Crash of a Learjet 35A in Buenos Aires

Date & Time: Mar 7, 2019 at 1930 LT
Type of aircraft:
Operator:
Registration:
LV-BNR
Survivors:
Yes
Schedule:
Rosario – Buenos Aires
MSN:
35-373
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Rosario-Islas Malvinas Airport at 1900LT on a charter flight to Buenos Aires, carrying two passengers and two pilots. On approach to Buenos Aires-Aeroparque-Jorge Newbury Airport by night, the crew encountered poor weather conditions with thunderstorm activity, heavy rain falls and strong winds. The aircraft landed 200 metres past the runway 13 threshold and the crew stated the braking procedure. After a course of about 500 metres, the aircraft deviated to the left and veered off runway. It rolled on a grassy area then contacted the concrete taxiway, causing both main landing gear to be torn off. The aircraft came to rest 860 metres from the runway threshold and was damaged beyond repair. All four occupants evacuated safely.
Probable cause:
Conclusions regarding factors related to the accident:
- At the time of the event, meteorological conditions were poor with a strong storm, rain and gusts of wind.
- Visual cues may have been reduced due to heavy rain falls.
- The aircraft was displaced from the runway center line when it made contact with the ground.
- The aircraft made contact with the left landing gear off the runway due to strong gusts of wind.
- The lateral excursion to the grassy area occurred due to the impossibility of recovering the trajectory of the aircraft, once it was displaced by the action of the wind.
Final Report:

Crash of an Embraer ERJ-145XR in Presque Isle

Date & Time: Mar 4, 2019 at 1129 LT
Type of aircraft:
Operator:
Registration:
N14171
Survivors:
Yes
Schedule:
Newark - Presque Isle
MSN:
145-859
YOM:
2004
Flight number:
UA4933
Crew on board:
3
Crew fatalities:
Pax on board:
28
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5655
Captain / Total hours on type:
1044.00
Copilot / Total flying hours:
4909
Copilot / Total hours on type:
470
Circumstances:
The first instrument landing system (ILS) approach to runway 1 appeared to be proceeding normally until the first officer (the pilot flying) transitioned from instrument references inside the flight deck to outside references. During a postaccident interview, the first officer stated that he expected to see the runway at that time but instead saw “white on white” and a structure with an antenna that was part of the runway environment but not the runway itself. The captain (the pilot monitoring) stated that she saw a tower and called for a go-around. (Both flight crewmembers were most likely seeing the automated weather observing system wind sensor pole, which was located about 325 ft to the right of the runway 1 centerline and about 870 ft beyond the runway threshold, and the damage to the lightning arrester at the top of the wind sensor pole was likely due to contact with the accident airplane as it flew over the pole.) According to the cockpit voice recorder (CVR), after the go-around, the first officer asked the captain if she saw the runway lights during the approach. The captain responded that she saw the lights but that “it’s really white down there that’s the problem.” Airport personnel stated that snow plowing operations on the runway had finished about 10 minutes before the first approach. The CVR recorded the flight crew’s discussion about turning on the pilot-controlled runway lights and sounds similar to microphone clicks before and after the discussion. However, the PQI maintenance foreman stated that, after the first approach, the runway lights were not on. Thus, the investigation could not determine, based on the available evidence, whether the flight crew had turned on the runway lights during the first approach. The captain thought that the airplane had drifted off course when the first officer transitioned from flight instruments to the outside, so she instructed the first officer to remain on the instruments during the second approach until the decision altitude (200 ft above ground level [agl]). The second approach proceeded normally with no problems capturing or maintaining the localizer and glideslope. During this approach, the captain asked airport maintenance personnel to ensure that the runway lighting was on, and the PQI maintenance foreman replied that the lights were on “bright”(the high-intensity setting). Thus, the flight crew had a means to identify the runway surface even with the reported snow cover at the time. As the airplane approached the decision altitude, the captain instructed the first officer to disconnect the autopilot, which he did. About nine seconds later, the airplane reached the decision altitude, and the captain called, “runway in sight twelve o’clock.” This callout was followed by the first officer’s statement, “I’m stayin’ on the flight director ‘cause I don’t see it yet.” A few seconds later, while the airplane was below 100 ft agl, the captain and the first officer expressed confusion, stating “what the [expletive]” and “I don’t know what I'm see in’,” respectively, but neither called for a go-around. The airplane subsequently impacted the snow-covered grassy area between runway 1 and a parallel taxiway. During a postaccident interview, the first officer stated that, when he transitioned from flight instruments to the outside during the second approach, he again saw “white on white” as well as blowing snow and that the airplane touched down before he could determine what he was seeing. The maintenance foreman estimated that, at the time of the accident, the runway had about 1/8 inch of snow with about 20% to 25% of the runway visible.
Probable cause:
The flight crew’s decision, due to confirmation bias, to continue the descent below the decision altitude when the runway had not been positively identified. Contributing to the accident were:
1) the first officer’s fatigue, which exacerbated his confirmation bias, and
2) the failure of CommutAir pilots who had observed the localizer misalignment to report it to the company and air traffic before the accident.
Final Report:

Crash of a Gulfstream G200 in Moscow

Date & Time: Feb 26, 2019 at 1244 LT
Type of aircraft:
Operator:
Registration:
4K-AZ88
Survivors:
Yes
Schedule:
Baku - Moscow
MSN:
189
YOM:
2008
Flight number:
EWS88
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7608
Captain / Total hours on type:
2356.00
Copilot / Total flying hours:
2554
Copilot / Total hours on type:
609
Aircraft flight hours:
4174
Aircraft flight cycles:
1787
Circumstances:
The airplane departed Baku-Bina Airport on a charter flight to Moscow, carrying three passengers and three crew members. Following an uneventful flight, the crew was cleared for an approach to Moscow-Sheremetyevo Airport runway 24C. The aircraft landed at a speed of 150 knots some 250 metres past the runway threshold. After touchdown, the crew started the braking procedure and activated the thrust reversers. After a course of several hundred metres, the aircraft deviated to the left, made an almost 180 turn and veered off runway to the left. While contacting soft ground, the right main gear was torn off and the aircraft came to rest in a snow covered area. All six occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The reason for the accident with the Gulfstream G200 4K-AZ88 was the stowing of the right-engine reverser by the pilot KVS from maximum thrust reversal while maintaining maximum thrust reversal on the left engine, which led to the appearance of a significant turning moment to the left. The aircraft turning to the left in the presence of a cross wind to the right, as well as turbulence of the airflow near the rudder due to the open thrust reversal mechanism of the left engine and possible ice deposition on the outer surfaces of the aircraft, which led to the development of a significant swing moment on the rudder. The development of a significant articulated moment on the rudder, in the absence of power steering in the rudder control system, led to its deviation to the leftmost position despite significant (up to 82 kg or 180 pounds) forces exerted by the crew on the pedals. The deviation of the rudder (pedals) to the left also led to the deviation of the nose wheel to the left. The total moment from the running reverse of the left engine, from the right engine in direct draft mode, and from the rudder and nose wheel deflection to the left, led to the aircraft rolling out of the runway and its damage. Separate braking applied by the crew could not prevent the aircraft from rolling out.

The following contributing factors were identified:
- The crew did not take into account the provisions of the AOM about the possible "destabilizing" effect of the thrust reverse when landing with a cross wind on the runway with a reduced braking coefficient;
- Increased psycho-emotional tension of the crew members due to long dissatisfaction and emotional discussion of instructions and actions of ATC controllers. At the same time, the instructions and actions of the ATC service controllers were in line with established procedures.
Final Report:

Crash of a De Havilland EO-5C (Dash-7-102) at Pyongtaek-Desiderio AAF

Date & Time: Feb 25, 2019
Operator:
Registration:
N89068
Flight Type:
Survivors:
Yes
Schedule:
Pyongtaek - Pyongtaek
MSN:
88
YOM:
1982
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was complering a survey mission on behalf of the US Ministry of Defense. For unknown reasons, the four engine airplane landed hard at Pyongtaek-Desiderio AAF (Camp Humphreys), causing the right main gear to collapse. The right wing fell on the ground and the aircraft slid for few dozen metres before coming to rest. All occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of an Embraer EMB-120 Brasília in Somalia

Date & Time: Feb 14, 2019
Type of aircraft:
Operator:
Registration:
5Y-FAU
Survivors:
Yes
MSN:
120-194
YOM:
1990
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The left main gear collapsed after the airplane landed on a gravel airstrip located somewhere in Somalia. There were no injuries among the occupants and the airplane was damaged beyond repair.
Probable cause:
Failure of the left main gear upon landing on a gravel airstrip.

Crash of a Cessna 208 Caravan I near Caracaraí

Date & Time: Feb 9, 2019 at 1040 LT
Type of aircraft:
Operator:
Registration:
PR-RTA
Survivors:
Yes
Schedule:
Manaus - Caracaraí
MSN:
208-0380
YOM:
2004
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine floatplane departed Manaus-Eduardo Gomes Airport on a charter flight to the area of the Xeriuini River near Caracaraí, carrying eight passengers and two pilots bound for a fish camp. Due to the potential presence of obstacles in the river due to low water level, the crew decided to land near the river bank. After landing, the left wing impacted a tree and the aircraft rotated to the left and came to rest against trees on the river bank. All 10 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The following findings were identified:
- Attention,
- Judgment,
- Perception,
- Management planning,
- Decision making processes,
- Organization processes,
- Support systems.
Final Report:

Crash of a Learjet 35A in Toluca

Date & Time: Feb 7, 2019 at 0714 LT
Type of aircraft:
Operator:
Registration:
XA-DOC
Flight Type:
Survivors:
Yes
MSN:
35A-447
YOM:
1981
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight, the crew configured the aircraft for landing when he realized that the right main landing gear was stuck in its wheel well. The crew continued the approach and landed on runway 15. The airplane fell on its belly, causing the right wing to struck the ground. The airplane slid for few hundred metres then veered off runway to the left and came to rest in a grassy area. All nine occupants were rescued and the aircraft was damaged beyond repair.

Crash of a Piper PA-46-350P Malibu Mirage in Aurora

Date & Time: Feb 6, 2019 at 1530 LT
Operator:
Registration:
N997MA
Flight Type:
Survivors:
Yes
Schedule:
Aurora - Aurora
MSN:
46-36126
YOM:
1997
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
970
Captain / Total hours on type:
23.00
Aircraft flight hours:
2670
Circumstances:
On February 6, 2019, about 1530 Pacific standard time, a Piper PA 46-350P, N997MA, was substantially damaged when it was involved in an accident near Aurora, Oregon. The private pilot and flight instructor were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The pilot reported that the purpose of the flight was to practice commercial pilot maneuvers. After practicing slow flight, chandelles, lazy eights, and eights on pylons, they returned to the airport and discussed how to conduct a practice a power-off 180° landing as they entered the traffic pattern. When the airplane was abeam the 1,000-foot runway markings, the pilot reduced the power to idle and started a left turn toward the runway. He stated that he realized that the airplane was “probably not going to make the runway” and that the airplane was “not on final course.” He recalled the airplane turning sharply to the left as he was pulled up on the control yoke and added right rudder. He could not recall whether he applied power. The pilot did not report any mechanical malfunctions or anomalies with the airplane. A video of the event showed the airplane in a left turn as it descended toward the runway. The airplane’s left bank decreased to a wings-level attitude before the airplane entered a steeper left bank, followed immediately by a right bank as the airplane descended into the ground short of the runway. The airplane’s right wing and fuselage sustained substantial damage.

Crash of a Beechcraft B200 Super King Air off Kake: 3 killed

Date & Time: Jan 29, 2019 at 1811 LT
Operator:
Registration:
N13LY
Flight Type:
Survivors:
No
Schedule:
Anchorage - Kake
MSN:
BB-1718
YOM:
2000
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
17774
Captain / Total hours on type:
1644.00
Aircraft flight hours:
5226
Circumstances:
The pilot of the medical transport flight had been cleared by the air traffic controller for the instrument approach and told by ATC to change to the advisory frequency, which the pilot acknowledged. After crossing the initial approach fix on the RNAV approach, the airplane began a gradual descent and continued northeast towards the intermediate fix. Before reaching the intermediate fix, the airplane entered a right turn and began a rapid descent, losing about 2,575 ft of altitude in 14 seconds; radar returns were then lost. A witness at the destination airport, who was scheduled to meet the accident airplane, observed the pilot-controlled runway lights illuminate. When the airplane failed to arrive, she contacted the company to inquire about the overdue airplane. The following day, debris was found floating on the surface of the ocean. About 48 days later, after an extensive underwater search, the heavily fragmented wreckage was located on the ocean floor at a depth of about 500 ft. A postaccident examination of the engines revealed contact signatures consistent with the engines developing power at the time of impact and no evidence of mechanical malfunctions or failures that would have precluded normal operation. A postaccident examination of the airframe revealed about a 10° asymmetric flap condition; however, significant impact damage was present to the flap actuator flex drive cables and flap actuators, indicating the flap actuator measurements were likely not a reliable source of preimpact flap settings. In addition, it is unlikely that a 10° asymmetric flap condition would result in a loss of control. The airplane was equipped with a total of 5 seats and 5 restraints. Of the three restraints recovered, none were buckled. The unbuckled restraints could suggest an emergency that required crewmembers to be up and moving about the cabin; however, the reason for the unbuckled restraints could not be confirmed. While the known circumstances of the accident are consistent with a loss of control event, the factual information available was limited because the wreckage in its entirety was not recovered, the CVR recording did not contain the accident flight, no non-volatile memory was recovered from the accident airplane, and no autopsy or toxicology of the pilot could be performed; therefore, the reason for the loss of control could not be determined. Due to the limited factual information that was available, without a working CVR there is little we know about this accident.
Probable cause:
A loss of control for reasons that could not be determined based on the available information.
Final Report:

Crash of a Boeing 707-3J9C in Fath: 15 killed

Date & Time: Jan 14, 2019 at 0830 LT
Type of aircraft:
Operator:
Registration:
EP-CPP
Flight Type:
Survivors:
Yes
Site:
Schedule:
Bishkek - Payam
MSN:
21128/917
YOM:
1976
Country:
Region:
Crew on board:
16
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
15
Circumstances:
The airplane, owned by the Islamic Republic of Iran Air Force (IRIAF) was completing a cargo flight from Bishkek, Kyrgyzstan, on behalf of Saha Airlines, and was supposed to land at Payam Airport located southwest of Karaj, carrying a load of meat. On approach, the crew encountered marginal weather conditions and the pilot mistakenly landed on runway 31L at Fath Airport instead of runway 30 at Payam Airport which is located 10 km northwest. After touchdown, control was lost and the airplane was unable to stop within the remaining distance (runway 31L is 1,140 meters long), overran and crashed in flames into several houses located past the runway end. The aircraft was destroyed by fire as well as few houses. The flight engineer was evacuated while 15 other occupants were killed.