Crash of a Sukhoï Superjet 100-95 on Mt Salak: 45 killed

Date & Time: May 9, 2012 at 1431 LT
Type of aircraft:
Operator:
Registration:
97004
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Jakarta - Jakarta
MSN:
95004
YOM:
2009
Flight number:
RA36801
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
41
Pax fatalities:
Other fatalities:
Total fatalities:
45
Captain / Total flying hours:
10347
Captain / Total hours on type:
1348.00
Copilot / Total flying hours:
3318
Copilot / Total hours on type:
625
Aircraft flight hours:
843
Aircraft flight cycles:
500
Circumstances:
Aircraft was performing a demo flight and left Jakarta-Halim Perdanakasuma Airport at 1400LT with 41 passengers (potential buyers) on board and a crew of four. About thirty minutes later, while turning around Mount Salak, pilots received the authorization to descend from 10,000 feet to 6,000 feet in low visibility. Aircraft hit the edge of a cliff and crashed few yards further and was totally destroyed by impact and post impact fire. SAR teams arrived on scene 18 hours later and all 45 occupants were killed. At the time of the accident, weather conditions were marginal with clouds shrouding both Mount Salak and Mount Gede. First accident involving a Sukhoi Superjet 100. Present model was manufactured 09AUG2009 and totalized 843 flying hours for 500 cycles. Captain had 10,347 flying hours and was a test pilot by Sukhoi Civil Aircraft Company.
Probable cause:
- The flight crew was not aware of the mountainous area in the vicinity of the flight path due to various factors such as available charts, insufficient briefing and statements of the potential customer that resulted in inappropriate response to the TAWS warning. The impact could have been avoided by appropriate action of the pilot up to 24 seconds after the first TAWS warning.
- The Jakarta Radar service had not established the minimum vectoring altitudes and the Jakarta Radar system was not equipped with functioning MSAW for the particular area around Mount Salak.
- Distraction of the flight crew from prolonged conversation not related to the progress of the flight, resulted in the pilot flying not constantly changing the aircraft heading while in orbit. Consequently, the aircraft unintentionally exited the orbit.
Final Report:

Crash of a Pilatus PC-6/B2-H4 Turbo Porter in Muaritan: 2 killed

Date & Time: Apr 25, 2012 at 1730 LT
Operator:
Registration:
PK-VVQ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Balikpapan - Balikpapan
MSN:
965
YOM:
2009
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1912
Captain / Total hours on type:
81.00
Aircraft flight hours:
2397
Aircraft flight cycles:
3466
Circumstances:
The Pilatus Porter PC-6 aircraft operated by PT. Puji Astuti Aviation (Susi Air) registered PK-VVQ on Areal Survey Flight, departed from Sepinggan-Balikpapan to Melak Area on 25 April 2012 at 0440 UTC (Universal Time Coordinate) or 1240 LT. There were one pilot and one pasenger on board, the estimate flight endurance was seven hours. At 0505 the aircraft reported leaving Balikpapan Approach. At 0910 the aircraft was reported to Melak Radio on radial 060 at the altitude of 3,500 feet, and that it would be leaving Survey after a further twenty minutes. Melak Radio reported that the aircraft lost contact at 0930. At 0922 a text message was sent by the passenger to his employer stating “Run out of fuel, landing on road”. The Search and Rescue Bureau informed that a distress signal was tetected on 1025 at the position of 00 25’.02” N 116.02’.48”E. On 26 April 2012 at 1730 UTC the aircraft was found in Muaritan – Kecamatan Tabang, Kutai Karta Negara at the position 00 25’.03” N 116.01’.55”E. The aircraft was substantially damaged, the pilot and the passenger were fatally injured.
Probable cause:
The engine flamed out caused by lack of fuel supply from main fuel tank to the engine. The pilot likely fixated on the survey flight execution and lost awareness of his fuel situation. The transferring of fuel from the auxiliary tank was not performed during the flight as required. The combination of inexperience of the pilot related to survey flying, fatigue and the highly demanding survey operator contributed to this sequence of events.
Final Report:

Crash of a PZL-Mielec AN-2R in Dârvari

Date & Time: Apr 23, 2012 at 0845 LT
Type of aircraft:
Operator:
Registration:
YR-BOR
Flight Phase:
Survivors:
Yes
Schedule:
Şirna - Şirna
MSN:
1G192-13
YOM:
1981
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4500
Copilot / Total flying hours:
5550
Aircraft flight hours:
5467
Circumstances:
The crew departed Şirna Aerodrome around 0830LT on a local spraying mission. About 15 minutes into the flight, the crew encountered engine problems and elected to make an emergency landing. He found a suitable terrain and attempted to land when the aircraft collided with a small concrete wall and some bushes before coming to rest in an open field. Both pilots escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
Failure of the crew who selected an unsuitable terrain for an emergency landing (rough terrain) and did not take into consideration the wind component.
Final Report:

Crash of a Cessna 421C Golden Eagle III in the Gulf of Mexico: 1 killed

Date & Time: Apr 19, 2012 at 1208 LT
Operator:
Registration:
N48DL
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Slidell - Sarasota
MSN:
421C-0511
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2350
Aircraft flight hours:
4659
Circumstances:
According to a statement provided by the Jacksonville Center air traffic control (ATC) facility, the pilot contacted ATC while at flight level 270. About 25 minutes later, the airplane began to deviate from the ATC-assigned altitude and route. The controller’s attempts to contact the pilot were unsuccessful. The North American Aerospace Defense Command launched military fighter aircraft to intercept the airplane. The military pilots reported that the airplane was circling in a left turn at a high altitude and low airspeed and that its windows were partially frosted over. They also reported that the pilot was slumped over in the cockpit and not moving. They fired flares, and the pilot continued to be unresponsive. The airplane circled for about 3 hours before it descended into the Gulf of Mexico and sank. The pilot and airplane were not recovered. Review of the pilot’s Federal Aviation Administration medical records did not reveal any recent medical conditions that would have deemed him unfit to fly.
Probable cause:
Pilot incapacitation, which resulted in the pilot’s inability to maintain airplane control and the airplane’s subsequent ocean impact.
Final Report:

Crash of a Beechcraft C90GTi King Air off Oranjestad

Date & Time: Apr 3, 2012 at 0920 LT
Type of aircraft:
Operator:
Registration:
N8116L
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Wichita - Fort Lauderdale - Willemstad - Belo Horizonte
MSN:
LJ-2042
YOM:
2011
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11700
Captain / Total hours on type:
2600.00
Copilot / Total flying hours:
3649
Copilot / Total hours on type:
33
Aircraft flight hours:
14
Circumstances:
On April 3, 2012, about 0920 atlantic standard time (ast), a Hawker Beechcraft C90GTx, N8116L, operated by Lider Taxi Aereo, was substantially damaged after ditching in the waters of the Caribbean Sea, 17 miles north of Aruba, following a dual loss of engine power during cruise. The flight departed Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida, and was destined for Hato International Airport (TNCC), Willemstad, Curacao. The airline transport pilot and the pilot rated passenger were uninjured. Visual meteorological conditions prevailed, and an instrument flight plan was filed for the delivery flight conducted under 14 Code of Federal Regulations Part 91. The Amsterdam arrived at the ditching location at 1120. The airplane was partially submerged. The crew of the Amsterdam attempted to prevent the airplane from sinking by placing a cable around it and hoisting it onboard. However during the attempted recovery, the fuselage broke in half and the airplane sank.
Probable cause:
Review of the fuel ticket revealed that the misspelled words; "Top Neclles" was handwritten on it. It was also signed by the pilot. Further review revealed that only 25 gallons had been uploaded to the airplane, and this number had been entered in the box labeled "TOTAL GALLONS DELIVERED". Review of the start reading and end reading from the truck meter also concurred with this amount. Furthermore, It was discovered that the "134 gallons" that the pilot believed had been uploaded to the airplane was in fact the employee number of the fueler that had topped off the nacelle tanks and had entered his employee number on the "FUEL DEL BY:" line. Utilizing the information contained on the fuel ticket, it was determined that the airplane had departed with only 261 gallons of fuel on-board. Review of performance data in the POH/AFM revealed that in order to complete the flight the airplane would have needed to depart with 328 gallons on-board.
Final Report:

Crash of a Pilatus AU-23A Turbo Porter in Phanom Thuan

Date & Time: Mar 23, 2012 at 1500 LT
Operator:
Registration:
74-2082
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Prachuap Khiri Khan - Prachuap Khiri Khan
MSN:
2082
YOM:
1974
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft departed Prachuap Khiri Khan for a local training flight, carrying two pilots and one engineer. En route, the crew encountered technical problems with the engine and was forced to attempt an emergency landing in a field located in the Phanom Thuan District. The aircraft was damaged beyond repair while both pilots were uninjured. The engineer was slightly injured.

Crash of a Beechcraft 350 Super King Air in Puerto Aguirre: 8 killed

Date & Time: Mar 22, 2012 at 0056 LT
Operator:
Registration:
CC-AEB
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Punta Arenas - Santiago
MSN:
FL-128
YOM:
1995
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
2578
Captain / Total hours on type:
61.00
Copilot / Total flying hours:
2296
Copilot / Total hours on type:
118
Aircraft flight hours:
6218
Circumstances:
The twin engine aircraft was performing an ambulance flight from Puntas Arenas to Santiago with two pilots on board, one patient, three doctors and two relatives. Following an uneventful flight at FL280, the crew was cleared to descend when the aircraft entered an uncontrolled descent while the crew was in contact with Puerto Montt ATC. The aircraft dove into the ground and crashed on the north slope of the Macá volcano, some 10 km northeast of Puerto Aguirre. The wreckage was found in the morning of March 24 at an altitude of 2,347 metres. The aircraft disintegrated and all 8 occupants were killed.
Probable cause:
The exact cause of the accident could not be determined.
Final Report:

Crash of an Antonov AN-2 near Byelaya Kalitva

Date & Time: Mar 22, 2012
Type of aircraft:
Operator:
Registration:
FLA-1041K
Flight Phase:
Flight Type:
Survivors:
Yes
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine airplane crashed in unknown circumstances in a forest located 50 km north of Byelaya Kalitva, Rostov oblast. There were no casualties but the aircraft was damaged beyond repair. The circumstances of the accident remains unknown. The flight was considered as illegal as this registration was not officially recorded in the Russian Civil Aviation register.

Crash of a Lockheed C-130J-30 Super Hercules near Kiruna: 5 killed

Date & Time: Mar 15, 2012 at 1457 LT
Type of aircraft:
Operator:
Registration:
5630
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Harstad - Kiruna
MSN:
5630
YOM:
2010
Flight number:
HAZE 01
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
6153
Captain / Total hours on type:
5937.00
Copilot / Total flying hours:
3285
Copilot / Total hours on type:
243
Aircraft flight hours:
856
Circumstances:
The accident occurred during a Norwegian military transport flight from Harstad/Narvik Airport (Evenes) in Norway to Kiruna Airport in Sweden. The flight was performed as a part of the Norwegian-led military exercise Cold Response. The aircraft, which was of the model C-130J-30 Super Hercules, had the call sign HAZE 01. HAZE 01 took off with a crew of four and one passenger on board. The aircraft climbed to Flight Level 130 and assumed a holding pattern south of Evenes. After one hour, the flight continued towards Kiruna Airport. The Norwegian air traffic control had radar contact and handed over the aircraft to the air traffic control on the Swedish side. Swedish air traffic control cleared HAZE 01 to descend to Flight Level 100 “when ready” and instructed the crew to contact Kiruna Tower. The crew acknowledged the clearance and directly thereafter, the aircraft left Flight Level 130 towards Flight Level 100. The lower limit of controlled airspace at the location in question is Flight Level 125. HAZE 01 informed Kiruna Tower that the aircraft was 50 nautical miles (NM) west of Kiruna and requested a visual approach when approaching. Kiruna Tower cleared HAZE 01, which was then in uncontrolled airspace, to Flight Level 70, and the aircraft continued to descend towards the cleared flight level. Neither ACC Stockholm nor Kiruna Tower had any radar contact with the aircraft during the sequence of events because the Swedish air navigation services do not have radar coverage at the altitudes at which HAZE 01 was situated. HAZE 01 levelled out at Flight Level 70 at 14.57 hrs. Half a minute later, the aircraft collided with the terrain between the north and south peaks on the west side of Kebnekaise. Data from the aircraft's recording equipment (CVR and DFDR) showed that HAZE 01 was flying in level flight at a ground speed of approximately 280 knots prior to the moment of collision and that the crew was not aware of the imminent danger of underlying terrain. The remaining distance to Kiruna Airport was 42 NM (77 km). Everyone on board received fatal injuries. Accidents in complex systems are rarely caused by a single factor, but there are often several circumstances that must coincide for an accident to occur. The analysis of the investigation deals with the circumstances which are deemed to have influenced the sequence of events and the barriers which are intended to prevent dangerous conditions from arising. In summary, the investigation indicates that latent weaknesses have existed both at the Norwegian Air Force and at LFV. It is these weaknesses and not the mistakes of individual persons that are assessed to be the root cause of the accident. On the part of flight operations, the investigation has found shortcomings with respect to procedures for planning and following up a flight. Together with a probably high confidence in air traffic control, this has led to the crew not noticing that the clearance entailed an altitude that did not allow for adequate terrain separation. In terms of the air traffic services, the investigation demonstrates that the aircraft was not issued clearances and flight information in accordance with applicable regulations. This is due to it not having been ensured that the air traffic controllers in question had sufficient experience and knowledge to guide air traffic from the west in towards Kiruna Airport in a safe manner under the present circumstances. The lack of radar coverage reduced the opportunities for air traffic control to monitor and guide air traffic. The aircraft's Ground Collision Avoidance System is the last barrier and is intended to be activated and provide warning upon the risk of obstacles in the aircraft's flight path. The investigation has shown that with the terrain profile in question and the settings in question, the criteria for a warning were not fulfilled. No technical malfunction on the aircraft has caused or contributed to the occurrence of the accident. The rescue operation was characterized by very good access to resources from both Sweden and abroad. The operations lasted for a relatively long time and were carried out under extreme weather conditions in difficult alpine terrain. The investigation of the rescue operation demonstrates the importance of further developing management, collaboration and training in several areas.
Probable cause:
The accident was caused by the crew on HAZE 01 not noticing to the shortcomings in the clearances issued by the air traffic controllers and to the risks of following these clearances, which resulted in the aircraft coming to leave controlled airspace and be flown at an altitude that was lower than the surrounding terrain.
The accident was rendered possible by the following organizational shortcomings in safety:
- The Norwegian Air Force has not ensured that the crews have had sufficiently safe working methods for preventing the aircraft from being flown below the minimum safe flight level on the route.
- LFV has not had sufficiently safe working methods for ensuring, partly, that clearances are only issued within controlled airspace during flight under IFR unless the pilot specifically requests otherwise and, partly, that relevant flight information is provided.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Niblack

Date & Time: Mar 13, 2012 at 1040 LT
Type of aircraft:
Operator:
Registration:
N82SF
Flight Phase:
Survivors:
Yes
Schedule:
Niblack - Ketchikan
MSN:
839
YOM:
1955
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
23000
Captain / Total hours on type:
12000.00
Aircraft flight hours:
17574
Circumstances:
The pilot departed from an off-airport site in marginal visual flight rules conditions. Shortly after departure, the weather worsened, and flight visibility dropped to near zero in heavy snow. He attempted to follow the shoreline at a low altitude but was unable to maintain visual contact with the ground. He stated that he saw trees immediately in front of the airplane and attempted a right turn toward what he thought was an open bay. During the turn, the right float contacted a rock outcrop, and the airplane impacted the water. The pilot did not report any mechanical anomalies that would have precluded normal operation.
Probable cause:
The pilot's decision to depart in marginal visual meteorological conditions, and his continued visual flight into instrument meteorological conditions.
Final Report: