Crash of a Swearingen SA226TC Metro II on Mt Seymour: 2 killed

Date & Time: Apr 13, 2015 at 0708 LT
Type of aircraft:
Operator:
Registration:
C-GSKC
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Vancouver – Prince George – Dawson Creek – Fort Saint John
MSN:
TC-235
YOM:
1977
Flight number:
CA066
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2885
Captain / Total hours on type:
1890.00
Copilot / Total flying hours:
1430
Copilot / Total hours on type:
57
Aircraft flight hours:
33244
Circumstances:
On 13 April 2015, Carson Air Ltd. flight 66 (CA66), a Swearingen SA226-TC Metro II (registration C-GSKC, serial number TC-235), departed Vancouver International Airport (CYVR), British Columbia, with 2 pilots on board for an instrument flight rules flight to Prince George, British Columbia. At 0709 Pacific Daylight Time (PDT), approximately 6 minutes after leaving Vancouver, the aircraft disappeared from air traffic control radar while climbing through an altitude of 8700 feet above sea level in instrument meteorological conditions, about 4 nautical miles north of the built-up area of North Vancouver. Deteriorating weather conditions with low cloud and heavy snowfall hampered an air search; however, aircraft wreckage was found on steep, mountainous, snow-covered terrain by ground searchers at approximately 1645 PDT. The aircraft had experienced a catastrophic in-flight breakup. Both pilots were fatally injured, and the aircraft was destroyed. Although the aircraft’s 406-megahertz emergency locator transmitter activated, the antenna was damaged and no signal was received by the Cospas-Sarsat (international satellite system for search and rescue). The accident occurred during daylight hours.
Probable cause:
Findings as to causes and contributing factors:
1. For unknown reasons, the aircraft descended in the direction of flight at high speed until it exceeded its structural limits, leading to an in-flight breakup.
2. Based on the captain’s blood alcohol content, alcohol intoxication almost certainly played a role in the events leading up to the accident.

Findings as to risk:
1. If cockpit or data recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded.
2. If Canadian Aviation Regulations Subpart 703 operators are not required to have a Transport Canada–approved safety management system, which is assessed on a regular basis, there is a risk that those companies will not have the necessary processes in place to manage safety effectively.
3. If safety issues, such as concerns related to drug or alcohol abuse, are not reported formally through a company’s safety reporting system, there is a risk that hazards will not be managed effectively.
4. Transport Canada’s Handbook for Civil Aviation Medical Examiners(TP 13312) does not address the complete range of conditions that may be affected by drug or alcohol dependence. As a result, there is an increased risk that undisclosed cases of drug or alcohol dependence in commercial aviation will go undetected, placing the travelling public at risk.
5. If there is no regulated drug- and alcohol-testing requirement in place to reduce the risk of impairment of persons while engaged in safety-sensitive functions, employees may undertake these duties while impaired, posing a risk to public safety.
Final Report:

Crash of a Cessna 441 Conquest II near Cañaote: 3 killed

Date & Time: Apr 1, 2015
Type of aircraft:
Operator:
Registration:
XB-KGS
Flight Phase:
Flight Type:
Survivors:
No
MSN:
441-0232
YOM:
1982
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
Crashed in unknown circumstances near Cañaote, State of Cojedes. The wreckage was found the following morning. The aircraft was destroyed, all three occupants were killed and a load of 999 kilos of cocaine was found among the debris.

Crash of a Dornier DO228-201 off Dabolim: 2 killed

Date & Time: Mar 24, 2015 at 2208 LT
Type of aircraft:
Operator:
Registration:
IN-240
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Dabolim - Dabolim
MSN:
4079
YOM:
2009
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was completing a training sortie from the Dabolim-Hansa Naval Air Station, State of Goa, on behalf of the 310th Naval Air Squadron. While flying by night, the twin engine aircraft crashed in the Indian Ocean about 45 km southwest of Dabolim Airport. A pilot was rescued and both other occupants (a second pilot and an observer) were killed.

Crash of a Cessna 208B Grand Caravan in Verdigris

Date & Time: Mar 24, 2015 at 1507 LT
Type of aircraft:
Operator:
Registration:
N106BZ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tulsa - Tulsa
MSN:
208B-0106
YOM:
1988
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6500
Captain / Total hours on type:
970.00
Aircraft flight hours:
11443
Circumstances:
The pilot reported that, during the postmaintenance test flight, the turboprop engine lost power. The airplane was unable to maintain altitude, and the pilot conducted a forced landing, during which the airplane was substantially damaged. The engine had about 9 total flight hours at the time of the accident. A teardown of the fuel pump revealed that the high-pressure drive gear teeth exhibited wear and that material was missing from them, whereas the driven gear exhibited little to no visible wear. A metallurgical examination of the gears revealed that the damaged drive gear was made of a material similar to 300-series stainless steel instead of the harder specified M50 steel, whereas the driven gear was made of a material similar to the specified M50 steel. Subsequent to these findings, the airplane manufacturer determined that the gear manufacturer allowed three set-up gears made from 300-series stainless steel to become part of the production inventory during the manufacturing process. One of those gears was installed in the fuel pump on the accident airplane, and the location of the two other gears could not be determined. Based on the evidence, it is likely that the nonconforming gear installed in the fuel pump failed because it was manufactured from a softer material than specified, which resulted in a loss of fuel flow to the engine and the subsequent loss of engine power. The manufacturer subsequently inspected its stock of gears and issued notices to customers that had engines with fuel pumps installed with the same part number gear set as the one installed on the accident airplane. The manufacturer also issued a service information letter and service bulletins regarding the fuel pump gear set for engines used in civilian and military applications. As of the date of this report, the two remaining gears have not been located.
Probable cause:
The fuel pump gear manufacturer’s allowance of set-up gears made from a nonconforming material to be put in the production inventory system, the installation of a nonconforming gear in the accident airplane’s production fuel pump, and the gear’s failure, which resulted in a loss of fuel flow to the engine and the subsequent loss of engine power.
Final Report:

Crash of an Airbus A320-211 near Prads-Haute-Bléone: 150 killed

Date & Time: Mar 24, 2015 at 1041 LT
Type of aircraft:
Operator:
Registration:
D-AIPX
Flight Phase:
Survivors:
No
Site:
Schedule:
Barcelona – Düsseldorf
MSN:
147
YOM:
1990
Flight number:
4U9525
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
144
Pax fatalities:
Other fatalities:
Total fatalities:
150
Captain / Total flying hours:
6763
Captain / Total hours on type:
3811.00
Copilot / Total flying hours:
919
Copilot / Total hours on type:
540
Aircraft flight hours:
58313
Aircraft flight cycles:
46748
Circumstances:
The aircraft left Barcelona at 1000LT on a scheduled flight to Düsseldorf (flight 4U9525/GWI18G). At 1032LT, one minute after reaching its assigned cruising altitude of 38,000 feet near Toulon (level off), the aircraft started to lose altitude and continued a straight in descent during nine minutes, until it reached the altitude of 6,800 feet. It was later confirmed that no distress call was sent by the crew. Radar contact was lost at a height of 6,800 feet at 1041LT when the aircraft hit a mountain slope located near Prads-Haute-Bléone, northeast of Digne-les-Bains. At the time of the accident, weather conditions were considered as good with no storm activity, reasonable wind component and no turbulence. The crash site was reached by first rescuers in the afternoon and the aircraft disintegrated on impact. None of the 150 occupants survived the crash. The second black box (DFDR) was found on April 2, nine days after the accident.
Probable cause:
The collision with the ground was due to the deliberate and planned action of the copilot who decided to commit suicide while alone in the cockpit. The process for medical certification of pilots, in particular self-reporting in case of decrease in medical fitness between two periodic medical evaluations, did not succeed in preventing the copilot, who was experiencing mental disorder with psychotic symptoms, from exercising the privilege of his licence. The following factors may have contributed to the failure of this principle:
-The copilot’s probable fear of losing his ability to fly as a professional pilot if he had reported his decrease in medical fitness to an AME,
-The potential financial consequences generated by the lack of specific insurance covering the risks of loss of income in case of unfitness to fly,
- The lack of clear guidelines in German regulations on when a threat to public safety outweighs the requirements of medical confidentiality.
Security requirements led to cockpit doors designed to resist forcible intrusion by unauthorized persons. This made it impossible to enter the flight compartment before the aircraft impacted the terrain in the French Alps.
Final Report:

Crash of a Canadair CL-601 Challenger off Aruba: 3 killed

Date & Time: Jan 29, 2015
Type of aircraft:
Operator:
Registration:
N214FW
Flight Phase:
Flight Type:
Survivors:
No
MSN:
3008
YOM:
1983
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The aircraft left an airfield located somewhere in the State of Apure, Venezuela, apparently bound for the US with three people on board. While flying north of Punto Fijo, above the sea, the crew was contacted by ATC but failed to respond. Convinced this was an illegal flight, the Venezuelan Authorities decided to send a fighter to intercept the Challenger that was shot down. Out of control, it dove into the Caribbean Sea and crashed off the coast of Aruba Island. All three occupants were killed and on site, more than 400 boxes containing cocaine were found.
Probable cause:
Shot down by the pilot of a Venezuelan Air Force fighter.

Crash of a Britten Norman BN-2T Islander near Dawlatabad

Date & Time: Jan 20, 2015
Type of aircraft:
Operator:
Registration:
ZS-NAT
Flight Phase:
Survivors:
Yes
MSN:
2158
YOM:
1986
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was completing a geophysical mission on behalf of Xcalibur Airborne Geophysics, with two pilots on board. En route, the crew encountered an unexpected situation and attempted an emergency landing. The aircraft crash landed in a rocky terrain, lost its undercarriage and came to rest. Both occupants escaped uninjured and the aircraft was damaged beyond repair.

Crash of a Pacific Aerospace PAC 750XL in Taupo Lake

Date & Time: Jan 7, 2015 at 1216 LT
Operator:
Registration:
ZK-SDT
Flight Phase:
Survivors:
Yes
Schedule:
Taupo - Taupo
MSN:
122
YOM:
2005
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
588
Captain / Total hours on type:
14.00
Circumstances:
On 7 January 2015 a Pacific Aerospace Limited 750XL aeroplane was being used for tandem parachuting (or ‘skydiving’) operations at Taupō aerodrome. During the climb on the fourth flight of the day, the Pratt & Whitney Canada PT6A-34 engine failed suddenly. The 12 parachutists and the pilot baled out of the aeroplane and landed without serious injury. The aeroplane crashed into Lake Taupō and was destroyed.
Probable cause:
The following findings were identified:
- The first compressor turbine blade failed after a fatigue crack, which had begun at the trailing edge, propagated towards the leading edge. The blade finally fractured in tensile overload. The separated blade fragment caused other blades to fracture and the engine to stop.
- The fatigue crack in the trailing edge of the blade was likely initiated by the trailing edge radius having been below the specification for a new blade.
- The P&WC Repair Requirement Document 725009-SRR-001, at the time the blades were overhauled, had generic requirements for trailing edge thickness inspections but did not specify a minimum measurement for the trailing edge radius.
- The higher engine power settings used by the operator since August 2014 were within the flight manual limits. Therefore it was unlikely that the operator’s engine handling policy contributed to the engine failure.
- The operator had maintained the engine in accordance with an approved, alternative maintenance programme, but the registration of the engine into that programme had not been completed. The administrative oversight did not affect the reliability of the engine or contribute to the blade failure.
- It was likely that the maintenance provider had not followed fully the engine manufacturer’s recommended procedure for inspecting the compressor turbine blades. It could not be determined whether the crack might have been present, and potentially detectable, at the most recent borescope inspection.
- The operator had not equipped its pilots with flotation devices to cover the possibility of a ditching or an emergency bale-out over or near water.
- The pilot had demonstrated that he was competent and he had the required ratings. However, it was likely that the operator’s training of the pilot in emergency procedures was inadequate. This contributed to the pilot making a hasty exit from the aeroplane that jeopardized others.
Final Report:

Crash of a Britten Norman BN-2A-6 Islander near Mahdia: 2

Date & Time: Dec 28, 2014 at 1145 LT
Type of aircraft:
Operator:
Registration:
8R-GHE
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mahdia – Karisparu
MSN:
269
YOM:
1971
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8000
Aircraft flight hours:
25818
Circumstances:
The crew (a pilot and a load master) was performing a regular cargo service to Karisparu and departed Mahdia Airport at 1142LT. The duration of the flight should be less than 20 minutes as the aircraft was scheduled to arrive at Karisparu Airfield at 1200LT. Less than three minutes after departure, the radio contact was lost with the pilot. SAR operations were initiated but after four days, no trace of the aircraft nor the crew was found. The Director General of the Guyana Civil Aviation Authority (GCAA), Zulfikar Mohamed, said that the crucial 72-hour window period since the aircraft vanished in the thick jungle in Region Eight expired on Tuesday December 30. On January 4, 2015, all SAR operations were suspended as no trace of the aircraft was found.
Probable cause:
Due to lack of evidences, the cause of the accident could not be determined.
Final Report:

Crash of an Airbus A320-216 into the Java Sea: 162 killed

Date & Time: Dec 28, 2014 at 0618 LT
Type of aircraft:
Operator:
Registration:
PK-AXC
Flight Phase:
Survivors:
No
Schedule:
Surabaya – Singapore
MSN:
3648
YOM:
2008
Flight number:
QZ8501
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
156
Pax fatalities:
Other fatalities:
Total fatalities:
162
Captain / Total flying hours:
20537
Captain / Total hours on type:
4687.00
Copilot / Total flying hours:
2247
Copilot / Total hours on type:
1367
Aircraft flight hours:
23039
Aircraft flight cycles:
13610
Circumstances:
The aircraft left Surabaya-Juanda Airport at 0535LT and climbed to its assigned altitude of FL320 that he reached 19 minutes later. The crew contacted ATC to obtain the authorization to climb to FL380 and to divert to 310° due to bad weather conditions. At 0617, the radio contact was lost with the crew and a minute later, the transponder stopped when the aircraft disappeared from the radar screen. At this time, the aircraft was flying at the altitude of 36,300 feet and its speed was decreasing to 353 knots. It is believed the aircraft crashed some 80 nautical miles southeast off the Pulau Belitung Island, some 200 km from the Singapore Control Area. The Indonesian Company confirmed there were 156 Indonesian Citizens on board, three South Korean, one Malaysian, one Singapore and one French (the copilot) as well. At the time of the accident, the weather conditions were marginal with storm activity, rain falls and turbulence in the area between Pulau Belitung and Kalimantan. First debris were spotted by the Indonesian Navy some 48 hours later, about 150 NM east-south-east off the Pulau Belitung Island. About forty dead bodies were found up to December 30. The tail was recovered on January 10, 2015 and the black boxes were localized a day later. On January 12 and 13 respectively, the DFDR and the CVR were out of water and sent to Jakarta for analysis and investigations.
Probable cause:
The cracking of a solder joint of both channel A and B resulted in loss of electrical continuity and led to RTLU (rudder travel limiter unit) failure.
The existing maintenance data analysis led to unresolved repetitive faults occurring with shorter intervals. The same fault occurred 4 times during the flight.
The flight crew action to the first 3 faults in accordance with the ECAM messages. Following the fourth fault, the FDR recorded different signatures that were similar to the FAC CB‟s being reset resulting in electrical interruption to the FAC‟s.
The electrical interruption to the FAC caused the autopilot to disengage and the flight control logic to change from Normal Law to Alternate Law, the rudder deflecting 2° to the left resulting the aircraft rolling up to 54° angle of bank.
Subsequent flight crew action leading to inability to control the aircraft in the Alternate Law resulted in the aircraft departing from the normal flight envelope and entering prolonged stall condition that was beyond the capability of the flight crew to recover.
Final Report: