Crash of a Beechcraft LR-2 Hayabusa near Assabu: 4 killed

Date & Time: May 15, 2017 at 1147 LT
Operator:
Registration:
23057
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Sapporo – Hakodate
MSN:
FL-677
YOM:
2009
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The Beechcraft LR-2 Hayabusa (a version of the Beechcraft 350 Super King Air) departed Sapporo-Okadama Airport at 1123LT on a flight to Hakodate to evacuate a patient. On board were two doctors and two pilots. While descending to Hakodate at an altitude of 3,000 feet, the crew encountered poor weather conditions with low clouds and rain showers when the airplane registered 23057 (JG-3057) impacted the slope of a mountain located near Assabu, about 40 km northwest of Hakodate Airport. The aircraft disintegrated on impact and all four occupants were killed.

Crash of a Piper PA-31-310 Navajo C near Colton: 1 killed

Date & Time: May 3, 2017 at 2030 LT
Type of aircraft:
Operator:
Registration:
C-GQAM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Quebec - Montreal
MSN:
31-7912093
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5250
Captain / Total hours on type:
1187.00
Circumstances:
The commercial pilot departed on a planned 1-hour cargo cross-country flight in the autopilot-equipped airplane. About 3 minutes after departure, the controller instructed the pilot to fly direct to the destination airport at 2,000 ft mean sea level (msl). The pilot acknowledged the clearance, and there were no further radio transmissions from the airplane. The airplane continued flying past the destination airport in straight-and-level flight at 2,100 ft msl, consistent with the airplane operating under autopilot control, until it was about 100 miles beyond the destination airport. A witness near the accident site watched the airplane fly over at a low altitude, heard three "pops" come from the airplane, and then saw it bank to the left and begin to descend. The airplane continued in the descending left turn until he lost sight of it as it dropped below the horizon. The airplane impacted trees in about a 45° left bank and a level pitch attitude and came to rest in a heavily wooded area. The airplane sustained extensive thermal damage from a postcrash fire; however, examination of the remaining portions of the airframe, flight controls, engines, and engine accessories revealed no evidence of preimpact failure or malfunction. The fuel selector valves were found on the outboard tanks, which was in accordance with the normal cruise procedures in the pilot's operating handbook. Calculations based on the airplane's flight records and the fuel consumption information in the engine manual indicated that, at departure, the outboard tanks of the airplane contained sufficient fuel for about 1 hour 10 minutes of flight. The airplane had been flying for about 1 hour 15 minutes when the accident occurred. Therefore, it is likely that the fuel in the outboard tanks was exhausted; without pilot action to switch fuel tanks, the engines lost power as a result of fuel starvation, and the airplane descended and impacted trees and terrain. The overflight of the intended destination and the subsequent loss of engine power due to fuel starvation are indicative of pilot incapacitation. The pilot's autopsy identified no significant natural disease:however, the examination was limited by the severity of damage to the body. Further, there are a number of conditions, including cardiac arrhythmias, seizures, or other causes of loss of consciousness, that could incapacitate a pilot and leave no evidence at autopsy. The pilot's toxicology results indicated that the pilot had used marijuana/tetrahydrocannabinol (THC) at some point before the accident. THC can impair judgment, but it does not cause incapacitation; therefore, the circumstances of this accident are not consistent with impairment from THC, and, the pilot's THC use likely did not contribute to this accident. The reason for the pilot's incapacitation could not be determined.
Probable cause:
The pilot's incapacitation for unknown reasons, which resulted in an overflight of his destination, a subsequent loss of engine power due to fuel starvation, and collision with terrain.
Final Report:

Crash of a Cessna 208B Grand Caravan near Chignik: 1 killed

Date & Time: May 1, 2017 at 1350 LT
Type of aircraft:
Operator:
Registration:
N803TH
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Port Heiden - Perryville
MSN:
208B-0321
YOM:
1992
Flight number:
GV341
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4989
Captain / Total hours on type:
904.00
Aircraft flight hours:
17990
Circumstances:
The airline transport pilot was conducting a commercial visual flight rules (VFR) flight. A passenger who was on the first segment stated that the pilot flew the airplane lower than usual for that route, and that the airplane flew through clouds during the flight. The passenger disembarked and the pilot departed on the second segment of the flight with a load of mail. The route included flight across a peninsula of mountainous terrain to a remote coastal airport that lacked official weather reporting or instrument approach procedures. About 28 minutes after departure, an emergency locator transmitter (ELT) signal from the airplane was received and a search and rescue operation was initiated. The wreckage was located about 24 miles from the destination in deep snow on the side of a steep, featureless mountain at an elevation about 3,000 ft mean sea level. The accident site displayed signatures consistent with impact during a left turn. Examination of the airplane revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation. The airplane was not equipped with any recording or flight tracking devices, nor was it required to be; therefore, the airplane's flight track before the accident could not be determined. The airplane was certified for instrument flight and flight in icing conditions and was equipped with a terrain avoidance warning system (TAWS) which was not inhibited during the accident. Although the TAWS should have provided the pilot with alerts as the airplane neared the terrain, it could not be determined if this occurred or if the pilot heeded the alerts. A review of nearby weather camera images revealed complete mountain obscuration conditions with likely rain shower activity in the vicinity of the accident site. Visible and infrared satellite imagery indicated overcast cloud cover over the accident site at the time of the accident. The graphical forecast products that were available to the pilot before the flight indicated marginal VFR conditions for the entire route. There was no evidence that the pilot obtained an official weather briefing, and what weather information he may have accessed before the flight could not be determined. Additionally, the cloud conditions and snow-covered terrain present in the area likely resulted in flat light conditions, which would have hindered the pilot's ability to perceive terrain features and closure rates. Based on the weather camera, surface, and upper air observations, it is likely that the pilot encountered instrument meteorological conditions inflight, after which he performed a left turn to return to visual meteorological conditions and did not recognize his proximity to the mountain due to the flat light conditions. The pilot and the dispatch agent signed a company flight risk assessment form before the flight, which showed that the weather conditions for the flight were within the company's acceptable risk parameters. Although the village agents at the departure and destination airports stated that the weather at those coastal locations was good, the weather assessment for the accident flight was based on hours-old observations provided by a village agent who was not trained in weather observation and did not include en route weather information, the area forecast, or the AIRMET for mountain obscuration effective during the dispatch time and at the time of the accident. Since acquiring the accident route from another operator years earlier, the company had not performed a risk assessment of the route and its associated hazards. Multiple company pilots described the accident route of flight as hazardous and considered it an undesirable route due to the terrain, rapidly changing weather, and lack of weather reporting infrastructure; however, the company did not address or attempt to mitigate these known hazards through its risk assessment processes. The company's controlled-flight-into-terrain (CFIT)-avoidance program stated that each pilot shall have one classroom training session and one CFIT-avoidance training session in an aviation training device (ATD) each year; however, the pilot's training records indicated that his most recent ATD session was 15 months prior. More recent CFIT avoidance training may have resulted in the pilot recognizing and responding to the reduced visibility and flat light conditions sooner.
Probable cause:
The pilot's continued visual flight rules flight into an area of mountainous terrain and instrument meteorological conditions, which resulted in controlled flight into terrain (CFIT). Contributing to the accident was the company's failure to provide the pilot with CFIT-avoidance recurrent simulator training as required by their CFIT avoidance program and the company's inadequate flight risk assessment processes, which did not account for the known weather hazards relevant to the accident route of flight.
Final Report:

Crash of an Antonov AN-26 near San Cristóbal: 8 killed

Date & Time: Apr 29, 2017
Type of aircraft:
Operator:
Registration:
CU-T1406
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Playa Baracoa - Playa Baracoa
MSN:
135 02
YOM:
1985
Flight number:
FAR1436
Country:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
The airplane departed Playa Baracoa Airport at 0638LT on a training flight and continued to the southwest. En route, it impacted the slope of Mt Loma de la Pimienta located about six km north of San Cristóbal, province of Artemisa. The aircraft was destroyed and all eight crew members were killed. Owned by Aerogaviota, the airplane was operated by the Cuban Air Force (Fuerzas Armadas Revolucionarias) under flight code FAR1436.

Crash of a Cessna 208 Caravan I near Oksibil: 1 killed

Date & Time: Apr 12, 2017 at 1240 LT
Type of aircraft:
Operator:
Registration:
PK-FSO
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Tanah Merah – Oksibil
MSN:
208-0313
YOM:
1999
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4236
Captain / Total hours on type:
2552.00
Aircraft flight hours:
6226
Aircraft flight cycles:
9371
Circumstances:
On 12 April 2017, a Cessna C208 aircraft registered PK-FSO was being operated by PT. Spirit Avia Sentosa (FlyingSAS) for unscheduled cargo flight. The flights of the day scheduled for the aircraft were Mopah Airport (WAKK) – Tanah Merah Airport (WAKT) – Oksibil Airport (WAJO) – Tanah Merah – Oksibil – Tanah Merah. The estimated time departure of first flight from Mopah Airport to Tanah Merah was 0800 LT and the flight departed at 0848 LT, on board the aircraft were two pilots and seven passengers. The aircraft arrived in Tanah Merah at about 0943 LT. At 1012 LT, the flight departed from Tanah Merah to Oksibil. About 10 Nm from Oksibil the pilot contacted the Oksibil tower controller to get air traffic services and landed at 1044 LT. The flight then departed from Oksibil to Tanah Merah at 1058 LT and arrived about 1126 LT. These flights were single pilot operation. At 1144 LT on daylight condition, the aircraft departed Tanah Merah with intended cruising altitude of 7,000 feet. Prior to departure, there was no report or record of aircraft system malfunction. On board the aircraft was one pilot, 1,225 kg of general cargo and 800 pounds of fuel which was sufficient for about 3 hours of flight time. After departure, the pilot advised Tanah Merah tower controller of the estimate time arrival at Oksibil would be 1224 LT. At 1149 LT, the pilot advised Tanah Merah tower controller that the aircraft position was about 10 Nm from Tanah Merah and passing altitude of 3,500 feet. The Tanah Merah tower controller acknowledged the message and advised the pilot to monitor radio communication on frequency 122.7 MHz for traffic monitoring. At about 29 Nm from Oksibil, the PK-FSO aircraft passed a Cessna 208B aircraft which was flying on opposite direction from Oksibil to Tanah Merah at altitude 6,000 feet. At this time, the aircraft ground speed recorded on the flight following system was about 164 knots. The Cessna 208B pilot advised to the pilot on radio frequency 122.7 MHz that the PK-FSO aircraft was in sight. The pilot responded that the aircraft was maintaining 7,000 feet on direct route to Oksibil. At 1230 LT, the Oksibil tower controller received phone call from the FlyingSAS officer at Jakarta which confirming whether the PK-FSO aircraft has landed on Oksibil. The Oksibil tower controller responded that there was no communication with the PK-FSO pilot. The Oksibil tower controller did not receive the flight plan for the second flight of the PK-FSO flight. Afterwards, the Oksibil tower controller called Tanah Merah tower controller confirming the PK-FSO flight and was informed that PK-FSO departed Tanah Merah to Oksibil at 1144 LT and the reported estimate time of arrival Oksibil was 1224 LT. At 1240 LT, the Oksibil tower controller received another phone call from the FlyingSAS officer at Jakarta which informed that the FlyingSAS flight following system received SOS signal (emergency signal) from PK-FSO aircraft and the last position recorded was on coordinate 04°48’47.7” S; 140°39’31.7” E which located approximately 6 Nm north of Oksibil. Afterwards, the Oksibil air traffic controller advised the occurrence to the Search and Rescue Agency. On 13 April 2017, at 0711 LT, the PK-FSO aircraft was found on ridge of Anem Mountain which located about 7 Nm north of Oksibil. The following figure showed the illustration of the aircraft track plotted on the Google earth refer to the known coordinates of Tanah Merah, Oksibil and the crash site.
Probable cause:
The possibility of the pilot being fatigue, physical and environment condition increased pilot sleepiness which might have made the pilot inadvertently falling asleep indicated by no pilot activity. The absence of GA-EGPWS aural alert and warning was unable to wake up the pilot.
Final Report:

Crash of a Piper PA-31-325 near Purísima de la Concepción

Date & Time: Apr 9, 2017 at 1241 LT
Type of aircraft:
Operator:
Registration:
HP-1928
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tolú - Montería
MSN:
31-7612020
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14791
Captain / Total hours on type:
700.00
Aircraft flight hours:
6840
Circumstances:
The twin engine aircraft departed Cali-Alfonso Bonilla Aragón Airport in the morning on a flight to Tolú, carrying seven passengers and one pilot. After takeoff from Tolú, the pilot decided to position to Montería-Los Garzones Airport. Shortly after takeoff, the pilot encountered engine problems and elected to make an emergency landing in a pasture. Upon landing, the right wing collided with obstacles then the nose gear collapsed and the aircraft came to rest near Purísima de la Concepción, about 10 km east of Tolú. The pilot was uninjured and the aircraft was damaged beyond repair.
Probable cause:
Inadequate fuel management and incomplete execution of procedures by the Pilot, by not activating in time the fuel supply from the external tanks (OUTBD) to the internal tanks (INBD) for the feeding of both the engines, causing the fuel in the internal tanks to run out and causing both engines to stop due to fuel starvation.
Contributing Factors:
- Poor flight planning on part of the pilot by not considering the amount of minimum fuel needed and not complying with the minimum fuel amount required for domestic flights.
- Loss of situational awareness by the pilot by not following the standard operation procedures.
Final Report:

Crash of a PZL-Mielec AN-2T in La Paragua

Date & Time: Mar 30, 2017
Type of aircraft:
Operator:
Registration:
YV1638
Flight Phase:
Survivors:
Yes
MSN:
1G108-59
YOM:
1969
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot was forced to attempt an emergency landing in a wasteland for unknown reason. There were no casualties and the aircraft was damaged beyond repair.

Crash of a Beechcraft B60 Duke in Duette: 2 killed

Date & Time: Mar 4, 2017 at 1330 LT
Type of aircraft:
Registration:
N39AG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sarasota - Sarasota
MSN:
P-425
YOM:
1977
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1120
Captain / Total hours on type:
200.00
Copilot / Total flying hours:
20900
Copilot / Total hours on type:
165
Aircraft flight hours:
3271
Circumstances:
The private pilot, who had recently purchased the airplane, and the flight instructor were conducting an instructional flight in the multi-engine airplane to meet insurance requirements. Radar data for the accident flight, which occurred on the second day of 2 days of training, showed the airplane maneuvering between 1,000 ft and 1,200 ft above ground level (agl) just before the accident. The witness descriptions of the accident were consistent with the airplane transitioning from slow flight into a stall that developed into a spin from which the pilots were unable to recover before the airplane impacted terrain. Examination of the wreckage did not reveal evidence of any preexisting mechanical malfunctions or anomalies that would have precluded normal operation of the airplane. After the first day of training, the pilot told friends and fellow pilots that the instructor provided non-standard training that included stall practice that required emergency recoveries at low airspeed and low altitude. The instructor used techniques that were not in keeping with established flight training standards and were not what would be expected from an individual with his extensive background in general aviation flight instruction. Most critically, the instructor used two techniques that introduced unnecessary risk: increasing power before reducing the angle of attack during a stall recovery and introducing asymmetric power while recovering from a stall in a multi-engine airplane; both techniques are dangerous errors because they can lead to an airplane entering a spin. At one point during the first day of training, the airplane entered a full stall and spun before control was regained at very low altitude. The procedures performed contradicted standard practice and Federal Aviation Administration guidance; yet, despite the pilot's experience in multi-engine airplanes and in the accident airplane make and model, he chose to continue the second day of training with the instructor instead of seeking a replacement to complete the insurance check out. The spin encountered on the accident flight likely resulted from the stall recovery errors advocated by the instructor and practiced on the prior day's flight. Unlike the previous flight, the accident flight did not have sufficient altitude for recovery because of the low altitude it was operating at, which was below the safe altitude required for stall training (one which allows recovery no lower than 3,000 ft agl).
Probable cause:
The pilots' decision to perform flight training maneuvers at low airspeed at an altitude that was insufficient for stall recovery. Contributing to the accident was the flight instructor's inappropriate use of non-standard stall recovery techniques.
Final Report:

Crash of a Beechcraft C90B King Air in Rattan

Date & Time: Feb 14, 2017 at 1145 LT
Type of aircraft:
Operator:
Registration:
N1551C
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
McAlester – Idabel
MSN:
LJ-1365
YOM:
1994
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
22000
Captain / Total hours on type:
400.00
Aircraft flight hours:
7862
Circumstances:
The pilot stated that the engine start and airplane power-up were normal for the air medical flight with two medical crewmembers. The engine ice vanes were lowered (as required for ground operations) and then were subsequently raised before takeoff. Takeoff and climbout were routine, and the pilot leveled off the airplane at the assigned cruise altitude. The air traffic controller informed the pilot of heavy showers near the destination airport, and the pilot "put the ice vanes down." The pilot indicated that, shortly afterward, the airplane experienced two "quick" electrical power fluctuations in which "everything went away and then came back," and "[s]econds later the entire [electrical] system failed." Due to the associated loss of navigation capability while operating in instrument meteorological conditions (IMC), the pilot set a general course for better weather conditions based on information from his preflight weather briefing. While the pilot attempted to find a suitable hole in the clouds to descend through under visual conditions, the left engine lost power. The pilot ultimately located a field through the cloud cover and executed a single-engine off-airport landing, which resulted in substantial damage to the right engine mount and firewall. A postaccident examination of the airplane and systems did not reveal any anomalies consistent with an in-flight electrical system malfunction. The three-position ignition and engine start/starter-only switches were in the ON position, and the engine anti-ice switches were in the ON position. When the airplane battery was initially checked during the examination, the voltmeter indicated 10.7 volts (normal voltage is 12 volts); the battery was charged and appeared to function normally thereafter. The loss of electrical power was likely initiated by the pilot inadvertently selecting the engine start switches instead of the engine anti-ice (ice vane) switches. This resulted in the starter/generators changing to starter operation and taking the generator function offline. Airplane electrical power was then being supplied solely by the battery, which caused it to deplete and led to a subsequent loss of electrical power to the airplane. A postaccident examination revealed that neither wing fuel tank contained any visible fuel. The left nacelle fuel tank did not contain any visible fuel, and the right nacelle fuel tank appeared to contain about 1 quart of fuel. The lack of fuel onboard at the time of the accident is consistent with a loss of engine power due to fuel exhaustion. This was a result of the extended flight time as the pilot attempted to exit instrument conditions after the loss of electrical power to locate a suitable airport. Further, the operator reported that 253 gallons (1,720 lbs) of fuel were on board at takeoff, and the accident flight duration was 3.65 hours. At maximum range power, the expected fuel consumption was about 406 lbs/hour, resulting in an endurance of about 4.2 hours. Thus, the pilot did not have the adequate fuel reserves required for flying in IMC. Both the pilot and medical crewmembers described a lack of communication and coordination among crewmembers as the emergency transpired. This resulted in multiple course adjustments that hindered the pilot's ability to locate visual meteorological conditions before the left engine fuel supply was exhausted.
Probable cause:
The loss of electrical power due to the pilot's inadvertent selection of the engine start switches and the subsequent fuel exhaustion to the left engine as the pilot attempted to locate visual meteorological conditions. Contributing to the accident were the pilot's failure to ensure adequate fuel reserves on board for the flight in instrument meteorological conditions and the miscommunication between the pilot and medical crewmembers.
Final Report:

Crash of a Grumman G-73 Mallard in Perth: 2 killed

Date & Time: Jan 26, 2017 at 1708 LT
Type of aircraft:
Operator:
Registration:
VH-CQA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Serpentine - Serpentine
MSN:
J-35
YOM:
1948
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
625
Captain / Total hours on type:
180.00
Circumstances:
On 26 January 2017, the pilot of a Grumman American Aviation Corp G-73 amphibian aircraft, registered VH-CQA (CQA), was participating in an air display as part of the City of Perth Australia Day Skyworks event. On board were the pilot and a passenger. The pilot of CQA was flying ‘in company’ with a Cessna Caravan amphibian and was conducting operations over Perth Water on the Swan River, that included low-level passes of the Langley Park foreshore. After conducting two passes in company, both aircraft departed the display area. The pilot of CQA subsequently requested and received approval to conduct a third pass, and returned to the display area without the Cessna Caravan. During positioning for the third pass, the aircraft departed controlled flight and collided with the water. The pilot and passenger were fatally injured.
Probable cause:
From the evidence available, the following findings are made regarding the loss of control and collision with water involving the G-73 Mallard aircraft, registered VH-CQA 10 km west-south-west of Perth Airport, Western Australia on 26 January 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual. Safety issues, or system problems, are highlighted in bold to emphasise their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.
Contributing factors:
- The pilot returned the aircraft to the display area for a third pass in a manner contrary to the approved inbound procedure and which required the use of increased manoeuvring within a confined area to establish the aircraft on the display path.
- During the final positioning turn for the third pass, the aircraft aerodynamically stalled at an unrecoverable height.
- The pilot's decision to carry a passenger on a flight during the air display was contrary to the Instrument of Approval issued by the Civil Aviation Safety Authority for this air display and increased the severity of the accident consequence.
Final Report: