Crash of a De Havilland DHC-3T Turbo Otter near Aleknagik: 5 killed

Date & Time: Aug 9, 2010 at 1442 LT
Type of aircraft:
Operator:
Registration:
N455A
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Nerka Lake - Nushagak River
MSN:
206
YOM:
1957
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
28768
Captain / Total hours on type:
35.00
Aircraft flight hours:
9372
Circumstances:
On August 9, 2010, about 1442 Alaska daylight time, a single-engine, turbine-powered, amphibious float-equipped de Havilland DHC-3T airplane, N455A, impacted mountainous, tree-covered terrain about 10 nautical miles (nm) northeast of Aleknagik, Alaska. The airline transport pilot and four passengers received fatal injuries, and four passengers received serious injuries. The airplane sustained substantial damage, including deformation and breaching of the fuselage. The flight was operated by GCI Communication Corp. (GCI), of Anchorage, Alaska, under the provisions of 14 Code of Federal Regulations (CFR) Part 91. About the time of the accident, meteorological conditions that met the criteria for marginal visual flight rules (MVFR) were reported at Dillingham Airport (DLG), Dillingham, Alaska, about 18 nm south of the accident site. No flight plan was filed. The flight departed about 1427 from a GCI-owned private lodge on the shore of Lake Nerka and was en route to a remote sport fishing camp about 52 nm southeast on the Nushagak River. According to GCI lodge personnel, the purpose of the flight was to transport the lodge guests to the fishing camp for an afternoon of fishing. The GCI lodge manager stated that the accident pilot had flown previously that morning in the accident airplane to DLG, where he dropped off another GCI pilot and then returned to the lodge. Sky Connect tracking system data for the accident airplane showed that, on that previous trip, the accident pilot departed the lodge for DLG about 0902 and returned about 1120. A review of DLG flight service station (FSS) recordings revealed that, about 1105, during the return flight from DLG to the lodge, the accident pilot filed a pilot report (PIREP) in which he reported ceilings at 500 feet, visibility of 2 to 3 miles in light rain, and “extremely irritating…continuous light chop” turbulence that he described as “kind of that shove-around type stuff rather than just bumps.” According to GCI lodge personnel, when the pilot returned to the lodge, he stated that the weather was not conducive for a flight to the fishing camp because of the turbulence and low ceilings. Passengers from the accident flight and GCI personnel indicated during postaccident interviews that, by the time that they had lunch about 1300, the weather had improved, and the group discussed with the pilot the option of going to the fishing camp. One passenger characterized the conversation as casual and stated that no pressure was placed on the pilot to make the flight or to depart by a certain time. The GCI lodge manager and some passengers stated that they thought that the pilot checked the weather on the computer during lunch, and the guest party co-host (one of GCI’s senior vice presidents) stated that the pilot informed him about 1400 that he was comfortable taking the group to the fishing camp if the group wanted to go. The GCI lodge manager stated that, before the airplane departed, he sent an e-mail to the fishing camp to indicate that the guests were coming, and personnel there informed him that the pilot had already contacted them. The lodge manager stated that he went down to the dock to help push the airplane off and that, when the flight departed, he could see all of Jackknife Mountain across the lake. (The mountain’s highest peak, which is about 3 nm from the dock, is depicted as 2,326 feet above mean sea level [msl] on an aviation sectional chart, and the elevation of Lake Nerka is depicted as about 40 feet msl on a topographical map.) He stated that the weather included broken ceilings about 2,000 feet above ground level (agl) with some blue patches in the sky and good visibility. The flight route from the lodge to the fishing camp traversed Class G airspace; 14 CFR 91.155 specifies that, for daytime flights below 1,200 feet agl, the flight must be flown clear of clouds and in conditions that allow at least 1 mile flight visibility. During a postaccident interview, the passenger who was in the right cockpit seat stated that, when the airplane departed, the visibility was “fine.” He stated that the pilot went a different direction during takeoff (compared to the passenger’s experiences during previous flights to the fishing camp) and that the pilot said it was to avoid “wind and weather.” The passenger described the weather as cloudy above with light turbulence. He stated that the airplane stayed below the clouds and that he noticed water “running across” the outside of the windshield before he fell asleep about 10 minutes into the flight. Another passenger, who was seated in the second seat behind the pilot on the left side of the airplane, stated that some fog was present beneath the airplane but that he did not think that the airplane flew into any clouds. He estimated that he fell asleep about 3 to 4 minutes after departure. The passenger who was in the first seat behind the pilot on the left side of the airplane stated in an initial interview that he could not see well out his side window and that he had no indication of the weather; however, in a subsequent interview, he stated that, once the airplane was airborne, he could not see the ground and could see only “white-out” conditions outside the airplane. He stated in the subsequent interview that he did not know if the airplane had climbed into clouds initially or if it had entered clouds at some point along the way. The passenger who was in the third seat behind the pilot on the left side of the airplane stated that the pilot kept the airplane below the cloud ceiling and flew along the tree line, followed streams, and maneuvered to avoid terrain. The passenger stated that the airplane banked into a left turn (he said that the bank angle was not unusual) and then immediately impacted terrain. Neither he nor the other passenger who was awake at the time of impact recalled noticing any unusual maneuvering, unusual bank or pitch angles, or change in engine noises that would indicate any problem before the airplane impacted terrain. The wreckage was found at an elevation of about 950 feet msl in steep, wooded terrain in the Muklung Hills, about 16 nm southeast of the GCI lodge. Figure 1 shows the accident site (view looking north-northwest).
Probable cause:
The pilot's temporary unresponsiveness for reasons that could not be established from the available information. Contributing to the investigation's inability to determine exactly what occurred in the final minutes of the flight was the lack of a cockpit recorder system with the ability to capture audio, images, and parametric data.
Final Report:

Crash of a Cessna 402C off Bequia Island: 1 killed

Date & Time: Aug 5, 2010 at 2216 LT
Type of aircraft:
Operator:
Registration:
J8-SXY
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kingstown - Canouan
MSN:
402C-0519
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The pilot was performing an ambulance flight from Kingstown-E. T. Joshua Airport to Canouan. En route, while cruising off Bequia Island, the twin engine aircraft entered an uncontrolled descent and crashed in the sea. Some debris were found the following day but no trace of the pilot.

Crash of a PZL-Mielec AN-2R near Kumushkino

Date & Time: Aug 3, 2010 at 1900 LT
Type of aircraft:
Operator:
Registration:
UR-17915
Flight Phase:
Survivors:
Yes
MSN:
1G205-56
YOM:
1984
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing a crop-spraying flight when a unexpected situation occurred. The pilot-in-command attempted an emergency landing in a dirt track located between Kumushkino and Botanichnoye, when the aircraft crash landed. Both occupants escaped uninjured while the aircraft was damaged beyond repair. According to Ukrainian authorities, it appears that the aircraft was operated without any CofA and CofR.

Crash of a Fairchild C-123K Provider in the Denali National Park: 3 killed

Date & Time: Aug 1, 2010 at 1500 LT
Type of aircraft:
Registration:
N709RR
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Palmer - Unalakleet
MSN:
20158
YOM:
1954
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
20000
Circumstances:
The pilot, co-pilot and the passenger departed on a day VFR cross country flight in a large, 1950's era former military transportb category airplane to deliver cargo. The pilot did not file a flight plan, and had no communication with any air traffic control facility during the flight. While en route, witnesses saw the airplane fly slowly across a valley near the entrance of a national park, which was not the intended route of flight. The airplane suddenly pitched up, stalled, and dived into wooded terrain within the park. Two pilot-rated witnesses said the engines were operating at the time of the accident, and the landing gear was retracted. An on-scene examination of the burned airplane structure and engines revealed no evidence of any preaccident mechanical deficiencies, or any evidence that the cargo had shifted during the flight. A former military pilot who had experience in the accident type airplane, stated that the airplane was considered unrecoverable from a stall, and for that reason, pilots did not typically practice stalls in it. He also indicated that if a problem was encountered with one of the two piston engines on the airplane, the auxiliary jet engine on the affected side should be started to provide additional thrust. Given the lack of mechanical deficiencies discovered during postaccident inspection, the absence of any distress communications, and the fact that neither of the two auxiliary jet engines had been started to assist in the event of a piston engine malfunction, it is likely the pilot allowed the airplane to lose airspeed and enter a low altitude stall from which he was unable to recover.
Probable cause:
The pilot's failure to maintain adequate airspeed to avoid a low altitude stall, resulting in a loss of control and collision with terrain.
Final Report:

Crash of a Convair CV-580 near Lytton: 2 killed

Date & Time: Jul 31, 2010 at 2024 LT
Type of aircraft:
Operator:
Registration:
C-FKFY
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Kamloops - Kamloops
MSN:
129
YOM:
1953
Flight number:
Tanker448
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
17000
Captain / Total hours on type:
900.00
Copilot / Total flying hours:
5200
Copilot / Total hours on type:
34
Circumstances:
Crew was fighting a forest fire near Siwash Road, about 15 km south of Lytton. The bombing run required crossing the edge of a ravine in the side of the Fraser River canyon before descending on the fire located in the ravine. About 22 minutes after departure, Tanker 448 approached the ravine and struck trees. An unanticipated retardant drop occurred coincident with the tree strikes. Seconds later, Tanker 448 entered a left-hand spin and collided with terrain. A post-impact explosion and fire consumed much of the wreckage. A signal was not received from the on-board emergency locator transmitter; nor was it recovered. Both crew members were fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. It could not be determined to what extent the initial collision with trees caused damage to the aircraft which may have affected its controllability.
2. Visual illusion may have precluded recognition, or an accurate assessment, of the flight path profile in sufficient time to avoid the trees on rising terrain.
3. Visual illusion may have contributed to the development of a low energy condition which impaired the aircraft performance when overshoot action was initiated.
4. The aircraft entered an aerodynamic stall and spin from which recovery was not possible at such a low altitude.
Findings as to Risk:
1. Visual illusions give false impressions or misconceptions of actual conditions. Unrecognized and uncorrected spatial disorientation, caused by illusions, carries a high risk of incident or accident.
2. Flight operations outside the approved weight and balance envelope increase the risk of unanticipated aircraft behaviour.
3. The recommended maintenance check of the emergency drop (E-drop) system may not be performed and there is no requirement for flight crews to test the E-drop system, thereby increasing the risk that an unserviceable system will go undetected.
4. The location of the E-drop selector requires crews to divert significant time and attention to identify and confirm the correct switch before operating it. This increases the risk of collision with terrain while attention is distracted.
5. The location of the angle-of-attack indicator on the instrument panel makes it difficult to see from the right seat, reducing its effectiveness.
6. When cockpit recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Ketchikan: 1 killed

Date & Time: Jul 23, 2010 at 0727 LT
Type of aircraft:
Operator:
Registration:
N9290Z
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Thorne Bay - Ketchikan
MSN:
1387
YOM:
1959
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5300
Captain / Total hours on type:
4500.00
Aircraft flight hours:
21065
Circumstances:
The pilot had been advised by the Federal Aviation Administration flight service station (FSS) specialist to remain clear of the destination airport until the specialist could issue a special visual flight rules clearance. Instrument meteorological conditions prevailed at the airport, with a strong southeasterly wind. About 8 minutes after initial contact, the FSS specialist attempted to contact the pilot to issue the clearance but received no response. A witness about 0.5 mile southeast of the accident site said he saw the accident airplane flying very low over the treetops. He said the weather conditions consisted of low clouds, rain, and gusty southeasterly wind estimated at 30 to 40 knots. He said that, as the airplane passed overhead, it turned sharply to the left. As he watched the airplane, the wings rocked violently from side to side, and the nose pitched up and down. As the airplane passed low over hilly, tree-covered terrain, it rolled to the right, the right wing struck a large tree and separated, and the airplane descended behind a stand of trees. Pilots flying in the accident area reported strong wind with significant downdrafts and turbulence. A postaccident examination of the airplane did not disclose any preimpact mechanical malfunctions. Given the lack of mechanical deficiencies and the reports of turbulence and downdrafts, as well as the witness’ account of the airplane’s physical movements, it is likely that the pilot encountered significant terrain-induced turbulence and downdrafts while flying at low altitude. The area surrounding the accident site and portions of the pilot's earlier flight path were bordered by large areas of open and protected water, several of which were suitable for landing the float-equipped airplane.
Probable cause:
The pilot’s decision to continue the flight toward his destination in significant turbulence and downdrafts, and his subsequent failure to maintain control of the airplane while flying low over rising terrain.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Chute des Passes: 4 killed

Date & Time: Jul 16, 2010 at 1117 LT
Type of aircraft:
Operator:
Registration:
C-GAXL
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Lac des Quatre - Lac Margane
MSN:
1032
YOM:
1957
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
11500
Captain / Total hours on type:
9000.00
Aircraft flight hours:
17204
Circumstances:
The float-equipped de Havilland Beaver DHC-2 Mk.I (registration number C-GAXL, serial number 1032), operated by Air Saguenay (1980) Inc., was flying under visual flight rules from Lac des Quatre to Lac Margane, Quebec, with 1 pilot and 5 passengers on board. A few minutes after take-off, the pilot reported intentions of making a precautionary landing due to adverse weather conditions. At approximately 1117, Eastern Daylight Time, the aircraft hit a mountain, 12 nautical miles west-south-west of the southern part of Lac Péribonka. The aircraft was destroyed and partly consumed by the fire that broke out after the impact. The pilot and 3 passengers were killed; 1 passenger sustained serious injuries and 1 passenger sustained minor injuries. No ELT signal was received.
Probable cause:
Causes and Contributing Factors:
1. The pilot took off in weather conditions that were below the minimum for visual flight rules, and continued the flight in those conditions.
2. After a late decision to carry out a precautionary alighting, the pilot wound up in instrument meteorological conditions (IMC). Consequently, the visual references were reduced to the point of leading the aircraft to controlled flight into terrain (CFIT).
3. The passenger at the rear of the aircraft was not seated on a seat compliant with aeronautical standards. The passenger was ejected from the plane at the moment of impact, which diminished his chances of survival.
Findings as to Risk:
1. The lack of training on pilot decision-making (PDM) for air taxi operators exposes pilots and passengers to increased risk when flying in adverse weather conditions.
2. In view of the absence of an ELT signal and the operator’s delay in calling, search efforts were initiated more than 3 ½ hours after the accident. That additional time lag can influence the seriousness of injuries and the survival of the occupants.
Final Report:

Crash of a Piper PA-31T Cheyenne II near La Fragua Dam: 8 killed

Date & Time: Jul 7, 2010 at 1020 LT
Type of aircraft:
Operator:
Registration:
XB-MPV
Flight Phase:
Survivors:
No
Schedule:
Piedras Negras - Piedras Negras
MSN:
31-7820077
YOM:
1978
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
The twin engine aircraft was chartered by the State of Coahuila to conduct a survey flight of the area around Piedras Negras following recent floods and damages caused by hurricane Alex. The aircraft departed Piedras Negras Airport at 0930LT bound to the northwest. En route, while performing an aerial inspection of the area around the La Fragua Lake, the aircraft went out of control and crashed in a field, bursting into flames. The wreckage was found 600 metres south of the La Fragua Dam, about 35 km northwest of Piedras Negras Airport. The aircraft was destroyed by a post crash fire and all 8 occupants were killed.
Crew:
Juan Roberto Rendón, pilot,
Guillermo Ainsle Ibarra, copilot.
Passengers:
Horacio del Bosque Dávila, Coahuila's Secretary of Public works,
José Manuel Maldonado Maldonado, Mayor of Piedras Negras,
Ricardo Garza Bermea, Director of the Piedras Negras Civil Protection,
David Rey Chavira Jiménez,
Guillermo Ainsle Montemayor,
Alfonso Ainsle Montemayor.

Crash of a PZL-Mielec AN-2R near Voznesenskoye

Date & Time: Jun 27, 2010 at 1545 LT
Type of aircraft:
Operator:
Registration:
RA-62631
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
1G178-23
YOM:
1978
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2643
Captain / Total hours on type:
2643.00
Copilot / Total flying hours:
645
Copilot / Total hours on type:
645
Aircraft flight hours:
3208
Circumstances:
The crew was performing a survey flight while in a fire fighting program. In flight, the engine failed and the crew elected to make an emergency landing. The aircraft stalled and crashed in the Varnavka River. Both pilots and the passenger were injured while the aircraft sank and was damaged beyond repair.
Probable cause:
The accident was the result of a forced landing on the water surface due to unstable operation of the engine after a loss of power which was caused by the re-enrichment of the fuel-air mixture because of jamming of the needle valve of the left float chamber of the carburetor. The most probable reason for jamming of the needle valve of the left float chamber is its clogging by foreign particles that resulted from failure to comply with section 2.02.01.20 of the rules of maintenance of the AN-2 while performing 100-hour maintenance works due to lack of RTO requirements for mandatory compliance.
Final Report:

Crash of a Casa 212 Aviocar 100 near Mintom: 11 killed

Date & Time: Jun 19, 2010 at 1000 LT
Type of aircraft:
Operator:
Registration:
TN-AFA
Flight Phase:
Survivors:
No
Schedule:
Yaoundé - Yangadou
MSN:
151
YOM:
1979
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The aircraft departed Yaoundé-Nsimalen Airport at 0913LT on a charter flight to Yangadou, a small airstrip serving several iron mines in north Congo. At 0951LT, the crew made its last radio contact with ATC then the aircraft disappeared from radar screens. The wreckage was found around 1700LT on June 21 near Mintom. The aircraft was totally destroyed and all 11 occupants were killed, among them Ken Talbot, an Australian investor in iron business. The flight was conducted for the Cameroon company Cam Iron, a subcontractor of the Australian Sundance Resources Group.