Crash of a Beechcraft E90 King Air in Casigua El Cubo: 3 killed

Date & Time: Sep 19, 2014
Type of aircraft:
Operator:
Registration:
YV1537
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Anaco – Santa Bárbara del Zulia
MSN:
LW-309
YOM:
1979
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
En route from Anaco to Santa Bárbara del Zulia, the twin engine aircraft crashed in unknown circumstances by a wooded area located near Casigua El Cubo. The aircraft was destroyed by a post crash fire and all three occupants were killed. It is believed that the aircraft was engaged in an illegal contraband flight.

Crash of a Socata TBM-900 off Port Antonio: 2 killed

Date & Time: Sep 5, 2014 at 1410 LT
Type of aircraft:
Operator:
Registration:
N900KN
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Rochester - Naples
MSN:
1003
YOM:
2014
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7100
Captain / Total hours on type:
4190.00
Aircraft flight hours:
97
Circumstances:
The commercial pilot and his wife departed New York in their turboprop airplane on a crosscountry flight to Florida. About 1 hour 40 minutes into the flight and while cruising at flight level (FL) 280, the pilot notified air traffic control (ATC) of an abnormal indication in the airplane and requested a descent to FL180. The responding controller instructed the pilot to descend to FL250 and turn left 30°, and the pilot acknowledged and complied with the instruction; he then again requested a lower altitude. Although the pilot declined emergency handling and did not specify the nature of the problem, the controller independently determined that the flight had encountered a pressurization issue and immediately coordinated with another ATC facility to clear nearby traffic. The controller then issued instructions to the pilot to descend to FL200 and change course; however, the pilot did not comply with the assignments despite acknowledging the instructions multiple times. The pilot's failure to comply with the controller's instructions, his long microphone pauses after concluding a statement over the radio, and his confusion were consistent with cognitive impairment due to hypoxia. Further, the pilot's transmissions to ATC indicated impairment within 2 minutes 30 seconds of reporting the abnormal indication, which is consistent with the Federal Aviation Administration's published time of useful consciousness/effective performance time ranges for the onset of hypoxia. Military airplanes were dispatched about 30 minutes after the pilot's final transmission to ATC to intercept and examine the airplane. The pilots of the military airplanes reported that the airplane appeared to be flying normally at FL250, that both occupants appeared to be asleep or unconscious, and that neither occupant was wearing an oxygen mask. Photographs taken from one of the military airplanes revealed that the airplane's emergency exit door was recessed into the fuselage frame, consistent with a depressurized cabin. The military airplanes escorted the airplane as it continued on a constant course and altitude until it approached Cuban airspace, at which point they discontinued their escort. Radar data indicated that the airplane continued on the same flight track until about 5 hours 48 minutes after takeoff, when it descended to impact in the Caribbean Sea north of Jamaica. The flight's duration was consistent with a departure with full fuel and normal cruise endurance. Some of the wreckage, including fuselage and engine components, was recovered from the ocean floor about 4 months after the accident. Data recovered from nonvolatile memory in the airplane's global air system controller (GASC) indicated that several fault codes associated with the cabin pressurization system were registered during the flight. These faults indicated that the overheat thermal switch (OTSW), which was associated with overheat protection, had activated, which resulted in a shutdown of the engine bleed air supply to the cabin pressurization system. Without a bleed air supply to maintain selected cabin pressure, the cabin altitude would have increased to the altitude of the outside environment over a period of about 4 minutes. The faults recorded by the GASC's nonvolatile memory and associated system alerts/warnings would have been displayed to the pilot, both as discrete system anomaly messages on the crew alerting system (CAS) and as master warning and/or master caution annunciations. A witness report indicated that the pilot was known to routinely monitor cabin altitude while flying in the airplane and in his previous pressurized airplanes. Based on his instrument scanning practices and the airplane's aural warning system, he likely would have observed any CAS message at or near its onset. Thus, the CAS messages and the associated alerts were likely the precipitating event for the pilot's call to ATC requesting a lower altitude. The pilot was likely not familiar with the physiological effects of hypoxia because he had not recently been in an altitude chamber for training, but he should have been familiar with the airplane's pressurization system emergency and oxygen mask donning procedures because he had recently attended a transition course for the accident airplane make and model that covered these procedures. However, the pressurization system training segment of the 5-day transition course comprised only about 90 minutes of about 36 total hours of training, and it is unknown if the pilot would have retained enough information to recognize the significance of the CAS messages as they appeared during the accident flight, much less recall the corresponding emergency procedures from memory. Coupled with the pilot's reported diligence in using checklists, this suggests that he would have attempted a physical review of the emergency procedures outlined in the Pilot's Operating Handbook (POH). A review of the 656-page POH for the airplane found that only one of the four emergency checklist procedures that corresponded to pressurization system-related CAS messages included a step to don an oxygen mask, and it was only a suggestion, not a mandatory step. The combined lack of emergency guidance to immediately don an oxygen mask and the rapid increase in the cabin altitude significantly increased the risk of hypoxia, a condition resistant to self-diagnosis, especially for a person who has not recently experienced its effects in a controlled environment such as an altitude chamber. Additionally, once the pilot reported the problem indication to ATC, he requested a descent to FL180 instead of 10,000 ft as prescribed by the POH. In a second transmission, he accepted FL250 and declined priority handling. These two separate errors were either early signs of cognitive dysfunction due to hypoxia or indications that the pilot did not interpret the CAS messages as a matter related to the pressurization system. Although the cabin bleed-down rate was 4 minutes, the pilot showed evidence of deteriorating cognitive abilities about 2 minutes 30 seconds after he initially reported the problem to ATC. Ultimately, the pilot had less than 4 minutes to detect the pressurization system failure CAS messages, report the problem to ATC, locate the proper procedures in a voluminous POH, and complete each procedure, all while suffering from an insidious and mentally impairing condition that decreased his cognitive performance over time. Following the accident, the airplane manufacturer revised the emergency procedures for newly manufactured airplanes to require flight crews to don their oxygen masks as the first checklist item in each of the relevant emergency checklists. Further, the manufacturer has stated that it plans to issue the same revisions for previous models in 2017. The airplane manufacturer previously documented numerous OTSW replacements that occurred between 2008 and after the date of the accident. Many of these units were removed after the GASC systems in their respective airplanes generated fault codes that showed an overheat of the bleed air system. Each of the OTSWs that were tested at the manufacturer's facility showed results that were consistent with normal operating units. Additionally, the OTSW from the accident airplane passed several of the manufacturer's functional tests despite the presence of internal corrosion from sea water. Further investigation determined that the pressurization system design forced the GASC to unnecessarily discontinue the flow of bleed air into the cabin if the bleed air temperature exceeded an initial threshold and did not subsequently fall below a secondary threshold within 30 seconds. According to the airplane manufacturer, the purpose of this design was to protect the structural integrity of the airplane, the system, and the passengers in case of overheat detection. As a result of this accident and the ensuing investigation, the manufacturer made changes to the programming of the GASC and to the airplane's wiring that are designed to reduce the potential for the GASC to shut off the flow of bleed air into the cabin and to maximize the bleed availability. Contrary to its normal position for flight, the cockpit oxygen switch was found in the "off" position, which prevents oxygen from flowing to the oxygen masks. A witness's description of the pilot's before starting engine procedure during a previous flight showed that he may not have precisely complied with the published procedure for turning on the oxygen switch and testing the oxygen masks. However, as the pilot reportedly was diligent in completing preflight inspections and checklists, the investigation could not determine why the cockpit oxygen switch was turned off. Further, because the oxygen masks were not observed on either occupant, the position of the oxygen switch would not have made a difference in this accident.
Probable cause:
The design of the cabin pressurization system, which made it prone to unnecessary shutdown, combined with a checklist design that prioritized troubleshooting over ensuring that the pilot was sufficiently protected from hypoxia. This resulted in a loss of cabin pressure that rendered the pilot and passenger unconscious during cruise flight and eventually led to an in-flight loss of power due to fuel exhaustion over the open ocean.
Final Report:

Crash of a Fokker F27 Friendship 500 near Kogatende: 3 killed

Date & Time: Aug 31, 2014 at 1945 LT
Type of aircraft:
Registration:
5Y-SXP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mwanza - Nairobi
MSN:
10681
YOM:
1985
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The aircraft departed Mwanza Airport at 1926LT on a cargo flight Nairobi. While passing FL169, the aircraft entered an uncontrolled descent. It passed FL146 at an excessive speed of 430 knots and eventually crashed in an open field located near Kogatende. The wreckage was found the following morning. The aircraft disintegrated on impact and all three occupants were killed.

Crash of a Let L-410UVP near Mulume Munene: 4 killed

Date & Time: Aug 23, 2014 at 1355 LT
Type of aircraft:
Operator:
Registration:
9Q-CXB
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Bukavu - Kama
MSN:
82 09 25
YOM:
1982
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The twin engine aircraft departed Bukavu-Kavumu Airport at 1342LT on a cargo flight to Kama, carrying two pilots, two passengers and a load of 1,500 kilos of books. Some 10 minutes later, the crew changed his frequency and no further contact was established. As the aircraft failed to arrive in Kama, Maniema Province, SAR operations were initiated. The crew of two helicopters from the same operator spotted the burnt wreckage two days later, in the region of Mulume Munene, some 30 km southwest of Bukavu. The aircraft was destroyed by impact forces and a post crash fire and all four occupants were killed.
Probable cause:
It is believed that the crew lost control of the aircraft following an engine failure in flight for unknown reasons.

Crash of a Socata TBM-700 in Saint-Jean-les-Deux-Jumeaux: 2 killed

Date & Time: Aug 6, 2014 at 1030 LT
Type of aircraft:
Operator:
Registration:
N129AG
Flight Phase:
Survivors:
Yes
Schedule:
Cannes – Courtrai
MSN:
171
YOM:
2000
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3000
Captain / Total hours on type:
700.00
Aircraft flight hours:
1385
Aircraft flight cycles:
1219
Circumstances:
The single engine aircraft departed Cannes-Mandelieu Airport at 1040LT bound for Courtrai-Wevelgem Airport, Belgium, with four passengers and one pilot on board. About one hour and 40 minutes into the flight, while cruising in IMC conditions at FL240, the aircraft start a quick descent to the right until FL149. Speed increased and the overspeed warning sound came on. Forty-five seconds after the start of the quick descent, the airplane initiated a climb with a rate of 10,000 feet per minute until it stalled at FL201, still in IMC conditions. The airplane then entered a dive and went into a flat attitude when it went out of clouds at an altitude estimated between 1,000 and 2,000 feet. This altitude was insufficient to the pilot to regain control and without external visual references, he lost control of the airplane that crashed in a wooded area. The pilot and a passenger were killed while three other passengers were injured. The aircraft was destroyed.
Probable cause:
Due to the absence of any flight data recorder, investigations were unable to determine with certainty the exact cause and circumstances of the accident.
Final Report:

Crash of an MD-83 near Gossi: 116 killed

Date & Time: Jul 24, 2014 at 0147 LT
Type of aircraft:
Operator:
Registration:
EC-LTV
Flight Phase:
Survivors:
No
Site:
Schedule:
Ouagadougou - Algiers
MSN:
53190/2148
YOM:
1996
Flight number:
AH5017
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
110
Pax fatalities:
Other fatalities:
Total fatalities:
116
Captain / Total flying hours:
12988
Captain / Total hours on type:
10007.00
Copilot / Total flying hours:
7016
Copilot / Total hours on type:
6180
Aircraft flight hours:
38362
Aircraft flight cycles:
32390
Circumstances:
The Swiftair MD-83 was performing flight AH5017 on behalf of Air Algérie (this regular schedule is performed four times a week). The aircraft left Ouagadougou at 0117Z and was attempting to land in Algiers at 0510LT but failed to arrive. 116 people (110 passengers and a crew of 6) were on board. The last position of the MD-83 was west of Gao, Mali. In the evening of July 24 (some 16 hours after the aircraft disappearance), the wreckage was eventually located and spotted some 50 km west of the city of Gossi, south Mali. The aircraft disintegrated on impact and no survivors was found among the 116 occupants. At the time of the accident, bad weather conditions with storm activity, winds, turbulence and icing was confirmed over the region of Gao, until an altitude of 40,000 feet. At the time of the accident, the aircraft was flying west of this marginal weather area and referring to the French BEA graphic, the aircraft did not properly get around this turbulent area. It was confirmed the aircraft started a left turn from the altitude of 31,000 feet and then spiraled to the ground in less than three minutes (140° bank left and 80° nose down until impact). The last position recorded by the FDR at 0147LT and 15 seconds was at the altitude of 1,600 feet (490 meters) and at a speed of 380 KIAS (740 km/h) with a very high rate of descent.
Probable cause:
About two minutes after leveling off at an altitude of 31,000 ft, calculations performed by the manufacturer and validated by the investigation team indicate that the recorded EPR, the main parameter for engine power management, became erroneous on the right engine and then about 55 seconds later on the left engine. This was likely due to icing of the pressure sensors located on the engine nose cones. If the engine anti-ice protection system is activated, these pressure sensors are heated by hot air. Analysis of the available data indicates that the crew likely did not activate the system during climb and cruise. As a result of the icing of the pressure sensors, the erroneous information transmitted to the auto throttle meant that the latter limited the thrust delivered by the engines. Under these conditions, the thrust was insufficient to maintain cruise speed and the aeroplane slowed down. The autopilot then commanded an increase in the airplane's pitch attitude in order to maintain the altitude in spite of this loss of speed. This explains how, from the beginning of the error in measuring the EPR values, the airplane’s speed dropped from 290 kt to 200 kt in about 5 minutes and 35 seconds and the angle of attack increased until the aeroplane stalled. About 20 seconds after the beginning of the aeroplane stall, the autopilot was disengaged. The aeroplane rolled suddenly to the left until it reached a bank angle of 140°, and a nose-down pitch of 80°. The recorded parameters indicate that there were no stall recovery maneuvers by the crew. However, in the moments following the aeroplane stall, the flight control surfaces remained deflected nose-up and in a right roll. It was concluded that the accident was caused by the combination of several factors, among them the fact that the engine anti-icing systems were not activated by the crew. The final report is not available in English yet.
Final Report:

Crash of a Boeing 777-2H6ER near Hrabove: 298 killed

Date & Time: Jul 17, 2014 at 1620 LT
Type of aircraft:
Operator:
Registration:
9M-MRD
Flight Phase:
Survivors:
No
Schedule:
Amsterdam – Kuala Lumpur
MSN:
28411/84
YOM:
1997
Flight number:
MH017
Country:
Region:
Crew on board:
15
Crew fatalities:
Pax on board:
283
Pax fatalities:
Other fatalities:
Total fatalities:
298
Captain / Total flying hours:
12385
Captain / Total hours on type:
7303.00
Copilot / Total flying hours:
3190
Copilot / Total hours on type:
227
Aircraft flight hours:
76322
Aircraft flight cycles:
11434
Circumstances:
Flight MH17 departed the gate at Amsterdam-Schiphol Airport, the Netherlands at 12:13 hours local time, bound for Kuala Lumpur, Malaysia. It was airborne at 12:31 (10:31 UTC) from runway 36C and reached a cruising altitude of FL310 at 12:53 (10:53 UTC). Ninety minutes into the flight, at 12:01 UTC and just prior to entering Ukrainian airspace, the flight climbed to FL330. According to the flight plan, flight MH17 would continue at the flight level until the waypoint PEKIT, which is on the Flight Information Region (FIR) boundary between Kiev FIR (UKBV) and Dnipropetrovs’k FIR (UKDV). From waypoint PEKIT the flight plan indicates a climb to FL350 on airway L980 for the remaining part over Ukraine. According to ATC data, at 12:53 UTC the aircraft was flying within the Dnipropetrovs’k FIR, Control Sector 2, at FL330, controlled by Dnipro Control. At that time, Dnipro Control asked whether MH17 was able to climb to FL350 in accordance with the flight plan and also to clear a potential separation conflict with other traffic in the area. This traffic was Singapore Airlines flight SQ351 from Copenhagen, a Boeing 777, flying at FL330 and approaching from behind. The crew replied they were unable to comply and requested to maintain at FL330. This was agreed by Dnipro Control. As an alternative to solve the separation conflict, the other traffic climbed to FL350. According to ATC data, at 13:00 UTC the crew of flight MH17 requested to divert the track 20 NM to the left, due to weather. This also was agreed by Dnipro Control, after which the crew requested whether FL340 was available. Dnipro control informed MH17 that FL340 was not available at that moment and instructed the flight to maintain FL330 for a while. At 13:07 UTC the flight was transferred to Dnipropetrovs’k CTA 4, also with call sign Dnipro Control. At 13:19:53 UTC, radar data showed that the aircraft was 3.6 NM north of centreline of airway L980 having deviated left of track, when Dnipro Control directed the crew to alter their route directly to waypoint RND due to other traffic. The crew acknowledged at 13:19:56 hrs. At 13.20:00 hrs, Dnipro Control transmitted an onward ATC clearance to "proceed direct to TIKNA after RND", no acknowledgement was received. Data from the Flight Data Recorder and the Digital Cockpit Voice Recorder both stopped at 13:20:03 hrs. No distress messages were received from the aircraft. The airplane apparently broke up in mid-air as debris was found in a large area. The centre section of the fuselage along with parts of the horizontal and vertical stabilizers was found near Hrabove. The cockpit and lower nose section came down in a sunflower field in Rozsypne, nearly four miles (6,5 km) west-southwest of Hrabove. The L2 and R2 doors along with various parts of the fuselage were found near Petropavlivka, about 5 miles (8 km) west of Hrabove. At the point of last contact it was flying 1000 feet above airspace that had been classified as restricted by Ukrainian authorities as a result of ongoing fighting in the area. In the preceding days before the accident two Ukraine Air Force aircraft that were shot down in the region: a Su-25 and an An-26 transport plane.
Probable cause:
Causes of the crash:
a. On 17 July 2014, Malaysia Airlines operated flight MH17, an airworthy Boeing 777-200 with the registration 9M-MRD, in cruise flight near the Ukrainian/Russian border at 33,000 feet, under the control of Ukrainian Air Traffic Control and was operated by a competent and qualified crew.
b. At 13.20:03 hours (15.20:03 CET) a warhead detonated outside and above the left hand side of the cockpit of flight MH17. It was a 9N314M warhead carried on the 9M38-series of missiles as installed on the Buk surface-to-air missile system.
c. Other scenarios that could have led to the disintegration of the aeroplane were considered, analyzed and excluded based on the evidence available.
d. The impact killed the three persons in the cockpit and caused structural damage to the forward part of the aeroplane leading to an in-flight break-up. The break-up resulted in a wreckage area of 50 square km between the village of Petropavlivka and the town of Hrabove, Ukraine. All 298 occupants lost their lives.
Final Report:

Crash of an Antonov AN-26 in Izvaryne: 2 killed

Date & Time: Jul 14, 2014 at 1200 LT
Type of aircraft:
Operator:
Registration:
19 blue
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
97 10
YOM:
1980
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The aircraft was flying over the Luhansk oblast at an altitude of some 6,500 metres when it was hit by a surface-to-air missile. All eight crew members were able to bail out. The aircraft entered an uncontrolled descent and crashed in an open field located in Izvaryne, near the Russian border. Four crew were uninjured, two others were taken prisoners by pro-Russian separatists and two others were killed.
Probable cause:
Shot down.

Crash of a Britten Norman BN-2A Islander near Chirundu

Date & Time: Jul 6, 2014 at 1630 LT
Type of aircraft:
Registration:
9Q-CYA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lanseria – Lubumbashi
MSN:
617
YOM:
1970
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew departed Lanseria on a positioning flight to Lubumbashi where the aircraft was based. En route, the crew encountered engine problems and elected to make an emergency landing on the Lusaka - Chirundu Road. Eventually, the twin engine aircraft crashed in a cliff. Both occupants were injured and the aircraft was destroyed.

Crash of a Learjet 35A near Olsberg: 2 killed

Date & Time: Jun 23, 2014 at 1438 LT
Type of aircraft:
Operator:
Registration:
D-CGFI
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hohn - Hohn
MSN:
35A-612
YOM:
1985
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7505
Captain / Total hours on type:
3554.00
Copilot / Total flying hours:
3560
Copilot / Total hours on type:
745
Aircraft flight hours:
8259
Circumstances:
On 23 June 2014 at 1522 hrs the Bundeswehr (German Armed Forces) informed the German Federal Bureau of Aircraft Accident Investigation (BFU) that a collision involving a civil Learjet 35A (Learjet) and a German Air Force Eurofighter had occurred during aerial target demonstrations. According to the Law Relating to the Investigation into Accidents and Incidents Associated with the Operation of Civil Aircraft (FlUUG) accidents and incidents involving civil and military aircraft will be investigated under the responsibility of the BFU. The BFU immediately deployed a team of five investigators to the accident site. The BFU was supported by the Directorate Aviation Safety of the German Armed Forces (AbtFlSichhBw). The Learjet, operated by a civil operator specializing in manned aerial target demonstrations, had taken off at Hohn Airport and had initially been flying with a southern heading in accordance with Instrument Flight Rules (IFR). At the time of the accident the Learjet had changed to Visual Flight Rules (VFR) and was flying in airspace E with a northern heading. A formation consisting of two Eurofighters had taken off from Nörvenich Air Base with the order to conduct a so-called Renegade mission, i.e. the unknown civil aircraft had to be intercepted, identified, and accompanied to a military airport. After the collision with a Eurofighter, the Learjet crashed to the ground. The pilots of the Learjet suffered fatal injuries and the aircraft was destroyed. The pilot of the Eurofighter could land the severely damaged airplane at Nörvenich Air Base.
Probable cause:
The causes of the flight accident were:
Immediate Causes:
- During positioning for the intervention the collision risk due to unexpected manoeuvres of the intercepted airplane was not sufficiently taken into consideration.
- The Learjet crew did not take into account the risks due to possible limitations of the field of vision and the distraction by using the computer when deciding about the task distribution. Due to insufficient situational awareness during the intervention, the Learjet crew continued the turn with an excessive bank angle despite the loss of visual contact with the Eurofighter flying at the inside of the turn.
Systemic Causes:
- The operator had not specified in detail how the crew should distribute their tasks during Renegade exercises.
- Neither the operator commissioned to conduct the aerial target demonstration nor the Air Force had sufficiently described the Renegade training nor had a commensurate risk analysis been done.
Final Report: