Crash of a Piper PA-61 Aerostar (Ted Smith 601P) in Springfield: 3 killed

Date & Time: Jan 28, 2020 at 1503 LT
Operator:
Registration:
N6071R
Flight Type:
Survivors:
No
Site:
Schedule:
Huntsville – Springfield
MSN:
61P-0686-7963324
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
5500
Aircraft flight hours:
3542
Circumstances:
The pilot was conducting an instrument landing system (ILS) approach in instrument meteorological conditions at the conclusion of a cross-country flight. The airplane had been cleared to land, but the tower controller canceled the landing clearance because the airplane appeared not to be established on the localizer as it approached the locator outer marker. The approach controller asked the pilot if he was having an issue with the airplane’s navigation indicator, and the pilot replied, “yup.” Rather than accept the controller’s suggestion to use approach surveillance radar (ASR) approach instead of the ILS approach, the pilot chose to fly the ILS approach again. The pilot was vectored again for the ILS approach, and the controller issued an approach clearance after he confirmed that the pilot was receiving localizer indications on the airplane’s navigation equipment. The airplane joined the localizer and proceeded toward the runway while descending. The pilot was instructed to contact the tower controller; shortly afterward, the airplane entered a left descending turn away from the localizer centerline. At that time, the airplane was about 3 nautical miles from the locator outer marker. The pilot then told the tower controller, “we’ve got a prob.” The tower controller told the pilot to climb and maintain 3,000 ft msl and to turn left to a heading of 180°. The pilot did not respond. During the final 5 seconds of recorded track data, the airplane’s descent rate increased rapidly from 1,500 to about 5,450 ft per minute. The airplane impacted terrain about 1 nm left of the localizer centerline in a left-wing-down and slightly nose down attitude at a groundspeed of about 90 knots. A postimpact fire ensued. Although the pilot was instrument rated, his recent instrument flight experience could not be determined with the available evidence for this investigation. Most of the fuselage, cockpit, and instrument panel was destroyed during the postimpact fire, but examination of the remaining wreckage revealed no anomalies. Acoustic analysis of audio sampled from doorbell security videos was consistent with the airplane's propellers rotating at a speed of 2,500 rpm before a sudden reduction in propeller speed to about 1,200 rpm about 2 seconds before impact. The airplane’s flightpath was consistent with the airplane’s avionics receiving a valid localizer signal during both instrument approaches. However, about 5 months before the accident, the pilot told the airplane’s current maintainer that the horizontal situation indicator (HSI) displayed erroneous heading indications. The maintainer reported that a replacement HSI was purchased and shipped directly to the pilot to be installed in the airplane; however, the available evidence for the investigation did not show whether the malfunctioning HSI was replaced before the flight. The HSI installed in the airplane at the time of the accident sustained significant thermal and fire damage, which prevented testing. During both ILS approaches, the pilot was cleared to maintain 3,000 ft mean sea level (msl) until the airplane was established on the localizer. During the second ILS approach, the airplane descended immediately, even though the airplane was below the lower limit of the glideslope. Although a descent to the glideslope intercept altitude (2,100 ft msl) would have been acceptable after joining the localizer, such a descent was not consistent with how the pilot flew the previous ILS approach, during which he maintained the assigned altitude of 3,000 ft msl until the airplane intercepted the glideslope. If the HSI provided erroneous heading information during the flight, it could have increased the pilot’s workload during the instrument approach and contributed to a breakdown in his instrument scan and his ability to recognize the airplane’s deviation left of course and descent below the glideslope; however, it is unknown if the pilot had replaced the HSI.
Probable cause:
The pilot’s failure to follow the instrument landing system (ILS) course guidance during the instrument approach.
Final Report:

