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:

Crash of a Cessna 208B Grand Caravan in Empakaai Camp: 11 killed

Date & Time: Nov 15, 2017 at 1113 LT
Type of aircraft:
Operator:
Registration:
5H-EGG
Flight Phase:
Survivors:
No
Site:
MSN:
208B-0476
YOM:
1995
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The single engine airplane departed Arusha Airport on a charter flight to the Serengeti National Park, carrying 10 tourists and one pilot. While flying in marginal weather conditions, the aircraft impacted hilly terrain near Empakaai Camp and was destroyed upon impact. All 11 occupants were killed.
Probable cause:
Controlled flight into terrain.

Crash of a Beechcraft B200C Super King Air in Nuevo Saposoa

Date & Time: Oct 19, 2017 at 1149 LT
Operator:
Registration:
OB-2077-P
Flight Phase:
Survivors:
Yes
Schedule:
Contamana – Pucallpa
MSN:
BL-5
YOM:
1980
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17659
Copilot / Total flying hours:
334
Copilot / Total hours on type:
131
Aircraft flight hours:
12334
Aircraft flight cycles:
9666
Circumstances:
The twin engine aircraft departed Contamana Airport at 1128LT on a charter flight to Pucallpa, carrying 11 passengers and two pilots. Few minutes after takeoff, while climbing to an altitude of 4,500 feet, the right engine lost power and failed. The crerw decided to return to Contamana but was able to transfer fuel from the left tank to the right tank to restart the right engine. Decision was taken to continue to Pucallpa at an altitude of 13,500 feet. At a distance of 42 km from Pucallpa, the crew started the descent when the right engine failed again, followed shortly later by the left engine. The captain declared an emergency and attempted an emergency landing when the aircraft crashed in a wooded area. All 13 occupants were injured and the aircraft was destroyed.
Probable cause:
Double engine failure in flight due to fuel starvation, forcing the crew to attempt an emergency landing in trees.
The following contributing factors were identified:
- Recurrent failures on the ground and in flight of the aircraft fuel quantity indicators, a situation that was maintained because the Maintenance Programme did not include an inspection and calibration of the fuel quantity gauges.
- Initiating the flight with a fuel indication system inoperative.
- Complacency on part of the crew who decided to continue the flight by having an aerodrome nearby after the first engine failure.
Final Report:

Crash of an Embraer EMB-120RT Brasília near Cuilo: 7 killed

Date & Time: Oct 12, 2017 at 1715 LT
Type of aircraft:
Operator:
Registration:
D2-FDO
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Dundo – Luanda
MSN:
120-082
YOM:
1988
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The twin engine aircraft departed Dundo Airport at 1658LT on an ambulance flight to Luanda, carrying three doctors, one patient from South Africa and three crew members. About 15 minutes into the flight, the crew reported engine problems when one of them caught fire shortly later. The airplane went out of control and crashed in an open field located near Cuilo, about 170 km southwest of Dundo. All seven occupants were killed.

Crash of a PZL-Mielec AN-28 in Mezhdurechenskoye: 5 killed

Date & Time: Oct 4, 2017 at 1853 LT
Type of aircraft:
Operator:
Registration:
UP-A2807
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Almaty - Shymkent
MSN:
1AJ007-14
YOM:
1990
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
12000
Captain / Total hours on type:
2930.00
Copilot / Total flying hours:
486
Copilot / Total hours on type:
110
Aircraft flight hours:
3631
Aircraft flight cycles:
3197
Circumstances:
The twine engine airplane departed Almaty Airport at 1835LT on an ambulance flight to Shymkent, carrying two doctors, two pilots and one flight mechanic. About 22 minutes into the flight, while cruising by night and poor weather conditions, the crew encountered an unexpected situation and was forced to shut down the right engine. Shortly later, the aircraft crashed near the village of Mezhdurechenskoye, some 28 km northwest of Almaty Airport, bursting into flames. The aircraft was totally destroyed by impact forces and a post crash fire and all five occupants were killed.
Probable cause:
The probable cause of the accident was the shut down of the right engine and then the left engine, possibly due to a faulty shut down on part of the crew. In the course of the subsequent emergency descent due to complete loss of power of the engines with no radio communication with air traffic controllers, as well as possibly due to the resulting confusion and nervousness, the crew unintentionally forgot to switch the pressure value on the mechanical barometric altimeter of the aircraft to the pressure on the landing airfield (704 mm Hg), leaving the pressure value of 760 mm Hg, which led to incorrect readings of true altitude of the flight. Subsequently, the crew was able to start the engines and attempt to make a forced landing at a distance of 28 km from the airfield of Almaty at night in poor weather conditions in an unlit area. Incorrect readings on the barometric altimeter of the true flight altitude (the radio altimeter showed 750 m) resulted in the aircraft colliding with a power line, causing a fire, as well as colliding with the ground, as a result of which the aircraft structure completely collapsed and burned down.
Final Report:

Crash of a Cessna 401B in Salters: 2 killed

Date & Time: Oct 4, 2017 at 1745 LT
Type of aircraft:
Registration:
N401HH
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Salters - Salters
MSN:
401B-0004
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
15000
Aircraft flight hours:
5557
Circumstances:
The commercial pilot and passenger departed on a local flight in the twin-engine airplane. According to a witness, the pilot took off from the private grass runway and departed the area for about 10 minutes. The airplane then returned to the airport, where the pilot performed a low pass over the runway and entered a steep climb followed by a roll. The airplane entered a nose-low descent, then briefly leveled off in an upright attitude before disappearing behind trees and subsequently impacting terrain. The pilot's toxicology testing was positive for ethanol with 0.185 gm/dl and 0.210 gm/dl in urine and cavity blood samples, respectively. The effects of ethanol are generally well understood; it significantly impairs pilot performance, even at very low levels. Federal Aviation Administration regulations prohibit any person from acting or attempting to act as a crewmember of a civil aircraft while having 0.040 gm/dl or more ethanol in the blood. While the identified ethanol may have come from sources other than ingestion, such as postmortem production, the possibility that the source of some of the ethanol was from ingestion and that pilot was impaired by the effects of ethanol during the accident flight could not be ruled out. Toxicology also identified a significant amount of diphenhydramine in cavity blood (0.122 µg/ml, which is within or above the therapeutic range of 0.0250 to 0.1120 µg/ml; diphenhydramine undergoes postmortem redistribution, and central postmortem levels may be about two to three times higher than peripheral or antemortem levels.). Diphenhydramine is a sedating antihistamine that causes more sedation than other antihistamines; this is the rationale for its use as a sleep aid. In a driving simulator study, a single dose of diphenhydramine impaired driving ability more than a blood alcohol concentration of 0.100%. The pilot had been diagnosed with memory loss about 8 months before the accident. It appears that he had some degree of mild cognitive impairment, but whether his cognitive impairment was severe enough to have contributed to the accident could not be determined from the available evidence. However, it is likely that the pilot's mild cognitive impairment combined with the psychoactive effects of diphenhydramine and possibly ethanol would have further decreased his cognitive functioning and contributed to his decision to attempt an aerobatic maneuver at low altitude in a non-aerobatic airplane.
Probable cause:
The pilot's decision to attempt a low-altitude aerobatic maneuver in a non-aerobatic airplane, and his subsequent failure to maintain control of the airplane during the maneuver.
Contributing to the accident was the pilot's impairment by the effects of diphenhydramine use, and his underlying mild cognitive impairment.
Final Report:

Crash of an Antonov AN-12B near Kinshasa: 12 killed

Date & Time: Sep 30, 2017 at 0730 LT
Type of aircraft:
Operator:
Registration:
EX-001
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kinshasa – Bukavu
MSN:
5 3 436 06
YOM:
1965
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
12
Circumstances:
The four engine aircraft departed Kinshasa-N'Djili Airport on a flight to Bukavu, carrying ammunition and two vehicles. Few minutes after takeoff, the crew reported technical problems and was cleared for an immediate return. Shortly later, the aircraft entered an uncontrolled descent and crashed in a prairie located in Nsele, about 20 km northeast of the airport, bursting into flames. The aircraft was destroyed and all 12 occupants were killed.

Crash of a Cessna 421B Golden Eagle II in Noviny pod Ralskem: 2 killed

Date & Time: Sep 26, 2017 at 0736 LT
Operator:
Registration:
OK-TKF
Flight Phase:
Survivors:
No
Schedule:
Příbram – Gdansk
MSN:
421B-0931
YOM:
1975
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
675
Captain / Total hours on type:
47.00
Aircraft flight hours:
6381
Aircraft flight cycles:
6797
Circumstances:
The twin engine airplane departed Příbram Airport Runway 06 at 0705LT on a charter flight to Gdansk, carrying one passenger and one pilot. About 30 minutes into the flight, while cruising at an altitude of 14,100 feet, the pilot was cleared to climb to FL180 when he declared an emergency and reported the failure of both engines. The aircraft entered an uncontrolled descent and crashed in a wooded area located 1,5 km northeast of Noviny pod Ralskem, bursting into flames. The aircraft was destroyed by impact forces and a post crash fire and both occupants were killed.
Probable cause:
The cause of the accident was an inner mechanical defect in the left engine past its stipulated TSO. The defect caused a forced stall of the engine. For this reason, the propeller on this engine could not be feathered. During the shutdown of the right engine, the feathering of the propeller on this engine did not take place. The aircraft entered to the fall and a stall-spin in which it fell to the ground.
Contributing factors:
- The left engine TSO was over the stipulated limit of 12 years. (The last general overhaul was performed on 29 October 2001.),
- Limited experience of the pilot on this type of aircraft.
Final Report: