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:

Crash of a PZL-Mielec AN-2R in Vyun

Date & Time: May 4, 2019 at 1335 LT
Type of aircraft:
Registration:
RA-01443
Flight Type:
Survivors:
Yes
Schedule:
Ust-Nera - Vyun
MSN:
1G231-24
YOM:
1988
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9700
Aircraft flight hours:
6305
Circumstances:
The single engine airplane departed Ust-Nera on a cargo flight to Vyun, carrying two pilots and a load of various equipment destined for the employees of a local gold mine. Upon landing on an unprepared terrain, the undercarriage collapsed. The airplane slid on its belly and came to rest. Both pilots escaped uninjured and the aircraft was damaged beyond repair. The accident occurred at location N 65° 54' E 138° 20'.
Probable cause:
The accident was the result of the destruction of the right main landing gear strut upon landing.
The following contributing factors were identified:
- Unsatisfactory performance of the welded joint in the manufacture of the strut with the formation of welding cracks in one of the most stressed zones of the strut,
- Pilot errors, which led to an early landing of the aircraft, possibly rough, on an unprepared (uncleared) area with possible obstacles.
Final Report:

Crash of a Boeing 737-81Q at Jacksonville NAS

Date & Time: May 3, 2019 at 2142 LT
Type of aircraft:
Operator:
Registration:
N732MA
Survivors:
Yes
Schedule:
Guantánamo Bay - Jacksonville
MSN:
30618/830
YOM:
2001
Flight number:
LL293
Crew on board:
7
Crew fatalities:
Pax on board:
136
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7500
Captain / Total hours on type:
2204.00
Copilot / Total flying hours:
7500
Copilot / Total hours on type:
18
Aircraft flight hours:
38928
Aircraft flight cycles:
15610
Circumstances:
According to both pilots, the takeoff, climb, and cruise portions of the flight were uneventful. The No. 1 (left) thrust reverser was not operational and deferred for the flight in accordance with the airplane’s minimum equipment list. The captain was the pilot flying for the accident flight, and the first officer was the pilot monitoring. The captain was also performing check airman duties for the first officer who was in the process of completing operating experience training. During the approach to Jacksonville Naval Air Station (NIP), the flight crew had two runway change discussions with air traffic controllers due to reported weather conditions (moderate to heavy precipitation) near the field; the pilots ultimately executed the area navigation GPS approach to runway 10, which was ungrooved and had a displaced threshold 997 ft from the threshold, leaving an available landing distance of 8,006 ft. As the airplane descended through 1,390 ft mean sea level (msl), the pilots configured it for landing with the flaps set at 30º and the landing gear extended; however, the speedbrake handle was not placed in the armed position as specified in the Landing checklist. At an altitude of about 1,100 ft msl and 2.8 nm from the runway, the airplane was slightly above the glidepath, and its airspeed was on target. Over the next minute, the indicated airspeed increased to 170 knots (17 knots above the target approach speed), and groundspeed reached 180 knots, including an estimated 7-knot tailwind. At an altitude of about 680 ft msl and 1.6 nm from the threshold, the airplane deviated further above the 3° glidepath such that the precision approach path indicator (PAPI) lights would have appeared to the flight crew as four white lights and would retain that appearance throughout the rest of the approach. Eight seconds before touchdown, multiple enhanced ground proximity warning system alerts announced “sink rate” as the airplane’s descent rate peaked at 1,580 fpm. The airplane crossed the displaced threshold 120 ft above the runway (the PAPI glidepath crosses the displaced threshold about 54 ft above the runway) and 17 knots above the target approach speed, with a groundspeed of 180 knots and a rate of descent about 1,450 ft per minute (fpm). The airplane touched down about 1,580 ft beyond the displaced threshold, which was 80 ft beyond the designated touchdown zone as specified in the operator’s standard operating procedures (SOP). After touchdown, the captain deployed the No. 2 engine thrust reverser and began braking; he later reported, however, that he did not feel the aircraft decelerate and increased the brake pressure. The speedbrakes deployed about 4 seconds after touchdown, most likely triggered by the movement of the right throttle into the idle reverse thrust detent after main gear tire spinup. The automatic deployment of the speedbrakes was likely delayed by about 3 seconds compared to the automatic deployment that could have been obtained by arming the speedbrakes before landing. The airplane crossed the end of the runway about 55 ft right of the centerline and impacted a seawall 90 ft to the right of the centerline, 9,170 ft beyond the displaced threshold, and 1,164 ft beyond the departure end of runway 10. After the airplane came to rest in St. Johns River, the flight crew began an emergency evacuation.
Probable cause:
An extreme loss of braking friction due to heavy rain and the water depth on the ungrooved runway, which resulted in viscous hydroplaning. Contributing to the accident was the operator’s inadequate guidance for evaluating runway braking conditions and conducting en route landing distance assessments.
Contributing to the continuation of an unstabilized approach were
1) the captain’s plan continuation bias and increased workload due to the weather and performing check airman duties and
2) the first officer’s lack of experience.
Final Report:

Crash of a Beechcraft B200 Super King Air in Gillam

Date & Time: Apr 24, 2019 at 1823 LT
Operator:
Registration:
C-FRMV
Flight Type:
Survivors:
Yes
Schedule:
Winnipeg – Churchill – Rankin Inlet
MSN:
BB-979
YOM:
1982
Flight number:
KEW202
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1350
Captain / Total hours on type:
1100.00
Copilot / Total flying hours:
3500
Copilot / Total hours on type:
1350
Circumstances:
On 24 April 2019, the Keewatin Air LP Beechcraft B200 aircraft (registration C‑FRMV, serial number BB979), equipped to perform medical evacuation flights, was conducting an instrument flight rules positioning flight (flight KEW202), with 2 flight crew members and 2 flight nurses on board, from Winnipeg/James Armstrong Richardson International Airport, Manitoba, to Rankin Inlet Airport, Nunavut, with a stop at Churchill Airport, Manitoba. At 1814 Central Daylight Time, when the aircraft was cruising at flight level 250, the flight crew declared an emergency due to a fuel issue. The flight crew diverted to Gillam Airport, Manitoba, and initiated an emergency descent. During the descent, both engines flamed out. The flight crew attempted a forced landing on Runway 23, but the aircraft touched down on the frozen surface of Stephens Lake, 750 feet before the threshold of Runway 23. The landing gear was fully extended. The aircraft struck the rocky lake shore and travelled up the bank toward the runway area. It came to rest 190 feet before the threshold of Runway 23 at 1823:45 Central Daylight Time. None of the occupants was injured. The aircraft sustained substantial damage. The 406 MHz emergency locator transmitter activated. Emergency services responded. There was no fire.
Probable cause:
Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. When the captain asked if the aircraft was ready for the flight, the first officer replied that it was, not recalling that the aircraft required fuel.
2. While performing the FUEL QUANTITY item on the AFTER START checklist, the captain responded to the first officer’s prompt with the rote response that the fuel was sufficient, without looking at the fuel gauges.
3. The aircraft departed Winnipeg/James Armstrong Richardson International Airport with insufficient fuel on board to complete the planned flight.
4. The flight crew did not detect that there was insufficient fuel because the gauges had not been included in the periodic cockpit scans.
5. When the flight crew performed the progressive fuel calculation, they did not confirm the results against the fuel gauges, and therefore their attention was not drawn to the low-fuel state at a point that would have allowed for a safe landing.
6. Still feeling the effect of the startle response to the fuel emergency, the captain quickly became task saturated, which led to an uncoordinated response by the flight crew, delaying the turn toward Gillam Airport, and extending the approach.
7. The right engine lost power due to fuel exhaustion when the aircraft was 1 nautical mile from Runway 23. From that position, a successful forced landing on the intended runway was no longer possible and, as a result, the aircraft touched down on the ice surface of Stephens Lake, short of the runway.

Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
1. If procedures are not developed to instruct pilots on their roles and responsibilities during line indoctrination flights, there is a risk that flight crew members may not participate when expected, or may work independently towards different goals.

Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
1. Because emergency medical services and the fire department were not notified immediately about the declared emergency, they were not on site before the aircraft arrived at Gillam Airport.
Final Report:

Crash of a Cessna 551 Citation II/SP in Siegerland

Date & Time: Apr 24, 2019 at 1442 LT
Type of aircraft:
Operator:
Registration:
D-IADV
Flight Type:
Survivors:
Yes
Schedule:
Siegerland - Siegerland
MSN:
551-0552
YOM:
1987
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6800
Captain / Total hours on type:
170.00
Copilot / Total flying hours:
1300
Copilot / Total hours on type:
0
Aircraft flight hours:
8479
Aircraft flight cycles:
7661
Circumstances:
The Cessna 551 Citation II/SP corporate jet took off at 13:30 local time from Reichelsheim Airfield, Germany, for a training flight at Siegerland Airport. It was a training flight to acquire the type rating for the aircraft. The right pilot's seat was occupied by the pilot in command, who was deployed on this flight as a flight instructor. The student pilot, as co-pilot, sat on the left pilot seat and was the pilot flying. For the co-pilot it was the second flight day of his practical training program on the Cessna 551 Citation II/SP. The day before, he had already completed about three flying hours on the plane. At Siegerland Airport, three precision approaches to runway 31 were carried out with the help of the Instrument Landing System (ILS). After the third landing, the tower, due to the changed wind, turned the landing direction to runway 13. The cockpit crew therefore rolled the aircraft to the end of the runway, turned and took off at 14:34 from runway 13. This was followed by a left-hand circuit at an altitude of 3,500 ft AMSL. The approach to runway 13 took place under visual flight conditions. According to both pilots, the checklists were processed during the circuit and the aircraft was prepared for landing on runway 13. In the final approach, the landing configuration was then established and the landing checklist performed. The copilot reported that shortly before the landing the speed decreased, the aircraft flew too low and the approach angle had to be corrected. He pushed the engine thrust levers forward to the stop. The pilot in command supported this action by also pushing the engine thrust levers forward with his hand. However, according to the pilot in command, the remaining time to touch down on the runway was no longer sufficient for the engines to accelerate to maximum speed in order to deliver the corresponding thrust. He also described that the aircraft had been in the stall area at that time. However, he had not noticed a stall warning. At 14:42, with the landing gear extended, the aircraft touched down in the grass in front of the asphalt area of runway 13. The left main landing gear buckled and damaged the tank of the left wing. The right main landing gear also buckled, the tank on the right side remained undamaged. The kerosene escaping from the left wing ignited and a fire broke out. The aircraft burned and slipped along runway 13 on the folded landing gear, the underside of the airframe and the extended landing flaps until it came to a standstill after a distance of approx. 730 m from runway threshold 13. After the plane had come to a standstill on the runway, the copilot noticed flames on the left side of the plane. The pilot switched off both engines. Then both pilots left the plane via the emergency exit door on the right side. The pilots were not injured.
Probable cause:
The accident, during which the airplane touched down ahead of the runway, was caused by an unstabilized approach and the non-initiation of a go-around procedure.
The following factors contributed to the accident:
- The organisation of the traffic pattern was performed too close to the airport.
- The final approach was flown too short and conducted in a way that it resulted in an unstabilized approach.
- During the final approach the approach angle was not correctly maintained until the runway threshold.
- During the final approach speed was too low.
- Both pilots did not recognize the decrease in speed early enough and had not increased engine performance in time.
- The flight instructor intervened too late and thus control of the flight attitude of the aircraft was not regained soon enough.
- The ascending terrain ahead of the runway threshold was also a contributory factor. It is highly likely that the student pilot had the impression of being too high and deliberately maintained a shallow approach angle.
Final Report:

Crash of a Casa C-295M in Santa Cilia

Date & Time: Apr 3, 2019 at 1130 LT
Type of aircraft:
Operator:
Registration:
T.21-10
Flight Type:
Survivors:
Yes
MSN:
S-027
YOM:
2005
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The airplane was engaged in the exercise 'ECCAragon2019' organized by the Aerial Evacuation Unit of the Air Force and was carrying six passengers and a crew of four on behalf of the 35th Aerial Unit based at Getafe AFB. Upon touchdown on runway 27 (850 meters long), the airplane bounced twice then landed firmly. It veered to the right and struck the concrete taxiway passing to the north apron. Unable to stop within the remaining distance, the airplane overran, struck trees and came to rest in a wooded area. All 10 occupants were slightly injured and evacuated.

Crash of an Embraer EMB-121A1 Xingu II in Campinas

Date & Time: Apr 2, 2019 at 2315 LT
Type of aircraft:
Registration:
PT-FEG
Survivors:
Yes
Schedule:
Sorocaba - Palmas
MSN:
121-057
YOM:
1982
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane departed Sorocaba-Estadual Bertram Luiz Leupolz Airport at 2300LT on a flight to Palmas, Tocantins, carrying three passengers and a crew of two. Few minutes after takeoff, the crew encountered technical difficulties and was cleared to divert to Campinas-Viracopos Airport. On final, he realized he could not make it so he attempted an emergency landing in a prairie located about 6 km short of runway 15 threshold. The wreckage was found less than a km from the Jardim Bassoli condominium and all five occupants, slightly injured, were evacuated. The aircraft was damaged beyond repair.