Crash of a McDonnell Douglas MD-83 in Bandar-e Mahshahr

Date & Time: Jan 27, 2020 at 0736 LT
Type of aircraft:
Operator:
Registration:
EP-CPZ
Survivors:
Yes
Schedule:
Tehran - Bandar-e Mahshahr
MSN:
53464
YOM:
1994
Flight number:
RV6936
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
136
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18430
Captain / Total hours on type:
7840.00
Copilot / Total flying hours:
300
Copilot / Total hours on type:
124
Circumstances:
On Jan. 27, 2020, at 03:12 UTC Caspian Airlines (CPN) Flight 6936, an MD83, EP-CPZ took off from Mehrabad International Airport and climbed to FL320 as final cruising level. At about 03:45:37 UTC, the aircraft was flying according to the flight plan route on Airway B417 at an assigned FL320. Due to another traffic departing flight, an A320, IRA356 from Abadan Airport (OIAA) to destination Mashhad International Airport (OIMM), the ACC controller issued direct routing to the flight CPN 6936 position GODMO. At 03:49:34 UTC, CPN6936 requested descent clearance, so the flight was cleared to FL100. At 03:52:30 UTC, the pilot called Mahshahr AFISO and reported position 50 nm inbound GODMO and estimated time over GODMO at 03:59 UTC. At 03:52:51 UTC, Mahshahr AFISO reported necessary information as below: "RWY active is 31; wind is now 280/08kts, CAVOK, temperature +06, DP 04 and QNH 1023, expected VOR approach RWY 31 via GODMO 1E ARRIVAL" At 03:53: 33 UTC, the pilot requested RWY 13 and Mahshahr AFISO performed VOR/DME approach RWY 13, via GODMO 1F arrival. At 03:59:39 UTC, the pilot reported, “we are approaching position GODMO in contact with destination Mahshahr.” At 04:00:41UTC, the pilot reported his position “GODMO” to Mahshahr AFISO. At 04:02:46 UTC, the pilot reported leaving of IAF and received landing clearance for RWY13. Finally, at 04:06:11 UTC, the aircraft landed on RWY 13, passed two-thirds of RWY length and ran off the end of runway13 after landing at Mahshahr Airport at 04:06 UTC, Khuzestan province. The accident flight was being operated on an Instrument Flight Rules (IFR) flight plan in a Visual Meteorological Condition (VMC). The main door of the accident aircraft was opened in emergency condition, but the slide skid did not operate automatically. The cabin floor was just too close to the ground (grass surface) due to the impact of the nose and main landing gears strut which were broken after the runway overrun. The evacuation was performed from the main door, and all 136 passengers and 8 crew members disembarked.
Probable cause:
The Aircraft Accident Investigation Board determines that the probable causes of this accident were the pilots’ failures below, resulting in a runway overrun:
- Poor decision-making for acceptance of the risk of high-speed landing;
- Un-stabilized approach against the normal flight profile;
- Poor CRM in the cockpit; and
- Poor judgment and not accomplishing go-around while performing an unstabilized approach.

Contributing Factors:
- Loading of 5 tons of extra fuel, which increased the landing distance required.
- Decision to make a landing on RWY 13 with tailwind.
- Inability of the copilot (PM) to take control of the aircraft and proper action to execute goaround.
Final Report:

Crash of a Lockheed C-130BZ Hercules in Goma

Date & Time: Jan 9, 2020
Type of aircraft:
Operator:
Registration:
403
Flight Type:
Survivors:
Yes
Schedule:
Beni - Goma
MSN:
3750
YOM:
1962
Location:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
59
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The four engine airplane was completing a flight from Beni to Goma, carrying 59 South African troops and eight crew members from the 28th Squadron on behalf of the MONUSCO (Mission de l’Organisation des Nations unies pour la stabilisation en République Démocratique du Congo). The approach and landing were completed in heavy rain falls. After touchdown, the airplane veered off runway to the left and came to rest in a grassy area with the left wing broken in two and the n°1 engine on fire. All 67 occupants escaped uninjured and the fire was quickly contained. However, the aircraft seems to be damaged beyond repair.

Crash of a Let L-410UVP-E10 in Kamina

Date & Time: Dec 28, 2019 at 1434 LT
Type of aircraft:
Operator:
Registration:
9S-GDX
Survivors:
Yes
Schedule:
Lubumbashi – Kamina
YOM:
1987
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown on a wet earth runway, the airplane went out of control. It veered off runway to the right, struck a shoulder and lost its nose gear before coming to rest. All 18 occupants escaped uninjured while the airplane was substantially damaged.

Crash of a Beechcraft A100 King Air in Charallave: 9 killed

Date & Time: Dec 19, 2019
Type of aircraft:
Operator:
Registration:
YV1104
Flight Type:
Survivors:
No
Schedule:
Guasipati – Charallave
MSN:
B-231
YOM:
1977
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
On final approach to Charallave-Óscar Machado Zuloaga Airport in marginal weather conditions, the twin engine airplane crashed in unknown circumstances about 8 km from the runway threshold. The aircraft was destroyed and all nine occupants were killed.

Crash of a Piper PA-60-602P Super 700 Aerostar on Gabriola Island: 3 killed

Date & Time: Dec 10, 2019 at 1805 LT
Operator:
Registration:
C-FQYW
Flight Type:
Survivors:
No
Schedule:
Cabo San Lucas – Chino – Bishop – Nanaimo
MSN:
60-8265-020
YOM:
1982
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
320
Aircraft flight hours:
5752
Circumstances:
On 09 December 2019, a private Piper Aerostar PA-60-602P aircraft (registration C-FQYW, serial number 60-8265020), departed Cabo San Lucas International Airport (MMSL), Baja California Sur, Mexico, with 3 people on board, for a 2-day trip to Nanaimo Airport (CYCD), British Columbia (BC). As planned the aircraft stopped for an overnight rest at Chino Airport (KCNO), California, U.S. At 1142, on 10 December 2019, the aircraft departed KCNO on a visual flight rules (VFR) flight plan to Bishop Airport (KBIH), California, U.S., for a planned fuel stop. The aircraft departed KBIH at approximately 1425 on an instrument flight rules (IFR) flight plan to CYCD. On 10 December 2019, night started at 1654. At 1741, the Vancouver area control centre air traffic controller advised the pilot that an aerodrome special meteorological report (SPECI) had been issued for CYCD at 1731. The SPECI reported visibility as 2 ½ statute miles (SM) in light drizzle and mist, with an overcast ceiling of 400 feet above ground level (AGL). The pilot informed the controller that he would be conducting an instrument landing system (ILS) approach for Runway 16. At 1749, when the aircraft was approximately 32 nautical miles (NM) south of CYCD, the pilot contacted the controller to inquire about the weather conditions at Victoria International Airport (CYYJ), BC. The controller informed the pilot that a SPECI was issued for CYYJ at 1709 and it reported the visibility as 5 SM in mist, a broken ceiling at 600 feet AGL, and an overcast layer at 1200 feet AGL. The controller provided the occurrence flight with pilot observations from another aircraft that had landed at CYCD approximately 15 minutes before. That crew had reported being able to see the Runway 16 approach lights at minimums, i.e., at 373 feet AGL. Between 1753 and 1802, the controller provided vectors to the pilot in order to intercept the ILS localizer. At 1803, the controller observed that the aircraft had not intercepted the localizer for Runway 16. The aircraft had continued to the southwest, past the localizer, at an altitude of 2100 feet above sea level (ASL) and a ground speed of 140 knots. The controller queried the pilot to confirm that he was still planning to intercept the ILS for Runway 16. The pilot confirmed that he would be intercepting the ILS as planned. The aircraft made a heading correction and momentarily lined up with the localizer before beginning a turn to the west. At 1804:03, the pilot requested vectors from the controller and informed him that he “just had a fail.” The controller responded with instructions to “turn left heading zero nine zero, tight left turn.” The pilot asked the controller to repeat the heading. The controller responded with instructions to “…turn right heading three six zero.” The pilot acknowledged the heading; however, the aircraft continued turning right beyond the assigned heading while climbing to 2500 feet ASL and slowing to a ground speed of 80 knots. The aircraft then began to descend, picking up speed as it was losing altitude. At 1804:33, the aircraft descended to 1800 feet ASL and reached a ground speed of 160 knots. At 1804:40, the pilot informed the air traffic controller that the aircraft had lost its attitude indicator.Footnote6 At the same time, the aircraft was climbing into a 2nd right turn. At 1804:44, the air traffic controller asked the pilot what he needed from him; the pilot replied he needed a heading. The controller provided the pilot with a heading of three six zero. At 1804:47, the aircraft reached an altitude of 2700 feet ASL and a ground speed of 60 knots. The aircraft continued its right turn and began to lose altitude. The controller instructed the pilot to gain altitude if he was able to; however, the pilot did not acknowledge the instruction. The last encoded radar return for the aircraft was at 1805:26, when the aircraft was at 300 feet ASL and travelling at a ground speed of 120 knotsControl of the aircraft was lost. The aircraft collided with a power pole and trees in a wooded park area on Gabriola Island, BC, and then impacted the ground. The aircraft broke into pieces and caught fire. The 3 occupants on board received fatal injuries. As a result of being damaged in the accident, the emergency locator transmitter (Artex ME406, serial number 188-00293) did not activate.
Probable cause:
The occurrence aircraft was equipped with a BendixKing KI 825 electronic horizontal situation indicator (HSI) that was interfaced to the flight control system and GPS (global positioning system) Garmin GNS530W/430W. The HSI also supplies the autopilot system with heading information. The investigation determined that the HSI had failed briefly during operation on 22 November 2019 and a 2nd time, 3 days later, on 26 November 2019. The KI 825 HSI is electrically driven and therefore is either on and working, or off and dark with no display. The aircraft owner was in contact with an aircraft maintenance organization located at Boundary Bay Airport (CZBB), BC, and an appointment to bring the occurrence aircraft in for troubleshooting of the 2 brief HSI malfunctions had been made for 11 December 2019, i.e., the day after the accident. In total, 13 flights had been conducted after the 1st failure of the HSI. There were no journey log entries for defects with the HSI or evidence of maintenance completed. RegulationsFootnote9 require that defects that become apparent during flight operations be entered in the aircraft journey logbook, and advisory guidance in the regulatory standardsFootnote10 states that all equipment required for a particular flight or type of operation, such as the HSI in this case, be functioning correctly before flight. The HSI was destroyed in the accident and the investigation was unable to determine if it was operational on impact. Similarly, it could not be determined if the HSI was supplying the autopilot with heading information, or if the autopilot was engaged during the approach.
Final Report:

Crash of a BAe 125-700A in San Andrés Villa Seca

Date & Time: Dec 2, 2019
Type of aircraft:
Operator:
Registration:
XB-PGP
Flight Type:
Survivors:
Yes
MSN:
257171
YOM:
1982
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The airplane was engaged in an illegal flight and its crew attempted to land in a bush area located in San Andrés Villa Seca. No one was found on site and the aircraft was damaged beyond repair. It is unclear if the registration is illegal or the original one.

Crash of a Beechcraft 200 King Air in Saint Jean

Date & Time: Nov 23, 2019
Operator:
Registration:
XB-PYB
Flight Type:
Survivors:
Yes
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft crashed in unknown circumstances in a pasture located near Saint Jean, Haiti. There were no casualties while the aircraft was damaged beyond repair. It was engaged in an illegal flight (contraband) and the registration XB-PYB is false. Local authorities were looking for both Mexican pilots and a local involved in the illegal mission.

Crash of a Boeing 737-8F2 in Odessa

Date & Time: Nov 21, 2019 at 2055 LT
Type of aircraft:
Operator:
Registration:
TC-JGZ
Survivors:
Yes
Schedule:
Istanbul – Odessa
MSN:
35739/2654
YOM:
2008
Flight number:
TK467
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
136
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6094
Captain / Total hours on type:
5608.00
Copilot / Total flying hours:
252
Copilot / Total hours on type:
175
Aircraft flight hours:
38464
Aircraft flight cycles:
22633
Circumstances:
On November 21, 2019, a regular THY2UT flight en-route Istanbul – Odesa at B737-800 aircraft, nationality and registration mark TC-JGZ of the Turkish Airlines, was performed by the aircraft crew consisting of the Pilot-in-Command (PIC), co-pilot and four flight attendants of the aircraft. In fact, the departure from Istanbul Airport was performed at 17:33. The actual aircraft landing took place at 18:55. According to the flight plan, the alternate aerodromes were Istanbul and Chișinău. There were 136 passengers and 2793 kg of luggage on board the aircraft. The PIC was a Pilot Flying, and the co-pilot was a Pilot Monitoring of the aircraft. The pre-flight briefing of the crew, according to its explanations, was carried out before departure from the Istanbul Airport, after which the PIC took the decision to perform the flight. The climb and level flight were performed in the normal mode. The landing approach was performed to the Runway16 with ILS system at a significant crosswind component of variable directions. At the final stage of approaching with ILS to Runway 16, the ATC controller of the aerodrome control tower (ATC Tower) gave the aircraft crew a clearance for landing. The aircraft crew confirmed the controller’s clearance and continued the landing approach. Subsequently, from a height of about 50 meters, the aircraft performed a go-around due to the aircraft non-stabilization before landing. Following the go-around, the aircraft headed to the holding area to wait for favorable values of wind force and direction. At 18:45, the PIC took the decision to carry out a repeated landing approach, reported of that to the ATC controller, who provided ATS in the Odesa Terminal Maneuvering Area (TMA.) At 18:51, the crew re-contacted the Tower controller and received the clearance to land. At 18:55, after touchdown, during the runway run, the aircraft began to deviate to the left and veered off of the runway to the left onto the cleared and graded area. After 550 m run on the soil, the aircraft returned to the runway with its right main landing gear and nose part (while moving on the soil, the nose landing gear collapsed) and came to rest at the distance of 1612 m from the runway entrance threshold. The crew performed an emergency evacuation of passengers from the aircraft. As a result of the accident, the aircraft suffered a significant damage to the nose part of the fuselage and left engine. None of the passengers or crew members was injured.
Probable cause:
The cause of the accident, i.e. runway excursion, which caused significant damage to the structural elements of the aircraft B-737-800 TC-JGZ of Turkish Airlines, which took place on 21.11.2019 during landing at «Odesa» Aerodrome, was failure to maintain the direction of the aircraft movement during the landing run in the conditions of a strong crosswind of variable directions.
Contributing Factors:
- Use by the crew of the landing approach method using the Touchdown in Crab technique, which is not recommended by FCTM B-737NG document for use on dry runways in the conditions of a strong crosswind;
- Untimely and insufficient actions of the crew to maintain the landing run direction;
- Presence of a significant cross component of the wind;
- Effect of an omnidirectional wind – from cross-headwind to cross-tailwind directions – during the landing run.
Final Report:

Crash of a Cessna 550 Citation II in Maraú: 5 killed

Date & Time: Nov 14, 2019 at 1417 LT
Type of aircraft:
Registration:
PT-LTJ
Flight Type:
Survivors:
Yes
Schedule:
Jundiaí – Maraú
MSN:
550-0225
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
8000
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
350
Copilot / Total hours on type:
25
Aircraft flight hours:
6978
Aircraft flight cycles:
6769
Circumstances:
The aircraft took off from the Comandante Rolim Adolfo Amaro Aerodrome (SBJD), Jundiaí - SP, to the Barra Grande Aerodrome (SIRI), Maraú - BA, at about 1458 (UTC), in order to carry out a private flight, with two pilots and eight passengers on board. Upon arriving at the destination Aerodrome, at 1717 (UTC), the aircraft made an undershoot landing on runway 11, causing the main and auxiliary landing gear to burst. The airplane moved along the runway, dragging the lower fuselage and the lower wing, leaving the runway by its left side, and stopping with the heading lagged, approximately, 210º in relation to the landing trajectory. Afterwards, there was a fire that consumed most of the aircraft. The aircraft was destroyed. One crewmember and four passengers suffered fatal injuries and the other crewmember and four passengers suffered serious injuries.
Probable cause:
Contributing factors.
- Control skills – a contributor
The inadequate performance of the controls led the aircraft to make a ramp that was lower than the ideal. This condition had the consequence of touching the ground before the runway’s threshold.
- Attention – undetermined
During the approach for landing, the commander divided his attention between the supervision of the copilot's activities and the performance of the aircraft's controls. Such circumstances may have impaired the flight management and limited the reaction time to correct the approach ramp.
- Attitude – undetermined
The report that the commander took two photographs of the runway and of the Aerodrome with his cell phone, during the wind leg, reflected an inadequate and complacent posture in relation to his primary tasks at that stage of the flight, which may have contributed to this occurrence.
- Communication – undetermined
As reported by the commander, the low tone and intensity of voice used by the copilot during the conduct of callouts, associated with the lack of use of the head phones, limited his ability to receive information, which may have affected his performance in management of the flight.
- Crew Resource Management – a contributor
The lack of proper use of CRM techniques, through the management of tasks on board, compromised the use of human resources available for the operation of the aircraft, to the point of preventing the adoption of an attitude (go-around procedure) that would avoid the accident, from the moment when the recommended parameters for a stabilized VFR approach are no longer present.
- Illusions – undetermined
It is possible that the width of the runway, narrower than the normal for the pilots involved in the accident, caused the illusion that the aircraft was higher than expected, for that distance from the thrashold 11 of SIRI, to the point of influence the judgment of the approach ramp. In addition, the fact that the pilot was surprised by the geography of the terrain (existence of dunes) and the coloring of the runway (asphalt and concrete), may have led to a false visual interpretation, which reflected in the evaluation of the parameters related to the approach ramp.
- Piloting judgment – a contributor
The commander's inadequate assessment of the aircraft's position in relation to the final approach ramp and landing runway contributed to the aircraft touching the ground before the thrashold.
- Perception – undetermined
It is possible that a decrease in the crew's situational awareness level resulted in a delayed perception that the approach to landing was destabilized and made it impossible to correct the flight parameters in a timely manner to avoid touching the ground before the runway.
- Flight planning – undetermined
It is possible that, during the preparation work for the flight, the pilots did not take into account the impossibility of using the perception and alarm system of proximity to the ground that equipped the aircraft, and the inexistence of a visual indicator system of approach ramp at the Aerodrome.
- Other / Physical sensory limitations – undetermined
The impairment of the hearing ability of the aircraft commander, coupled with the lack of the use of head phones, may have interfered with the internal communication of the flight cabin, in the critical phase of the flight.
Final Report: