, densely-vegetated ridge. The remainder of the wreckage was found about 130 m from the aileron along the projected track. The aircraft impacted the ground in a steep nose-down, right wing-low attitude. The majority of the aircraft wreckage was contained at the ground impact point. The aircraft was destroyed by impact forces. The pilot, the sole occupant, who initially survived, was reported deceased by the rescue team on 27 December 2017 at 22:10. The pilot had made contact with one of the operator’s pilots at 16:15 on 23 December. The pilot’s time of death, recorded on the Death Certificate, was 10:40 am local on 24 December. Rescuers felled trees on the steep heavily timbered, densely vegetated slope about 20 metres from the wreckage and constructed a helipad.
Probable cause:
Cloud build up along the pilot’s chosen route may have forced him to manoeuvre closer than normal to the ridge, in order to avoid flying into the cloud. The aircraft’s right wing struck a tree protruding from the forest canopy during controlled flight into terrain. It is likely that the right aileron mass balance became snagged on the tree and rapidly dislodged the aileron from the wing. The loss of roll control, and the aerodynamic differential, forced the aircraft to descend steeply through the forest and impacted terrain.
Final Report: