Crash of a Cessna 208B Grand Caravan in Bethel

Date & Time: Jul 8, 2019 at 1505 LT
Type of aircraft:
Operator:
Registration:
N9448B
Survivors:
Yes
Schedule:
Newtok – Bethel
MSN:
208B-0121
YOM:
1988
Flight number:
GV262
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2258
Captain / Total hours on type:
787.00
Aircraft flight hours:
21206
Circumstances:
The commercial pilot was conducting a visual flight rules scheduled passenger flight with five passengers. During the return leg to the company’s base airport, the pilot requested, and was given clearance to, a short gravel runway of 1,858 ft that terminated at parallel cross-runways and had inbound airplanes. The wind was reported as variable at 3 knots, and the outside air temperature was 88°F which was 25° warmer than usual. The pilot stated that he conducted a steeper than normal approach and performed a normal 30° flap landing flare; however, the airplane floated halfway down the runway. He initiated a go-around by advancing the throttle to takeoff power and retracting the flaps to 20° as the main landing gear briefly touched down. Automatic dependent surveillance-broadcast (ADS-B) data indicated that the airplane arrived 0.1 mile from the runway threshold at 149 ft above ground level (agl) and 110 knots of ground speed, which was 32 knots faster than the short field landing approach speed listed in the pilot operating handbook. A witness in the air traffic control tower (the ground controller) stated that the airplane “bled off a lot of airspeed,” during the landing attempt and climbed out in a very flat profile. The tower local controller stated that after liftoff, the airplane’s right wing dropped and the airplane appeared to be turning right into conflicting landing traffic, so he twice instructed the airplane to “left turn out immediately.” The pilot stated that he attempted to comply with the tower controller’s instruction, but when he applied left aileron, the airplane appeared to stall, rolled rapidly right, and descended in a right-wing-low attitude. It subsequently impacted the surface between runways. A postimpact fire ensued, and the pilot helped the passengers egress. The airplane was destroyed by postimpact fire. Given the evidence, it is likely that the pilot decided to land on the short runway to expedite the arrival and did not perform an appropriate short field landing approach, which resulted in excessive airspeed and altitude over the runway threshold, a long landing flare, rapid deceleration, and a self-initiated go-around from a slow airspeed. Had the pilot initiated the go-around as he approached the runway with indications of an unstable visual approach, the airspeed would have been well above stall speed, which would have allowed for the desired positive climb out on runway heading. The pilot likely attempted to comply with the tower local controller’s urgent commands to turn while the airplane was near the limit of performance (the temperature was about 25 degrees warmer than average, which would have resulted in a higher density altitude than the pilot was accustomed to and degraded aircraft and engine performance). The pilot’s maneuvering resulted in the exceedance of the critical angle-of-attack of the high wing (right wing) during the left turn, and an aerodynamic stall.
Probable cause:
The pilot’s failure to maintain adequate airspeed while maneuvering during an attempted go around, which resulted in an exceedance of the airplane's critical angle of attack and an aerodynamic stall at low altitude. Contributing to the accident, was the pilot’s decision to perform an approach to a short runway at an excessive airspeed and his late decision to perform a go-around, which resulted in a slow climb at a reduced safe margin above stall airspeed.
Final Report:

Crash of a Boeing 737-85R in Mumbai

Date & Time: Jul 1, 2019 at 2351 LT
Type of aircraft:
Operator:
Registration:
VT-SYK
Survivors:
Yes
Schedule:
Jaipur - Mumbai
MSN:
30410/1228
YOM:
2002
Flight number:
SG6237
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
160
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5355
Captain / Total hours on type:
5113.00
Copilot / Total flying hours:
4826
Copilot / Total hours on type:
4625
Circumstances:
On 01.07.2019, B737-800 aircraft was involved in an accident (runway excursion) at Mumbai airport while landing in moderate to heavy rain. The aircraft was under the command of an ATPL holder (PF) with a CPL holder as First Officer (PM). There were 160 passengers and 7 crew members on board. There was no injury to any of the passengers or crew members. The aircraft suffered substantial damage. The subject flight was fifth of the day for the aircraft and second for the flight crew. The flight crew had earlier operated Mumbai-Jaipur sector and the incident flight was from Jaipur to Mumbai. There were no technical issues reported by the flight crew either during Mumbai Jaipur sector or on the return leg (Jaipur- Mumbai) till descent into Mumbai. The pilots had carried out briefing amongst themselves for the approach including the weather and Go Around actions, if required. The aircraft commenced descent into Mumbai in the late evening hours. As per the reported weather at the time of approach visibility was 2100 metres in rain making it dark. Reported winds were 090/12 Knots. Runway was wet and the trend provided was ³temporary reduction in visibility to 1500 metres with thunder/ showers of rain´. During descend at approximately 7000' Pressure Altitude, the crew observed an indication for IAS disagree, indicating a discrepancy of airspeed between the instrument sources for the flight crew. Although this indication was momentary, the 'Non-Normal Checklist' was carried out. The indication discrepancy did not recur for the remainder of the flight. The aircraft was radar vectored for an ILS approach for Runway 27 at Mumbai. The approach was stabilized by 3800' Pressure Altitude with landing gear down, flaps 30 and auto brake selected at 3. The autopilot was engaged throughout the descent phase and during approach, the second autopilot was also coupled for the ILS approach. At 100', the autopilot and the auto-throttle were disengaged by the PF. The flare manoeuvre consumed approximately 5807' of the runway length prior to the aircraft touchdown with 3881' of runway remaining. After touchdown, the speed brakes deployed automatically and maximum reverse thrust and wheel brakes were applied. The aircraft exited the paved surface at 65 Knots and came to rest at a distance of 615' beyond the end of the runway. Once the aircraft came to rest, the flight crew advised cabin crew to be at their stations. The pilots were unable to contact ATC through VHF communication. The PF contacted his airline personnel using mobile phone and informed that the aircraft had overrun the runway and requested for step ladders. The ATC activated fire services and the runway was closed for operation. The Cabin crew carried out check on the passengers in the cabin. The fire services reached the aircraft location and verbal communication was established with the flight crew once the cockpit window was opened. Two Fire Services personnel boarded the aircraft from the L1 door using a fire ladder. An assessment of the aircraft structure and occupants was made and the fire services personnel informed the cabin crew that deplaning was to be carried out using fire ladders. There were no injuries during evacuation or otherwise.
Probable cause:
The runway excursion occurred because of combination of:
- Disconnection of auto pilot at an altitude 118' RA with the nose up trim bias without adequate compensation.
- Disconnection of auto throttle at 118' RA at a higher thrust setting for that phase of flight.
- Late touchdown of the aircraft on the runway.
- Reduced visual cues due to heavy rain impacting depth perception and ascertaining of actual touchdown position.
- Tailwind conditions at the time of landing resulting In increasing the distance covered during the extended flare (float).
- Approach with lower flaps (30) than recommended (40).
Final Report:

Crash of a BAe 3212 Jetstream 31 in Canaima

Date & Time: Jun 27, 2019 at 1130 LT
Type of aircraft:
Operator:
Registration:
YV2536
Survivors:
Yes
Schedule:
Puerto Ordaz - Canaima
MSN:
9966
YOM:
1992
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown on runway 18/36 at Canaima Airport, the twin engine airplane went out of control, veered off runway and came to rest in the bush, bursting into flames. All occupants evacuated safely while the aircraft was partially destroyed by fire. It was reported that a tire burst upon landing.

Crash of an Antonov AN-24RV in Nizhneangarsk: 2 killed

Date & Time: Jun 27, 2019 at 1024 LT
Type of aircraft:
Operator:
Registration:
RA-47366
Survivors:
Yes
Schedule:
Ulan-Ude - Nizhneangarsk
MSN:
7 73 108 04
YOM:
1977
Flight number:
AGU200
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
43
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
15167
Captain / Total hours on type:
10667.00
Copilot / Total flying hours:
6012
Copilot / Total hours on type:
1325
Aircraft flight hours:
38014
Aircraft flight cycles:
18584
Circumstances:
On a flight from Ulan-Ude to Nizhneangarsk, while descending to an altitude of 3,050 metres about 30 km from the destination airport, the crew contacted ATC and reported the failure of the left engine. The approach was continued to runway 22. After touchdown, the crew started the braking procedure when the airplane deviated to the right then veered off runway. It rolled in a grassy area, cwent through the perimeter fence and eventually impacted the building of a sewage treatment plant located 380 metres to the right of the runway centerline. The captain and the flight engineer were killed and the copilot was seriously injured. 10 other occupants were injured. The aircraft was destroyed by a post crash fire.

Crash of a Cessna 425 Conquest I in Butler: 1 killed

Date & Time: Jun 10, 2019 at 1020 LT
Type of aircraft:
Registration:
N622MM
Flight Type:
Survivors:
No
Schedule:
Vero Beach - Olathe
MSN:
425-0187
YOM:
1983
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3457
Captain / Total hours on type:
1891.00
Aircraft flight hours:
6092
Circumstances:
During a cross-country flight, the pilot initiated a descent to his intended destination. During the descent, the pilot informed air traffic control (ATC) that he could not retard power on the right engine. Later in the descent, the pilot decided to shut down the right engine. The pilot communicated his desire to land at the nearest airport to ATC, and ATC provided the pilot with the clearance to divert. Radar data showed the airplane in a steady descent toward the airport. When the airplane was at an altitude of about 2,500 ft mean sea level, the pilot contacted ATC and stated that he was trying to get the airplane under control; radar data showed the airplane in a 360° right turn at the time. The pilot contacted ATC again and stated that he was going to land on a highway. No further transmissions were received from the pilot. After the right turn, the airplane continued in a descent through 1,300 ft mean sea level, at which point radar contact was lost. A witness saw the airplane and stated that the airplane was low and slow but appeared to be in stable flight with both propellers spinning. She did not see any smoke coming from the airplane. She saw the airplane flying northeast to southwest when it suddenly descended nose first into the ground. The airplane impacted a gravel road adjacent to a 100-fttall grain silo about 1 mile from the highway and about 3.3 miles from the airport.
Probable cause:
The pilot’s loss of airplane control during a descent to a diversion airport with only the left engine operating. Contributing to the accident was a malfunction of the right engine throttle, the cause of which could not be determined.
Final Report:

Crash of a De Havilland DHC-2 Beaver off Metlakatla: 2 killed

Date & Time: May 20, 2019 at 1556 LT
Type of aircraft:
Operator:
Registration:
N67667
Survivors:
No
Schedule:
Ketchikan – Metlakatla
MSN:
1309
YOM:
1959
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1623
Captain / Total hours on type:
20.00
Aircraft flight hours:
29575
Circumstances:
The commercial pilot was conducting his first scheduled commuter flight from the company’s seaplane base to a nearby island seaplane base with one passenger and cargo onboard. According to company pilots, the destination harbor was prone to challenging downdrafts and changing wind conditions due to surrounding terrain. Multiple witnesses at the destination stated that the airplane made a westerly approach, and the wind was from the southeast with light chop on the water. Two witnesses reported the wings rocking left and right before touchdown. One witness stated that a wind gust pushed the tail up before the airplane landed. A different witness reported that the airplane was drifting right during the touchdown, and another witness saw the right (downwind) float submerge under water after touchdown, and the airplane nosed over as it pivoted around the right wingtip, which impacted the water. Flight track and performance data from the cockpit display units revealed that, as the airplane descended on the final approach, the wind changed from a right headwind of 6 knots to a left quartering tailwind of 8 knots before touchdown. The crosswind and tailwind components were within the airplane’s operational limitations. Examination of the airframe, engine, and associated systems revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation or egress. During the final approach and descent, the pilot had various wind information available to him; the sea surface wind waves and signatures, the nearest airport observation winds, the cockpit display calculated wind, and the visual relative ground speed. Had the pilot recognized that the winds had shifted to a quartering tailwind and the airplane’s ground speed was faster than normal, he could have aborted the landing and performed another approach into the wind. Although crosswind landings were practiced during flight training, tailwind landings were not because new pilots were not expected to perform them. Although the crosswind component was well within the airplane’s limits, it is possible that combined with the higher ground speed, the inexperienced pilot was unable to counteract the lateral drift during touchdown in a rapidly shifting wind. The pilot was hired the previous month with 5 hours of seaplane experience, and he completed company-required training and competency checks less than 2 weeks before the accident. According to the chief pilot (CP), company policy was to assign newly hired pilots to tour flights while they gained experience before assigning them to commuter flights later in the season. The previous year, the CP distributed a list of each pilot’s clearances for specific types of flights and destinations; however, an updated list had not been generated for the season at the time of the accident, and the flight coordinators, who were delegated operational control for assigning pilots to flights, and station manager were unaware of the pilot’s assignment limitations. Before the flight, the flight coordinator on duty completed a company flight risk assessment that included numerical values based on flight experience levels. The total risk value for the flight was in the caution area, which required management notification before releasing the flight, due to the pilot’s lack of experience in the accident airplane make and model and with the company, and his unfamiliarity with the geographical area; however, the flight coordinator did not notify management before release because the CP had approved a tour flight with the same risk value earlier in the day. Had the CP been notified, he may not have approved of the pilot's assignment to the accident flight. The pilot's minimal operational experience in seaplane operations likely affected his situational awareness in rapidly changing wind conditions and his ability to compensate adequately for a quartering tailwind at a higher-than-normal ground speed, which resulted in a loss of control during the water landing and a subsequent nose-over.
Probable cause:
The pilot’s inadequate compensation for a quartering tailwind during a water landing, which resulted in a loss of control and subsequent nose-over. Contributing to the accident was the company’s inadequate operational control of the flight release process, which resulted in assignment of an inexperienced pilot to a commuter seaplane flight.
Final Report:

Crash of a Beechcraft 60 Duke in Loveland: 1 killed

Date & Time: May 15, 2019 at 1248 LT
Type of aircraft:
Operator:
Registration:
N60RK
Flight Type:
Survivors:
No
Schedule:
Broomfield – Loveland
MSN:
P-79
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7000
Captain / Total hours on type:
100.00
Aircraft flight hours:
3119
Circumstances:
The commercial pilot was relocating the multiengine airplane following the completion of an extensive avionics upgrade, which also included the installation of new fuel flow transducers. As the pilot neared the destination airport, he reported over the common traffic advisory frequency that he had "an engine out [and] smoke in the cockpit." Witnesses observed and airport surveillance video showed fire emanating from the airplane's right wing. As the airplane turned towards the runway, it entered a rightrolling descent and impacted the ground near the airport's perimeter fence. The right propeller was found feathered. Examination of the right engine revealed evidence of a fire aft of the engine-driven fuel pump. The fuel pump was discolored by the fire. The fire sleeves on both the fuel pump inlet and outlet hoses were burned away. The fuel outlet hose from the fuel pump to the flow transducer was found loose. The reason the hose was loose was not determined. It is likely that pressurized fuel sprayed from the fuel pump outlet hose and was ignited by the hot turbocharger, which resulted in the inflight fire.
Probable cause:
A loss of control due to an inflight right engine fire due to the loose fuel hose between the engine-driven fuel pump and the flow transducer.
Final Report:

Crash of a De Havilland Dash-8-Q402 in Yangon

Date & Time: May 8, 2019 at 1852 LT
Operator:
Registration:
S2-AGQ
Survivors:
Yes
Schedule:
Dhaka - Yangon
MSN:
4367
YOM:
2011
Flight number:
BG060
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
28
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9646
Captain / Total hours on type:
1474.00
Copilot / Total flying hours:
580
Copilot / Total hours on type:
405
Aircraft flight hours:
8115
Circumstances:
The route of the aircraft on that day was DAC-RGN-DAC. At (18:03) the Bombardier DHC-8-402 aircraft, registered (S2-AGQ) contacted Yangon control tower and at (18:16) had ILS established and reported to the Yangon control tower. Due to adverse weather, Yangon control tower asked them to execute a go-around and the aerodrome operations was closed for the aviation safety for 2 hours. When the weather condition got better, the aerodrome operations was opened. And then the DHC-8-402 aircraft, registered S2-AGQ made RNP approach because only localizer was available at that moment. While the Bombardier DHC-8-402 aircraft was and making approach to runway 21, it was a bit higher than on slope 3 degree and landed on runway 21, remaining on the ground for upwards of 7 seconds, but the aircraft ran parallel to the runway, and then it flew up in the air up to 44 ft above the ground and sank again and collided with runway 03 and slid forward out of the runway and came to a complete stop on the over-run of the runway 03. There was no fire. All gears were collapsed and fuselage was broken into three sections. All 33 occupants were evacuated, among them 20 were injured. The aircraft was destroyed.
Probable cause:
While the aircraft was unstabilized on approach, the pilot did not execute a go-around.
Final Report:

Crash of a Sukhoi Superjet 100-95B in Moscow: 41 killed

Date & Time: May 5, 2019 at 1830 LT
Type of aircraft:
Operator:
Registration:
RA-89098
Survivors:
Yes
Schedule:
Moscow - Murmansk
MSN:
95135
YOM:
2017
Flight number:
SU1492
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
73
Pax fatalities:
Other fatalities:
Total fatalities:
41
Captain / Total flying hours:
6800
Captain / Total hours on type:
1570.00
Copilot / Total flying hours:
765
Copilot / Total hours on type:
615
Aircraft flight hours:
2710
Aircraft flight cycles:
1658
Circumstances:
The aircraft departed runway 24C at Moscow-Sheremetyevo Airport at 1803LT on a schedule service to Murmansk. Few minutes after takeoff, while climbing to an altitude of 10,000 feet, the crew encountered problems with the electrical system and informed ATC about an emergency situation via the transponder codes 7700 because communication systems were unserviceable. The crew initiated a circuit to return to the airport, continued the approach to runway 24L. On approach at an altitude between 900 and 1,100 feet, the windshear warning system sounded five times 'Go around. Windshear ahead'. From a height of 80 m (260 ft) above ground level, the aircraft descended below the glide path and at a height of 55 m (180 ft) the TAWS warning sounded: "Glide Slope." From that moment on the airspeed increased to 170 knots. At 18:30 the aircraft overflew the runway threshold and touched down at a distance of 900 m past the threshold at a speed of 158 knots. Touchdown occurred at a g-force of at least 2.55g with a subsequent bounce to a height of about 2 m. After two seconds the aircraft landed again on the nose landing gear with a vertical load 5.85g, and bounced to a height of 6 m. The third landing of the aircraft occurred at a speed of 140 knots with a vertical overload of at least 5g. This caused a rupture of the wing structure and fuel lines. The aircraft caught fire, went out of control, veered off runway to the right and came to rest in a grassy area, bursting into flames. The aircraft was destroyed by fire. 37 occupants were evacuated while 41 people, among them a crew member, were killed.

Crash of a Beechcraft A60 Duke in Santa Rosa: 2 killed

Date & Time: May 5, 2019 at 1600 LT
Type of aircraft:
Operator:
Registration:
N102SN
Flight Type:
Survivors:
No
Schedule:
Arlington - Santa Fe
MSN:
P-217
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4100
Circumstances:
The pilot was performing a personal cross-country flight. While en route to the intended destination, the pilot contacted air traffic control to report that the airplane was having a fuel pump issue and requested to divert to the nearest airport. The pilot stated that the request was only precautionary and did not declare an emergency during the flight; he provided no further information about the fuel pump. As the airplane approached the diversion airport, witnesses observed the airplane flying low and rolling to the left just before impacting terrain, after which a postcrash fire ensued. An examination of the airframe revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. A postaccident examination and review of recorded data indicated that the left engine was secured and in the feather position, and that the right engine was operating at a high RPM setting. The left engine-driven fuel pump was found fractured. Further examination of the fuel pump revealed fatigue failure of the pressure relief valve. The fatigue failure initiated in upward bending on one side of the valve disk and progressed around both sides of the valve stem. As the cracks grew, the stem separated from the disk on one side and began to tilt in relation to the disk and the valve guide due to the non-symmetric support, which caused the lower end of the stem to rub against the valve guide, creating wear marks. The increasing stem tilt would have impinged against the valve guide, and the valve might have begun to stick in the closed position. If the valve were stuck in the closed position, it would not be able to open, and the outlet fuel pressure could rise above the set point pressure. Because the pump was driven by the engine, there would not be a way for the pilot to shut it off, disconnect it, or bypass it. Instead, the fuel pressure would continue to rise until the valve were to unstick. Thus, the pilot was likely experiencing variable fuel pressure as the valve became stuck and unstuck. Examination of the spring seat and the diaphragm plate, which were in contact with each other in the fuel pump assembly, revealed wear marks on the surface of each component, with one mark on the diaphragm plate and two wear marks on the spring seat. The two wear marks on the spring seat were distinct features separated by material with no wear indications in between. The only way that these wear marks could have occurred were if the spring seat was separated from the diaphragm plate and reinstalled in a different orientation. Thus, it is likely that the pilot had encountered a fuel pump problem before the accident flight and that someone tried to troubleshoot the problem. The last radar data point indicated that the airplane was traveling at a groundspeed of about 98 knots, and had passed north of the airport, traveling to the southwest. The minimum control speed for the airplane with single-engine operation was 88 knots. However, it is likely that if the pilot initiated a left turn back toward the airport, that the right engine torque and the 14 knot wind with gusts to 24 knots would have necessitated a higher speed. Because appropriate control inputs and airspeed were not maintained, the airplane rolled in the direction of the feathered engine (due to the left fuel pump problem), resulting in a loss of control. The pilot's toxicology report was positive for cetirizine, sumatriptan, gabapentin, topiramate, and duloxetine. All of these drugs act in the central nervous system and can be impairing alone or in combination. Although this investigation could not determine the reason(s) for the pilot's use of these drugs, they are commonly used to treat chronic pain syndromes or seizures. It is likely that the pilot was experiencing some impairment because of multiple impairing medications and was unable to successfully respond to the in-flight urgent situation and safely land the airplane.
Probable cause:
The pilot's loss of airplane control due to his failure to maintain appropriate control inputs and airspeed after shutting down an engine because of a progressive failure of the pressure relief valve in the fuel pump, which resulted in variable fuel pressure in the engine. Contributing to the loss of control was the pilot's use of multiple impairing medications.
Final Report: