Ground fire of a Transall C-160NG in Dolow

Date & Time: Nov 3, 2021
Type of aircraft:
Operator:
Registration:
EY-360
Flight Type:
Survivors:
Yes
Schedule:
Mogadishu - Dolow
MSN:
F233
YOM:
1985
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a cargo flight from Mogadishu to Dolow. After landing, the crew stopped the aircraft on the runway and was able to evacuate the cabin before the aircraft would be partially destroyed by fire.

Crash of a Cessna 208B Grand Caravan in Dagi Baru

Date & Time: Oct 29, 2021 at 1030 LT
Type of aircraft:
Registration:
PK-RVH
Flight Type:
Survivors:
Yes
Schedule:
Dekai - Dagi Baru
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft departed Dekai-Nop Goliat Airport for a short cargo flight to the Dagi Baru Airstrip with two pilots on board. Weather conditions were considered as good upon arrival. After landing, the aircraft went out of control, veered off runway and came to rest down a ravine. Both occupants were injured and the aircraft was destroyed.

Crash of a Cessna 208 Caravan I in Ilaga: 1 killed

Date & Time: Oct 25, 2021 at 0810 LT
Type of aircraft:
Operator:
Registration:
PK-SNN
Flight Type:
Survivors:
Yes
Schedule:
Timika - Ilaga
MSN:
208-0556
YOM:
2014
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
On final approach to Ilaga Airport, the crew encountered poor visibility due to foggy conditions. The single engine airplane impacted ground near the runway 25 threshold, lost its undercarriage and slid for few dozen metres before coming to rest on the runway. One of the pilot was killed.

Crash of a Cessna 340A in Santee: 2 killed

Date & Time: Oct 11, 2021 at 1214 LT
Type of aircraft:
Registration:
N7022G
Flight Type:
Survivors:
No
Site:
Schedule:
Yuma – San Diego
MSN:
340A-0695
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1566
Circumstances:
The pilot was on a cross-country flight, receiving vectors for an instrument approach while in instrument meteorological conditions (IMC). The approach controller instructed the pilot to descend to 2,800 ft mean sea level (msl) until established on the localizer, and subsequently cleared the flight for the instrument landing system (ILS) approach to runway 28R, then circle to land on runway 23. About 1 minute later, the controller told the pilot that it looked like the airplane was drifting right of course and asked him if he was correcting back on course. The pilot responded “correcting, 22G.” About 9 seconds later, the pilot transmitted “SoCal, is 22G, VFR runway 23” to which the controller told the pilot that the airplane was not tracking on the localizer and subsequently canceled the approach clearance and instructed the pilot to climb and maintain 3,000 ft. As the pilot acknowledged the altitude assignment, the controller issued a low altitude alert, and provided the minimum vectoring altitude in the area. The pilot acknowledged the controller’s instructions shortly after. At this time, recorded advanced dependent surveillance-broadcast (ADS-B) data showed the airplane on a northwesterly heading at an altitude of 2,400 ft msl. Over the course of the following 2 minutes, the controller issued multiple instructions for the pilot to climb to 4,000 ft, which the pilot acknowledged; however, ADS-B data showed that the airplane remained between 2,500 ft and 3,500 ft. The controller queried the pilot about his altitude and the pilot responded, “2,500 ft, 22G.” The controller subsequently issued a low altitude alert and advised the pilot to expedite the climb to 5,000 ft. No further communication was received from the pilot despite multiple queries from the controller. ADS-B data showed that the airplane had begun to climb and reached a maximum altitude of 3,500 ft before it began a descending right turn. The airplane remained in the right descending turn at a descent rate of about 5,000 ft per minute until the last recorded target at 900 ft msl, located about 1,333 ft northwest of the accident site. The airplane and two houses were destroyed. The pilot and the driver of a UPS truck were killed. Two other people on the ground were injured.
Probable cause:
Loss of control due to spatial disorientation.
Final Report:

Crash of a Socata TBM-910 in Westlock

Date & Time: Oct 10, 2021 at 1102 LT
Type of aircraft:
Registration:
C-FFYM
Flight Type:
Survivors:
Yes
Schedule:
Vernon – Calgary – Westlock
MSN:
1190
YOM:
2017
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
235.00
Aircraft flight hours:
449
Circumstances:
The airplane was conducting an instrument flight rules flight from Vernon Airport, British Columbia, to Westlock Aerodrome, Alberta, with a stop at Calgary/Springbank Airport, Alberta, to pick up passengers, after which 1 pilot and 3 passengers were on board. At 1102:26 Mountain Daylight Time, while the aircraft was landing on Runway 28 at Westlock Aerodrome, the aircraft bounced and the pilot initiated a go-around. During the application of engine power for the go-around, the aircraft rolled to the left, struck the runway inverted, and came to rest on the runway’s south side. The 3 passengers exited the aircraft through the main cabin door with the assistance of persons nearby. One passenger received serious injuries, and the other 2 had minor injuries. The pilot, who was seriously injured, was trapped in the cockpit for approximately 2 hours before first responders could safely rescue him from the wreckage. An emergency locator transmitter signal was received by the search and rescue satellite system. The aircraft was significantly damaged and there was no post-impact fire.
Probable cause:
Findings as to causes and contributing factors:
1. The aircraft joined the final approach well above the optimal 3° descent path and, during the steep approach that followed, the aircraft’s airspeed continually decelerated and resulted in an unstabilized approach.
2. On short final, the pilot reduced the rate of descent by increasing pitch rather than by adding power. As a result, the airspeed continued to decrease and the aircraft entered a stall, resulting in a hard landing and a subsequent bounce.
3. During the attempted rejected landing, the aircraft entered a 25° nose-high attitude and approached a stall condition. This low-speed condition combined with the high power setting resulted in the aircraft entering a rapid roll to the left and striking the runway in an inverted attitude.
4. The passengers did not receive a safety briefing before departure or before landing, and multiple items in the cabin were not secured. As a result, 1 passenger sustained serious injuries due to the deceleration forces and the loose items that were thrown around in the cabin during the accident.
5. The pilot was not wearing the available shoulder harness, and his torso was unrestrained during the impact. As a result, he sustained serious injuries.

Findings as to risk:
1. If pilots do not declare all health issues to Transport Canada Civil Aviation Medical Examiners and pilots’ family physicians do not declare issues assessed to be a risk to aviation safety to Transport Canada, there is an increased risk that pilots will operate with diagnosed medical conditions or medical side effects that could affect flight safety.
2. If an aircraft propeller is rotating and passengers are not supervised during boarding operations, there is a risk that passengers may inadvertently contact the propeller, potentially causing fatal injuries.

Other findings:
1. Following a review of the pilot’s medical history and prescription medication use, the investigation determined that the medication did not contribute to the accident.
Final Report:

Crash of a Dassault Falcon 20CC in Thomson: 2 killed

Date & Time: Oct 5, 2021 at 0544 LT
Type of aircraft:
Registration:
N283SA
Flight Type:
Survivors:
No
Schedule:
Lubbock - Thomson
MSN:
83
YOM:
1967
Flight number:
PKW887
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
11955
Captain / Total hours on type:
1665.00
Copilot / Total flying hours:
10908
Copilot / Total hours on type:
1248
Aircraft flight hours:
18798
Circumstances:
The captain and first officer were assigned a two-leg overnight on-demand cargo flight. The flight crew were accustomed to flying night cargo flights, had regularly flown together, and were experienced pilots. The first leg of the trip was uneventful and was flown by the captain; however, their trip was delayed 2 hours and 20 minutes at the intermediate stop due to a delay in the freight arriving. The flight subsequently departed with the first officer as the pilot flying. While enroute, about forty minutes from the destination, the flight crew asked the air traffic controller about the NOTAMs for the instrument landing system (ILS) instrument approach procedure at the destination. The controller informed the flight crew of two NOTAMs: the first pertained to the ILS glidepath being unserviceable and the second applied to the localizer being unserviceable. When the controller read the first NOTAM, he stated he did not know what “GP” meant, which was the abbreviation for the glideslope/glidepath on the approach. The controller also informed the flight crew that the localizer NOTAM was not in effect until later in the morning after their expected arrival, which was consistent with the published NOTAM. The flight crew subsequently requested the ILS approach and when the flight was about 15 miles from the final approach fix, the controller cleared the flight for the ILS or localizer approach, to which the captain read back that they were cleared for the ILS approach. As the flight neared the final approach fix, the captain reported that they had the airport in sight; he cancelled the instrument flight rules flight plan, and the flight continued flying towards the runway. The airplane crossed the final approach fix off course, high, and fast. The cockpit voice recorder (CVR) transcript revealed that the captain repeatedly instructed the first officer to correct for the approach path deviations. Furthermore, the majority of the approach was conducted with a flight-idle power setting and no standard altitude callouts were made during the final approach. Instead of performing a go-around and acknowledging the unstable approach conditions, the captain instructed the first officer to use the air brakes on final approach to reduce the altitude and airspeed. Shortly after this comment was made, the captain announced that they were low on the approach and a few seconds later the captain announced that trees were observed in their flight path. The CVR captured sounds consistent with power increasing; however, the audible stall warning tone was also heard. Subsequently, the airplane continued its descent and impacted terrain about .70 nautical mile from the runway. The airplane was destroyed by impact forces and both occupants were killed.
Probable cause:
The flight crew’s continuation of an unstable dark night visual approach and the captain’s instruction to use air brakes during the approach contrary to airplane operating limitations, which resulted in a descent below the glide path, and a collision with terrain. Contributing to the accident was the captain’s poor crew resource management and failure to take over pilot flying responsibilities after the first officer repeatedly demonstrated deficiencies in flying the airplane, and the operator’s lack of safety management system and flight data monitoring program to proactively identify procedural non-compliance and unstable approaches.
Final Report:

Crash of a Britten Norman BN-2B-26 Islander in Montserrat

Date & Time: Sep 29, 2021 at 1733 LT
Type of aircraft:
Operator:
Registration:
J8-VBI
Survivors:
Yes
Schedule:
Saint John’s – Montserrat
MSN:
2025
YOM:
1981
Flight number:
SVD207
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2650
Captain / Total hours on type:
712.00
Circumstances:
After an uneventful return flight to Barbuda, the aircraft departed Antigua at 2114 hrs (1714 hrs local) for John A Osborne Airport, Montserrat, with the pilot and six passengers on board. The aircraft cruised at 2,000 ft enroute and the pilot recalled there were good visual meteorological conditions throughout the 19 minute flight. On arriving at Montserrat there were no other aircraft operating in the vicinity of the airport and the pilot positioned the aircraft visually on a downwind leg for Runway 10. The pilot reported he commenced the approach, flying an approach speed of 65 kt, reducing to 60 kt as the aircraft touched down. The runway surface was dry and the pilot described the landing as “smooth”. After the main landing gear touched down, but prior to the nosewheel contacting the runway, the pilot applied the brakes. He reported that the left brake felt “spongy” and did not seem to act, but that the right brake felt normal. The pilot was unable to maintain directional control of the aircraft which veered to the right two seconds after touchdown, departing the runway a further three seconds later. The aircraft continued across the adjacent grassed area before impacting an embankment close to the runway. After the aircraft had come to a stop, the pilot shut down the engines using the normal shut down procedure. The left main gear had collapsed and rendered the left cabin exit unusable. The pilot evacuated through the flight deck door which was on the left of the aircraft. The six passengers were able to evacuate through the right cabin exit. The airport fire service then arrived at the aircraft, less than one minute after the accident.
Probable cause:
On landing at John A. Osborne Airport, Montserrat, the pilot was unable to maintain directional control of the aircraft, later reporting the left brake felt “spongy”. The aircraft veered off the right side of the runway and came to rest in an adjacent drainage ditch. An inspection of the aircraft’s braking system revealed a slight brake fluid leak from one of the pistons in the left outboard brake calliper. This would have prevented full brake pressure being achieved on the left brakes, resulting in an asymmetric braking effect. Difficulty in maintaining directional control was compounded by the use of an incorrect braking technique on landing. The investigation identified shortcomings with the operator’s manuals, procedures and regulatory oversight.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Bilogai: 3 killed

Date & Time: Sep 15, 2021 at 0730 LT
Operator:
Registration:
PK-OTW
Flight Type:
Survivors:
No
Site:
Schedule:
Nabire – Bilogai
MSN:
493
YOM:
1976
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
13158
Captain / Total hours on type:
8051.00
Copilot / Total flying hours:
974
Copilot / Total hours on type:
807
Aircraft flight hours:
10333
Aircraft flight cycles:
1569
Circumstances:
On 15 September 2021, a DHC-6-300 (Twin Otter) aircraft registered PK-OTW was being operated for an unscheduled cargo flight from Douw Aturure Airport (WABI), Nabire, Papua to Bilorai Airport (WAYB), Intan Jaya, Papua. The aircraft was operated by two pilots accompanied by one engineer on board. The filed flight plan for the flight indicated that the aircraft would be operated under Visual Flight Rule (VFR) with fuel endurance of 2 hours 30 minutes. The estimate time departure for the flight was at 0640 LT. At 0610 LT, the pilot received weather observation report from the Bilorai aeronautical communication officer (ACO) that the visibility was 5 up to 7 kilometers, several clouds over the airport and all final areas were clear. About 7 minutes later, the ACO updated the observation report which indicated that the visibility changed to 7 up to 8 kilometers (km). After the cargo loading process and the flight preparation had completed, the aircraft taxied to Runway 16. At 0644 LT, the aircraft departed and climbed to the cruising altitude of 9,500 feet. Prior to the departure, there was no record or report of aircraft system malfunction. The Pilot in Command (PIC) acted as Pilot Monitoring (PM) while the Second in Command (SIC) acted as Pilot Flying (PF). At 0658 LT, the PK-OTW pilot reported to the Nabire air traffic control that the aircraft was at 25 Nm with altitude of 9,500 feet. At 0702 LT, the SIC asked the PIC to have the aircraft control as PF. During flight, the PK-OTW pilots monitored weather information provided by the pilots of two other aircraft that flew ahead of the PK-OTW to Bilorai. Both pilots monitored that the first aircraft (Cessna 208B EX) landed using Runway 27 while the second aircraft (Cessna 208B) would use Runway 09. At 0715 LT, the PIC advised the SIC to use the Runway 27 for landing. At 0719 LT, the SIC made initial contact with the ACO and advised that the aircraft was approaching Bilai at altitude of 9,500 feet and the estimate time arrival at Bilorai was 0726 LT. The ACO acknowledged the pilot report and provided current weather observation as follows “…wind westerly 3 until 5 knots, final 09 open with broken fog and final 27 open, visibility 5 until 7 km, blue sky overhead”. The SIC acknowledged the weather information and advised the ACO would report when the aircraft position was on left downwind Runway 27. At 0721 LT, the SIC read the descent checklist included the item of Landing Data/Approach Briefing and was replied by completed. The Cockpit Voice Recorder (CVR) did not record any pilot’s discussion regarding to the airport minimum safe altitude since the beginning of the recording. At 0723 LT, a pilot of DHC-6-400 aircraft registered PK-OTJ, asked the PK-OTW pilot of the weather condition in Bilorai. The PK-OTJ flew behind the PK-OTW with from Nabire to Bilorai. The SIC then responded that the PK-OTW was on descend and would fly through clouds about 5 Nm to Bilorai. Thereafter, the ACO provided traffic information to PK-OTW pilot that there was an aircraft (Cessna 208B aircraft) on final Runway 09. The PIC who acted as PF acknowledged the traffic information and advised to the ACO that the PK-OTW would join left downwind Runway 27 for the landing approach. At 0725 LT, the SIC advised to the ACO that the aircraft was on left downwind Runway 27. The ACO then advised the PK-OTW pilot to report when on final Runway 27. At 07:26:12 LT, a stall warning recorded in the Cockpit Voice Recorder (CVR) then the PIC asked to the SIC to check the aircraft speed. The SIC responded the aircraft speed was 65 knots. At 07:26:16 LT, the PIC asked to the SIC to advise the ACO that they were making a go around. The SIC then advised the ACO that the PK-OTW was making a go around and was responded to report when on final. The CVR did not record pilot’s discussion about the plan maneuver of the go around. At 07:26:45 LT, the PIC informed that they were making a go around to the PK-OTJ pilot. The PK-OTJ pilot responded that the aircraft was approaching Homeyo and would reduce the speed to make enough separation with the PK-OTW. The PIC then advised the PK-OTJ that the PK-OTW would attempt to land using Runway 09. Based on the data transmitted from the flight following system, at 07:27:57 LT, the aircraft was about 3 Nm outbound from Bilorai on direction of 238°. At 07:28:22 LT, the PK-OTJ pilot advised to the ACO that the aircraft was about 6 nm to Bilai and the pilot intended to make holding maneuver over Bilai to make enough separation with the PK-OTW. At 07:28:33 LT, the SIC advised the PIC that the aircraft was at 8,200 feet and was responded that the PIC initiated turning the aircraft. A few second later, the SIC advised to the PIC that the aircraft was turning, and the aircraft was at 3.2 Nm outbound from Bilorai. At 07:28:38 LT, the last data of the flight following system recorded that the aircraft was on direction of 110°. At 07:29:25 LT, the SIC advised the PIC to fly left. Thereafter, the SIC advised the PIC that the aircraft was passing 8,000 feet. At 07:29:35 LTC, the PIC asked to the SIC about the distance to Bilorai and was responded 2.5 Nm. The SIC, reminded the PIC to fly left as the aircraft flew too close to the terrain. At 07:29:49 LT, the CVR recorded the first impact sound and the CVR recording stopped at 07:29:55 LT. At 0730 LT, the ACO asked the PK-OTW pilot intention as the aircraft was not visible from the ACO working position, and the pilot did not respond the ACO. At about the same time, the ACO heard impact sound that was predicted coming from terrain area on west of Bilorai. The ACO then called the PK-OTW pilot several times without response. Several pilots also attempted to contact the PK-OTW with the same result. The PK-OTW was found on a ridge at elevation of 8,100 feet, about 2 Nm on bearing 260° from Bilorai.

Crash of a Beechcraft 3NMT Expeditor in Bastia

Date & Time: Sep 14, 2021 at 1025 LT
Type of aircraft:
Registration:
G-BKGL
Flight Type:
Survivors:
Yes
Schedule:
Bastia - Bastia
MSN:
A-764
YOM:
1952
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4000
Captain / Total hours on type:
15.00
Circumstances:
On August 19, 2021, the airplane was acquired by a British citizen in Saudi Arabia and repatriated to UK via Egypt, Crete, Greece, Croatia and France. On August 25, en route from Croatia to France, the right engine suffered a loss of hydraulic pressure after the cylinder n°5 failed. The crew diverted to Bastia-Poretta Airport where he landed safely. On September 13, the cylinder n°5 was replaced by a qualified technician and a post maintenance control flight was scheduled for September 14, despite the pilot was slightly ill. The airplane departed Bastia-Poretta Airport at 1010LT and six minutes later, the pilot informed ATC that the control was completed and that he wanted to return to the airport. Due to departure traffic, the pilot was asked to fly along the mountain for a left hand circuit to land on runway 34. Seven minutes later, the right engine failed, followed 20 seconds later by a loss of power on the left engine. With a rate of descent between 900 and 1,500 feet per minute, the pilot was unable to reach the airport and attempted an emergency landing when the airplane impacted trees and crashed in an orchard, bursting into flames. All three occupants escaped the airplane by their own and were injured. The airplane was totally destroyed by a post crash fire.
Probable cause:
Most likely, the fuel selectors were in the 'Nose' position at start-up. The pilot thought that the main tanks were selected. He probably took off and flew on the 'Nose' tank, common to both engines, without realizing it. At the end of the downwind leg, having probably consumed all the fuel available in the 'Nose' tank, the right engine stopped. In this hypothesis, the left engine would also have suffered the effects of a fuel supply failure. This hypothesis is consistent with the observation of the position of the left and right fuel selectors on 'Nose' in the wreckage, and the pilot's initial testimony that the selectors had not been manipulated. The pilot, who was no longer able to hold the landing and was too far from the runway to reach it, was unable to avoid colliding with trees during the forced landing. His attention was focused on the aircraft's path, and he didn't think to switch off the battery, magnetos or the fuel supply system. During the collision with trees, the right engine and wing were torn off, and a fire broke out.
It is considered that the following factors may have contributed to the probable selection of fuel selectors on the 'Nose' instead of the main tanks:
- The pilot's lack of experience on type, which could have exposed him to a selection error and which was not conducive to his detection during the pre-start-up and pre-takeoff checks;
- The ergonomics of the fuel tank selector levers, which could have led him to think that they were positioned on 'Front';
- The pilot's state of health and fatigue at the time he undertook the flight, which was likely to have impaired his cognitive abilities.
- A form of objective-destination linked to the accumulated delay in repairing the cylinder may have contributed to the pilot's decision not to postpone the flight, despite his altered general state;
- A misrepresentation of the position of the fuel selectors may have led the pilot not to change their position when the engine problem occurred.
Final Report:

Crash of a Let L-410UVP-E20 in Kazashinskoye: 4 killed

Date & Time: Sep 12, 2021 at 2315 LT
Type of aircraft:
Operator:
Registration:
RA-67042
Survivors:
Yes
Schedule:
Irkutsk – Kazashinskoye
MSN:
14 29 16
YOM:
2014
Flight number:
SL51
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
4
Aircraft flight hours:
5480
Aircraft flight cycles:
3632
Circumstances:
On approach to Kazashinskoye Airport, the crew encountered poor visibility due to the night and fog and initiated a go-around procedure. During the second attempt to land, the twin engine aircraft descended too low, impacted trees and crashed in a wooded area located 4 km short of runway. Three passengers and a pilot were killed while 12 others occupants were injured. The aircraft was totally destroyed by impact forces.