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:

Crash of an Antonov AN-26 near Uvira: 6 killed

Date & Time: Dec 28, 2014 at 0300 LT
Type of aircraft:
Operator:
Registration:
4L-AFS
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Entebbe – Bujumbura – Pointe-Noire
MSN:
86 08
YOM:
1979
Flight number:
AGS902
Location:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The aircraft was performing a cargo flight from Entebbe to Pointe-Noire with an intermediate stop in Bujumbura, Burundi, to refuel. After takeoff, while proceeding to the west by night, the aircraft struck the slope of Mt Kafinda (3,100 metres high), about 25 km south of Uvira. The wreckage was found on hilly and wooded terrain. All six occupants were killed.

Crash of a Cessna T207A Turbo Stationair 8 in Piedecuesta: 7 killed

Date & Time: Dec 24, 2014 at 1527 LT
Operator:
Registration:
HK-4892
Flight Phase:
Survivors:
No
Site:
Schedule:
Bucaramanga – Málaga
MSN:
207-0646
YOM:
1981
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total hours on type:
370.00
Aircraft flight hours:
13055
Circumstances:
The single engine aircraft departed Bucaramanga-Palonegro Airport on a charter flight to Málaga-Jerónimo de Aguayo Airport, carrying six passengers and one pilot. En route, the aircraft started a descent then a turn to the left when it impacted the slope of a mountain and crashed near Piedecuesta. The wreckage was found the following day and all seven occupants were killed. There was no fire.
Probable cause:
The investigation determined that the accident was caused by a combination of the following factors:
- A probable partial loss of engine power during flight,
- A probable loss of aerodynamic performance of the aircraft.
The following factors that could affect the performance of the aircraft are added to the two hypotheses:
1. Lack of knowledge by the dispatcher and the pilot of the exact weight of the aircraft, as well as the location of its center of gravity.
2. Decision by the pilot to fly at an altitude lower than the one stipulated in the Flight Plan submitted to the Aeronautical Authority, as well as in the SOP's.
Final Report:

Crash of a Partenavia P.68C-TC in La Bonanza: 1 killed

Date & Time: Dec 23, 2014
Type of aircraft:
Operator:
Registration:
YV1706
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Valencia – Charallave
MSN:
242-07-TC
YOM:
1982
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The pilot Amílcar Suárez, sole on board, was killed when the twin engine aircraft crashed in unknown circumstances in a mountainous area located near La Bonanza. The aircraft was destroyed by a post crash fire. It was en route from Valencia to Charallave.

Crash of a Piper PA-31-350 Navajo Chieftain off Nassau: 1 killed

Date & Time: Dec 2, 2014 at 0845 LT
Operator:
Registration:
C6-REV
Flight Phase:
Survivors:
Yes
Schedule:
Governor’s Harbour – Nassau
MSN:
31-7652062
YOM:
1976
Flight number:
302
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7650
Aircraft flight hours:
11744
Circumstances:
On Tuesday December 2nd, 2014 at approximately 8:45 am (1345Z) a Ferg’s Air Limited, Piper PA-31-350 Navajo aircraft, registration C6-REV, operated as Southern Air Limited Flight 302, ditched in waters approximately 6nm from shore in the southwestern district of New Providence. The flight originated at Governor’s Harbour, Eleuthera (MYEM) with 10+1 persons on board at approximately 8:15 am in Visual Meteorological Conditions (VMC). At around 8:30am, the aircraft 15 nautical miles east of Lynden Pindling International Airport at 4,500 feet contacted Nassau Air Traffic Control Tower. The aircraft was instructed that runway 09 was in use and they can expect a landing on that runway. Upon final approach to runway 09, with the landing gears selected to the “EXTEND” position, only the nose and right main landing gear lights indicated the “down and locked” position. The left main landing gear light did not illuminate to indicate the “down and locked” position, so the landing was aborted and the pilot requested to go around so he could recycle and troubleshoot the landing gear issue. The pilot made a left turn, flew over the north western shoreline and recycled the landing gears a few times and also tried the emergency hand pump in an attempt to extend the gear. Despite all efforts, the left main landing gear light still did not illuminate to indicated the gear was in the safe “down and locked” position. At this time the aircraft was allowed to fly by the tower so that the controller may make a visual check of the landing gears to see if they were in the extended position. The controller advised the pilot that all gears “appeared to be extended”. Once again the pilot proceeded outbound to make another attempt for landing. For this approach the pilot made a right turn over the southwestern shoreline and proceeded downwind to runway 09. While on the downwind to runway 09 the pilot stated he began to experience problems with the right engine. The engine eventually stopped and all attempts to restart were unsuccessful. As a result of single engine operation, level flight could not be maintained even after retracting the gears and cleaning up the airplane. The decision was made by the pilot to ditch in the water vs. attempting to make the airport where numerous trees and obstacles would make the landing more difficult if the runway could not be made. After touching down on the water the most of the occupants were able to evacuate the aircraft through the normal and emergency exits before the aircraft sank into the ocean. One passenger died during the process. Witness stated that “the plane skipped across the water three times before rotating and hitting with a severe impact. The port (left) tail section received the bulk of the impact as did the port side of the plane.” Eye witness further stated that the passenger that died and “luggage from the baggage compartment were ejected from the rear of the plane on the port side.” “Multiple passengers could not swim or were extremely limited in their ability to swim.” Despite the plane having the full complement of survival equipment (life vests), only two were taken out of the aircraft. Passengers were holding on to bags and other debris that floated out of the aircraft as it submerged. Passengers helped each other until rescuers arrived to assist. Estimates from eye witness were that “the entire plane disappeared under water from 30 to 60 seconds after impact.” The depth where the aircraft came to rest on the water was reported as in excess of 6,500 feet. Once the aircraft settled, it submerged and was not able to be recovered. Safety concerns raised by eye witness could not be confirmed as the plane was never recovered.
Probable cause:
The AAIPU determines that the probable causes of this accident as:
- Engine failure and the inability of the aircraft to maintain a safe altitude.
Contributing Factors includes:
- Failure of the left main landing gear.
The following findings were identified:
1. Weather was not a factor in the accident.
2. Air Traffic Services were proper and did not contribute to the cause of the accident.
3. The pilot was properly certified, trained and qualified for the flight.
4. The loss of power on the right engine resulted in the aircraft inability to maintain a safe altitude.
5. The Police and other emergency services response were timely and effective.
6. The depth of the water where the aircraft came to rest made it impossible for the aircraft to be recovered.
7. The aircraft was properly maintained in accordance with Bahamas and United States regulations and maintenance practices.
Final Report:

Crash of a Rockwell Aero Commander 500A in McDade: 1 killed

Date & Time: Nov 23, 2014 at 0945 LT
Operator:
Registration:
N14AV
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Tomball – Austin
MSN:
500-914-22
YOM:
1960
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7075
Captain / Total hours on type:
168.00
Aircraft flight hours:
12859
Circumstances:
The airline transport pilot was conducting a cross-country repositioning flight. While en route to the destination airport, the pilot contacted air traffic control and stated that he was beginning to descend. No further radio transmissions were made by the pilot. Radar and GPS information showed, about the same time as the pilot's last transmission, the airplane's flightpath began descending in a westerly direction. The last recorded GPS point showed the airplane about 200 ft southwest of the initial impact point, 90 ft above ground level, and at a groundspeed of 66 knots. The airplane wreckage was located in an open field and impact signatures were consistent with a stall/spin, which had resulted in a near-vertical impact at a slow airspeed. The right propeller blades were found in the feathered position. Examination of the right engine found that the oil gauge housing extension was improperly secured to the oil gauge housing, which resulted in a loss of engine oil. Additionally, the examination revealed a hole in the right engine's crankcase, metal material in the oil sump, and signatures consistent with the lack of lubrication. Cockpit switches were positioned in accordance with the in-flight shutdown of the right engine. No anomalies were found with the left engine or airframe that would have precluded normal operation. Another pilot who had flown with the accident pilot reported that the pilot typically used the autopilot, and the autopilot system was found with the roll, heading, and pitch modes active. During the descent, no significant changes of heading were recorded, and the direction of travel before the stall was not optimal for the airplane to land before a fence line. It is likely that the autopilot was controlling the airplane's flightpath before the stall. Despite one operating engine, the pilot did not maintain adequate airspeed and exceeded the airplane's critical angle-of-attack (AOA), which resulted in an aerodynamic stall/spin. Correcting the last GPS recorded airspeed for prevailing wind, the airplane's indicated airspeed would have been about 72 knots, which is above the airplane's 0-bank stall speed, but an undetermined mount of bank would have been applied to maintain heading, which would have accelerated the stall speed. It could not be determined why the pilot did not maintain adequate airspeed or notify air traffic controller of an engine problem. Although a review of the pilot's medical records revealed that he had several historical medical conditions and the toxicology tests detected several sedating allergy medications in his system, it was inconclusive whether the medical conditions or medications impaired the pilot's ability to fly the airplane or if the pilot was incapacitated. It is also possible that the pilot was distracted by the loss of oil from the right engine and that this resulted in his failure to maintain adequate airspeed, his exceedance of the airplane's critical AOA, and a subsequent stall/spin; however, based on the available evidence, the investigation could not determine the reason for the pilot's lack of corrective actions.
Probable cause:
The pilot's failure to maintain adequate airspeed and his exceedance of the airplane's critical angle-of-attack for reasons that could not be determined based on the available evidence, which resulted in an aerodynamic stall/spin. Contributing to the accident was the improperly installed oil gauge housing extension, which resulted in a loss of oil quantity and right engine power.
Final Report:

Crash of a Cessna 207 Stationair near La Molina: 3 killed

Date & Time: Nov 20, 2014 at 1430 LT
Operator:
Registration:
PNP-248
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Lima – Pisco
MSN:
207-0379
YOM:
1977
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The single engine aircraft departed Lima-Callao-Jorge Chávez Airport bound for Pisco. While cruising in foggy conditions east of Lima, the airplane collided with a mountain located between La Molina and Villa Maria del Triunfo. The wreckage was found in the evening, around 1840LT, and all three occupants were killed.
Probable cause:
Controlled flight into terrain.

Crash of a Cessna 208B Grand Caravan in Great Slave Lake

Date & Time: Nov 20, 2014 at 0721 LT
Type of aircraft:
Operator:
Registration:
C-FKAY
Flight Phase:
Survivors:
Yes
Schedule:
Yellowknife – Fort Simpson
MSN:
208B-0470
YOM:
1995
Flight number:
8T223
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3500
Captain / Total hours on type:
1800.00
Aircraft flight hours:
25637
Circumstances:
The Air Tindi Ltd. Cessna 208B Caravan departed Yellowknife Airport, Northwest Territories, on 20 November 2014 at 0642 Mountain Standard Time under instrument flight rules as Discovery Air flight DA223 to Fort Simpson, Northwest Territories. The flight had been rescheduled from the previous night because of freezing drizzle at Fort Simpson. During the climb to 8000 feet above sea level, DA223 encountered icing conditions that necessitated a return to Yellowknife. On the return to Yellowknife, DA223 was unable to maintain altitude. At 0721, flying in darkness approximately 18 nautical miles west of Yellowknife, it contacted the frozen surface of the North Arm of Great Slave Lake. The aircraft sustained substantial damage when it struck a rock outcropping, but there were no injuries to the pilot or to the 5 passengers. The pilot established communication with Air Tindi via satellite phone, and the pilot and passengers were recovered approximately 4 hours after the landing. The emergency locator transmitter did not activate during the landing, but was activated manually by the pilot.
Probable cause:
Findings as to causes and contributing factors:
1. Not using all enroute information led the pilot to underestimate the severity and duration of the icing conditions that would be encountered.
2. Inadequate awareness of aircraft limitations in icing conditions and incomplete weight-and-balance calculations led to the aircraft being dispatched in an overweight state for the forecast icing conditions. The aircraft centre of gravity was not within limits, and this led to a condition that increased stall speed and reduced aircraft climb performance.
3. The pilot’s expectation that the flight was being undertaken at altitudes where it should have been possible to avoid icing or to move quickly to an altitude without icing conditions led to his decision to continue operation of the aircraft in icing conditions that exceeded the aircraft’s performance capabilities.
4. The severity of the icing conditions encountered and the duration of the exposure resulted in reductions in aerodynamic performance, making it impossible to prevent descent of the aircraft.
5. The inability to arrest descent of the aircraft resulted in the forced landing on the surface of Great Slave Lake and the collision with terrain.
6. The Type C pilot self-dispatch system employed by Air Tindi did not have quality assurance oversight or adequate support systems. This contributed to the aircraft being dispatched in conditions not suitable for safe flight.
Findings as to risk:
1. If passenger briefings on cabin door operations are ineffective, there is a risk of passenger egress in an accident being compromised, affecting survivability.
2. If survival equipment is stowed in a location that may be inaccessible following an accident, such as the belly pod, there is a risk of survival being compromised if search and rescue is delayed.
Other findings:
1. The aircraft was under control and in a level attitude when it contacted the ice. This minimized structural damage and increased survivability for the aircraft’s occupants.
2. The survival skills of the crew and passengers were indispensable in a situation in which access to the survival equipment on the aircraft was limited.
Final Report: