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

Date & Time: Dec 11, 2015 at 0909 LT
Type of aircraft:
Operator:
Registration:
C-FKDL
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Pickle Lake – Angling Lake
MSN:
208B-0240
YOM:
1990
Flight number:
WSG127
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2990
Captain / Total hours on type:
245.00
Aircraft flight hours:
36073
Aircraft flight cycles:
58324
Circumstances:
On 11 December 2015, the pilot of Wasaya Airways Limited Partnership (Wasaya) flight 127 (WSG127) reported for duty at the Wasaya hangar at Pickle Lake Airport (CYPL), Ontario, at about 0815. The air taxi flight was to be the first of 3 cargo trips in the Cessna 208B Caravan (registration C-FKDL, serial number 208B0240) planned from CYPL to Angling Lake / Wapekeka Airport (CKB6), Ontario. The first flight was planned to depart at 0900. The pilot went to the Wasaya apron and conducted a pre-flight inspection of C-FKDL while a ground crew was loading cargo. A Wasaya aircraft fuel-handling technician confirmed with the pilot that the planned fuel load was 600 pounds per wing of Jet A fuel. After completing the fueling, the technician used the cockpit fuel-quantity indicators to verify that the distribution was 600 pounds per wing. The pilot returned to the hangar and received a briefing from the station manager regarding the planned flights. The pilot was advised that the first officer assigned to the flight had been reassigned to other duties in order to increase the aircraft’s available payload and load a snowmobile on board. The pilot completed and signed a Wasaya flight dispatch clearance (FDC) form for WSG127, and filed a copy of it, along with the flight cargo manifests, in the designated location in the company operations room. The FDC for WSG127 showed that the flight was planned to be conducted under visual flight rules (VFR), under company flight-following, at an altitude of 5500 feet above sea level (ASL). Time en route was calculated to be 66 minutes, with fuel consumption of 413 pounds. The pilot returned to the aircraft on the apron. Loading and fueling were complete, and the pilot conducted a final walk-around inspection of C-FKDL. Before entering the cockpit, the pilot conducted an inspection of the upper wing surface. At 0854, the pilot started the engine of C-FKDL and conducted ground checks for several minutes. At 0858, the pilot advised on the mandatory frequency (MF), 122.2 megahertz (MHz), that WSG127 was taxiing for departure from Runway 09 at CYPL. WSG127 departed from Runway 09 at 0900, and, at 0901, the pilot reported on the MF that the flight was airborne. The flight climbed eastward for several miles and then turned left toward the track to CKB6. At about 3000 feet ASL, WSG127 briefly descended about 100 feet over 10 seconds, and then resumed climbing. At 0905, the pilot reported on the MF that WSG127 was clear of the MF zone. WSG127 intercepted the track to CKB6 and climbed northward until the flight reached a peak altitude of about 4600 feet ASL at 0908:41, and then began descending at 0908:46. At 0909:16, the flight made a sharp right turn of about 120° as it descended through about 4000 feet ASL. At 0909:39, the descent ended at about 2800 feet and the aircraft climbed to about 3000 feet ASL before again beginning to descend. At approximately 0910, WSG127 collided with trees and terrain at an elevation of 1460 feet ASL during daylight hours.
Probable cause:
Findings as to causes and contributing factors:
1. Although the aircraft was prohibited from flying in known or forecast icing conditions, Wasaya Airways Limited Partnership (Wasaya) flight 127 (WSG127) was dispatched into forecast icing conditions.
2. The high take-off weight of WSG127 increased the severity of degraded performance when the flight encountered icing conditions.
3. The pilot of WSG127 continued the flight in icing conditions for about 6 minutes, resulting in progressively degraded performance.
4. WSG127 experienced substantially degraded aircraft performance as a result of ice accumulation, resulting in aerodynamic stall, loss of control, and collision with terrain.
5. The Type C pilot self-dispatch procedures and practices in use at Wasaya at the time of the occurrence did not ensure that operational risk was managed to an acceptable level.
6. Wasaya had not implemented all of the mitigation strategies from its January 2015 risk assessment of Cessna 208B operations in known or forecast icing conditions, and the company remained exposed to some unmitigated hazards that had been identified in the risk assessment.
7. There was a company norm of dispatching Cessna 208B flights into forecast icing conditions, although 4 of Wasaya’s 5 Cessna 208B aircraft were prohibited from operating in these conditions.

Findings as to risk:
1. Without effective risk-management processes, aircraft may continue to be dispatched into forecast or known icing conditions that exceed the operating capabilities of the aircraft, increasing the risk of degraded aircraft performance or loss of control.
2. If pilots operating under self-dispatch do not have adequate tools to complete an operational risk assessment before releasing a flight, there is an increased likelihood that hazards will not be identified or adequately mitigated.
3. If aircraft that are not certified for flight in known or forecast icing conditions are dispatched into, and encounter, such conditions, there is an increased risk of degraded performance or loss of control.
4. If aircraft that are certified for flight in known or forecast icing conditions are dispatched into, and encounter, such conditions, at weights exceeding limitations, there is an increased risk of loss of control.
5. If flights are continued in known icing conditions in aircraft that are not certified to do so, there is an increased risk of degraded aircraft performance and loss of control.
6. If operators exceed aircraft manufacturers’ recommended ICEX II servicing intervals, there is an increased risk of degraded aircraft performance or loss of control resulting from greater accretion of ice on the leading-edge de-icing and propeller blade anti-icing boots.
7. If pilots do not receive the minimum required training, there is an increased risk that they will lack the necessary technical knowledge to operate aircraft safely.
8. If pilots are not provided with the information they need to calculate the aircraft’s centre of gravity accurately, they risk departing with their aircraft’s centre of gravity outside the limits, which can lead to loss of control.
9. If emergency locator transmitter antennas and cable connections are not robust enough to survive impact forces, potentially life-saving search-and-rescue operations may be impaired by the absence of a usable signal.

Other findings:
1. Wasaya’s use of a satellite aircraft flight-following system provided early warning of WSG127’s abnormal status and an accurate last known position for search-and-rescue operations.
2. The investigation could not determine whether the autopilot had been used by the pilot of WSG127 at any time during the flight.
Final Report:

Crash of an Eclipse EA500 near Swellendam: 1 killed

Date & Time: Dec 7, 2015 at 1057 LT
Type of aircraft:
Registration:
ZS-DKS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Lanseria - Cape Town
MSN:
142
YOM:
2008
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2977
Captain / Total hours on type:
506.00
Aircraft flight hours:
714
Circumstances:
The aircraft had taken off on a private flight with the pilot being the sole occupant on board. The pilot had filed an IFR flight plan and had informed air traffic control (ATC) at FALA that the aircraft had a fuel endurance of 4 hours and his estimated flying time to FACT was approximately 2 hours and 30 minutes. After take-off the aircraft climbed to its cruising altitude of 36 000 feet (FL360) as was seen on the radar recordings. The pilot maintained communication with ATC until overhead Kimberley. Shortly thereafter the aircraft was observed to change course, turning slightly left before the town of Douglas. The aircraft remained at FL360 and was observed to fly south towards the waypoint OKTED, which was a substantial distance to the east of FACT. FACT could not get communication with the aircraft and the aeronautical rescue co-ordination centre (ARCC) was advised of the situation. The aircraft was kept under constant radar surveillance. The ARCC requested assistance from the South African Air Force (SAAF) and a Gripen (military jet) from Air Force Base Overberg (FAOB) was dispatched to intercept the aircraft. The pilot of the Gripen intercepted the aircraft approximately 3 minutes before it impacted the terrain. The Gripen pilot was unable to get close enough to the aircraft as it was flying very erratically, and he could therefore not see whether the pilot was conscious or not. The aircraft was observed entering a left spiral and continue spiraling down until it impacted the ground. The pilot was fatally injured and the aircraft was destroyed during the impact sequence.
Probable cause:
The investigation revealed no anomalies on the part of the aircraft and all damage was attributed to the impact with the ground. The fatal injuries sustained by the pilot made it impossible to determine if the pilot was incapacitated or not. It was observed that the aircraft performed a series of unexplainable as well as erratic flying manoeuvres, which resulted in a loss of control and the aircraft to enter into a spiral dive, which was observed by the Gripen pilot before colliding with the ground.
Final Report:

Crash of a Cessna 650 Citation VII in Guarda-Mor: 4 killed

Date & Time: Nov 10, 2015 at 1904 LT
Type of aircraft:
Operator:
Registration:
PT-WQH
Flight Phase:
Survivors:
No
Schedule:
Brasília – São Paulo
MSN:
650-7083
YOM:
1998
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
13143
Copilot / Total flying hours:
2527
Copilot / Total hours on type:
1633
Circumstances:
The aircraft took off from the Presidente Juscelino Kubitschek (SBBR) Aerodrome, Brasília - DF, to the Congonhas Aerodrome (SBSP), São Paulo - SP, at 2039 (UTC), to carry out a personnel transportation flight with two crewmembers and two passengers on board. During the cockpit preparation procedure, the crew members commented about the operation of the Pitch Trim System. The first flight of the day, that occurred in the morning, was from São Paulo to Brasilia and with no abnormalities. About thirty minutes after take-off from Brasília, still during the climb, near the FL370, the cabin voice recorder recorded a characteristic sound of the aircraft’s horizontal stabilizer moving. Then, the aircraft made a downward trajectory with high speed and a big rate of descent until the impact against the ground. The aircraft was destroyed. All occupants perished at the site, among them Lúcio Flávio de Oliveira and Marco Antonio Rossi, two Directors of Banco Brasdesco.
Probable cause:
Contributing factors:
- Control skills – undetermined
It is possible that, after inadvertent movement of the horizontal stabilizer, the crewmembers did not operate on the control switches of the secondary pitch trim system, since no other warning sound (Clacker) was recorded on the CVR recordings. The action prevised in the emergency procedures Pitch Trim Runaway or Failure, item 3, regarding trimming of the aircraft through the secondary system, possibly, was not performed. The performance of the crew may have been restricted only to the elevator control on the aircraft controls or to the control of the stabilizer associated with the primary trimming mode.
- Attitude – undetermined
The decision to make the flight without the proper functioning of the primary pitch trim and autopilot system may have been the result of the pilot's self-confidence because of the successful previous flight under similar operating conditions. Considering the hypothesis that the updated Shutdown Checklist, which should incorporate the Stabilizer Trim Backdrive Monitor - TEST, was not performed after the precrash flight, one could consider that there was a lack of adhesion to the aircraft operating procedures. Such an attitude could be associated with the pilot's self-confidence about the aircraft's operating routine, whose acquired experience could have given him the habit of ignoring some of the procedures deemed less important during the flight completion phase.
- Crew Resource Management – a contributor
Throughout the flight, there was an absence of verbalization and communication of the actions on the checklist. Similarly, in the face of the emergency situation of the horizontal stabilizer (Pitch Trim Runaway or Failure), no statements were identified regarding the actions required to manage this situation among the crew. These characteristics denote inefficiency in the use of human resources available for the aircraft operation.
- Training – undetermined
It is possible that the absence of a periodic training in simulator, especially the emergency Pitch Trim Runway or Failure, has affected the performance of the crew, as far as the CVR did not record statements related to the actions required by the abnormal condition experienced.
- Organizational culture – undetermined
The operator did not usually properly fill out the PT-WQH flight logbook. This condition evidenced the existence of informal rules regarding the monitoring of the operational conditions of the aircraft. In this context, it is possible that the history of failures related to the pitch trim system has not been registered.
- Piloting judgment – undetermined
Moments prior to takeoff, it was recorded in the CVR speeches related to the flight without the autopilot, possibly related to a failure or inoperativeness of the primary pitch trim system. The takeoff with a possible failure in the pitch trim system of the aircraft, showed an inadequate assessment of the risks involved in the operation under those conditions.
- Aircraft maintenance – undetermined
It was not possible to establish a link between the maintenance services performed on the aircraft in September 2015 and the events that resulted in the accident occurred on 10NOV2015. However, it was not ruled out that an incomplete crash survey was carried out in the pitch trim system of the aircraft, due to the lack of detail of the service orders.
- Decision-making process – a contributor
The sounds related to the test positions of the Rotary Test Switch have not been recorded in the CVR recording, so it is possible to conclude that the Warning Systems - Check item of the Cockpit Preparation Checklist has not been performed. The decision to perform the flight without the complete execution of all items of the Cockpit Preparation Checklist, prevented the correct verification of the primary longitudinal Trim system of the aircraft and reflected an inadequate judgment about the risks involved in that operation.
- Interpersonal relationship – undetermined
According to the CVR data, there was a possible rush of the crew to take-off, even though it was verified that the aircraft's pitch trim system did not work properly. It was not possible to determine if this rush was motivated by passengers’ pressure or self-imposed by the pilot.
- Support systems – undetermined
It is possible that the Pilots' Abbreviated Checklist - NORMAL PROCEDURES, aboard the aircraft, was outdated, without the incorporation of the Stabilizer Trim Backdrive Monitor - TEST procedure in the Shutdown Checklist. The possible completion of Shutdown Checklist with outdated procedures would have hampered the manufacturer's suggested verification for identification of abnormalities in the aircraft's pitch trim system.
- Managerial oversight – undetermined
The records and control of the operational check flights, both by the maintenance shop and by the operator, prevised in documentation issued by the manufacturer (SB650- 27-53 and ASL650-55-04) were not performed in an adequate manner, indicating possible weaknesses in the supervision of the maintenance activities.
Final Report:

Crash of a Cessna 441 Conquest II in Climax: 2 killed

Date & Time: Nov 9, 2015 at 1016 LT
Type of aircraft:
Operator:
Registration:
N164GP
Flight Phase:
Survivors:
No
Schedule:
Lakeland - Cairo
MSN:
441-0164
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1150
Captain / Total hours on type:
150.00
Aircraft flight hours:
18422
Circumstances:
The purpose of the flight was for the commercial pilot/owner to pick up passengers at the destination airport and return to the departure airport. The airplane was 33 miles from its destination in cruise flight at 3,300 ft mean sea level (msl) and above a solid cloud layer when the pilot declared to air traffic control (ATC) that he had the destination airport "in sight" and cancelled his instrument flight rules (IFR) clearance. During the 13 minutes after cancellation of the IFR clearance, the airplane's radar track made an erratic sequence of left, right, and 360° turns that moved the airplane away from the destination airport in a westerly direction. The altitudes varied between about 4,000 and 900 ft msl. Later, the pilot reestablished communication with ATC, reported he had lost visual contact with the airport, and requested an instrument approach to the destination airport. The controller then provided a sequence of heading and altitude assignments to vector the airplane onto the approach, but the pilot did not maintain these assignments, and the controller provided several corrections. The pilot expressed his inability to identify the initial approach fix (IAF) and asked the controller for the correct spelling. The radar target then climbed and subsequently entered a descending right turn at 2,500 ft msl and 180 knots ground speed near the IAF, before radar contact with the airplane was lost. Although a review of airplane maintenance records revealed that the airplane was overdue for several required inspections, examination of the wreckage revealed signatures consistent with both engines being at high power at impact, and no evidence of any preimpact mechanical anomalies were found that would have precluded normal operation. Examination of the airplane's panel-mounted GPS, which the pilot was using to navigate the flight, revealed that the navigation and obstruction databases were expired. During a weather briefing before the flight, the pilot was warned of low ceilings and visibility. The weather conditions reported near the destination airport about the time of the accident also included low ceilings and visibilities. The restricted visibility conditions and the high likelihood of inadvertent entry into instrument meteorological conditions were conducive to the development of spatial disorientation. The flight's erratic track, which included altitude and directional changes inconsistent with progress toward the airport, were likely the result of spatial disorientation. After reestablishing contact with ATC and being cleared to conduct an instrument approach to the destination, the airplane's flight track indicated that the pilot was not adequately prepared to execute the controller's instructions. The pilot's subsequent loss of control was likely the result of spatial disorientation due to his increased workload and operational distractions associated with his attempts to configure his navigation radios or reference charts. Postaccident toxicological testing of samples obtained from the pilot revealed the presence of ethanol; however, it could not be determined what percentage was ingested or produced postmortem. The testing also revealed the presence of amphetamine, an opioid painkiller, two sedating antihistamines, and marijuana. Although blood level quantification of these medications and drugs could not be made from the samples provided, their combined effects would have directly impacted the pilot's decision-making and ability to fly the airplane, even if each individual substance was only present in small amounts. Based in the reported weather conditions at the time the pilot reported the airport in sight and canceled his IFR clearance, he likely was not in a position to have seen the destination airport even though he may have been flying between cloud layers or may have momentarily observed the ground. His decision to cancel his IFR clearance so far from the destination, in an area characterized by widespread low ceilings and reduced visibility, increased the pilot's exposure to the hazards those conditions posed to the successful completion of his flight. The pilot showed other lapses in judgment associated with conducting this flight at the operational, aircraft, and the personal level. For example, 1) the pilot did not appear to recognize the significance of widespread low ceilings and visibility along his route of flight and at his destination (nor did he file an alternate airport even though conditions warranted); 2) the accident airplane was being operated beyond mandatory inspection intervals; and 3) toxicological testing showed the pilot had taken a combination of multiple medications and drugs that would have likely been impairing and contraindicated for the safe operation of an airplane. The pilot's decision-making was likely affected by the medications and drugs.
Probable cause:
The pilot's loss of airplane control due to spatial disorientation. Also causal to the accident was the pilot's impairment by the combined effects of multiple medications and drugs.
Final Report:

Crash of a Fokker F27 Friendship 400M near Koussané

Date & Time: Nov 2, 2015
Type of aircraft:
Operator:
Registration:
6W-STF
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
10591
YOM:
1979
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Enroute from Nioro, the crew encountered technical problems and attempted an emergency landing. The aircraft crash landed in a field located 2 km from Koussané. It skidded for few dozen metres, lost its undercarriage, hit a tree with its left wing that was partially torn and came to rest. All 10 occupants were rescued, among them two were injured. The aircraft was damaged beyond repair.

Crash of an Airbus A321-231 near Hasna: 224 killed

Date & Time: Oct 31, 2015 at 0613 LT
Type of aircraft:
Operator:
Registration:
EI-ETJ
Flight Phase:
Survivors:
No
Site:
Schedule:
Sharm el-Sheikh - Saint Petersburg
MSN:
663
YOM:
1997
Flight number:
KGL9268
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
217
Pax fatalities:
Other fatalities:
Total fatalities:
224
Captain / Total flying hours:
12000
Captain / Total hours on type:
3800.00
Aircraft flight hours:
55772
Aircraft flight cycles:
21175
Circumstances:
The aircraft departed Sharm el-Sheikh at 0549LT bound for Saint Petersburg-Pulkovo Airport and was cleared to climb to FL350. On board were 217 passengers and a crew of seven. Some 23 minutes after takeoff, the aircraft entered a steep descent and reached a descent rate of 6,000 feet per minute with a simultaneous reduction of speed before all radar and radio contact were lost at 0613LT. The aircraft crashed in a desert area located about 50 km southeast of Hasna, in the Sinai. None of the 224 occupants survived the accident. It appears the aircraft crashed in a slightly flat attitude and was destroyed by impact forces and a post crash fire (the central part of the fuselage and wings). Based on the debris scattered on a zone of 16 km2, it is now understood that the engines and the tail have been found few hundred metres from the main wreckage. It is believed the aircraft partially disintegrated in the air but probably during the last phase of the descent and not at high altitude.
Probable cause:
On November 17, 2015, Alexander Bortnikov, Chief of the Russian Secret Services, confirmed to Vladimir Putin that the crash was caused by the detonation of a small 'home made' bomb equivalent to one kilo of TNT that was placed on board the airplane in a beverage can. This was confirmed by the Egyptian Presidency on 24 February 2016.

Crash of a Pilatus PC-6/B2-H2 Turbo Porter in Buenos Aires: 2 killed

Date & Time: Oct 28, 2015 at 1615 LT
Operator:
Registration:
GN-804
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Buenos Aires - Buenos Aires
MSN:
786
YOM:
1977
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The single engine aircraft was completing a local mission in Buenos Aires. In flight, the left wing detached, causing the aircraft to enter an uncontrolled descent and to crash, bursting into flames. The aircraft was totally destroyed by a post crash fire and both occupants were killed. The left wing was found about 180 metres from the wreckage.

Crash of a Learjet 31A in Apaseo el Alto: 4 killed

Date & Time: Oct 22, 2015 at 1528 LT
Type of aircraft:
Operator:
Registration:
XB-GYB
Flight Phase:
Survivors:
No
Schedule:
Toluca - Zacatecas
MSN:
31-166
YOM:
1998
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Copilot / Total flying hours:
2693
Aircraft flight hours:
3237
Aircraft flight cycles:
2368
Circumstances:
The aircraft departed Toluca Airport at 1528LT on an executive flight to Zacatecas, carrying two passengers and two pilots. Four minutes later, the crew was cleared to climb to FL380 and later reported moderate but continue turbulences. Then the aircraft entered an uncontrolled descent and disintegrated in the air before crashing near Apaseo el Alto. Debris were found on a large area and all four occupants were killed.
Probable cause:
Due to lack of evidences, the exact cause of the loss of control could not be determined.
Final Report:

Crash of a Cessna 208B Grand Caravan near Yumbo: 3 killed

Date & Time: Oct 14, 2015 at 1146 LT
Type of aircraft:
Operator:
Registration:
PR-MIC
Flight Phase:
Survivors:
No
Site:
Schedule:
Cali - Cali
MSN:
208B-0841
YOM:
2000
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
9388
Captain / Total hours on type:
4155.00
Copilot / Total flying hours:
6343
Copilot / Total hours on type:
1029
Aircraft flight hours:
10519
Circumstances:
The single engine airplane departed Cali-Alfonso Bonilla Aragón Airport on an geophysical exploration mission of the south part of Chocó, carrying three crew members, two pilots and one operator in charge of the LIDAR equipment. At 1144LT, the crew reported his altitude at 5,600 feet. Two minutes later, while cruising in poor visibility, the aircraft struck trees and crashed in wooded and hilly terrain near Yambo. The wreckage was found few hours later and all three occupants were killed.
Probable cause:
The following factors were identified:
- Controlled flight into terrain,
- Execution of a VFR flight in reduced visibility weather conditions,
- Poor decision making by the crew in continuing VFR operation as they were in an environment of significantly reduced visibility,
- Inadequate operational risk assessment due to the lack of familiarity of the foreign crew with the topography and meteorological evolution of the sector.
Final Report:

Crash of a Rockwell Grand Commander 680FL near Capatárida: 2 killed

Date & Time: Oct 5, 2015 at 2040 LT
Operator:
Registration:
N577ZB
Flight Phase:
Flight Type:
Survivors:
No
Site:
MSN:
680-1663-129
YOM:
1967
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The aircraft was probably engaged in an illegal flight when it crashed under unknown circumstances in a desert area located in Los Hatos, about 5 km northeast of Capatárida, Venezuela. The aircraft was destroyed and both occupants were killed. No flight plan was filed to enter the Venezuelan airspace.