Crash of an Epic LT in Egelsbach: 3 killed

Date & Time: Mar 31, 2019 at 1527 LT
Type of aircraft:
Operator:
Registration:
RA-2151G
Survivors:
No
Schedule:
Cannes - Egelsbach
MSN:
019
YOM:
2008
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
11425
Captain / Total hours on type:
676.00
Aircraft flight hours:
2221
Circumstances:
At 1357 hrs the airplane had taken off from Cannes-Mandelieu Airport, France, to a private flight to Egelsbach Airfield, Germany. On board were the pilot and two passengers. According to the flight plan cruise flight was planned for Flight Level (FL)260. At 1519:03 hrs the pilot established contact with Frankfurt Radar, and informed the controller that the airplane was in descent to FL60 towards reporting point UBENO. The radar recordings show that the airplane was flying towards 335° and transmitted the transponder code 4065. The radar controller issued the descent clearance to 4,000 ft AMSL and conveyed a QNH of 1,020 hPa. At 1519:25 hrs the controller addressed the pilot: “[…] proceed direct DELTA, runway zero eight in use.” The pilot acknowledged the clearance. At 1520:20 hrs the controller instructed the pilot to descend to 3,500 ft AMSL. After the pilot had acknowledged the controller’s question, the change of flight rules from IFR to VFR was conducted at 1521 hrs about 16 NM south of Egelsbach Airfield. At the time, the airplane was at about 5,000 ft AMSL with a ground speed of approximately 240 kt. At 1522:34 hrs, the airplane was at 3,500 ft AMSL and about 14 NM from the airfield, the pilot established radio contact with Egelsbach Information with the words: “[…] inbound DELTA, descending VFR.” The Flugleiter (A person required by German regulation at uncontrolled aerodromes to provide aerodrome information service to pilots) answered: “Hello […] runway zero eight, QNH one zero two zero, squawk four four four one.” The pilot acknowledged the landing direction and the QNH. The communicated transponder code was not acknowledged, and did not change during the remainder of the flight, according to the radar recording. At 1524:34 hrs the Flugleiter gave the pilot the hint: “[…] the maximum altitude in this area is one thousand five hundred feet.” The pilot answered: “Roger, continue descent […].” At this time, altitude was still about 2,000 ft AMSL. According to the radar recording, at 1524:45 hrs the airplane turned right in northern direction toward the DELTA approach path to runway 08 of Egelsbach Airfield. Altitude was about 1,900 ft AMSL, and ground speed 170 kt. At 1526:30 hrs, at about the Tank- und Rastanlage Gräfenhausen (resting facility) at the Bundesautobahn A5 (motorway), it began to turn right up to north-eastern direction. At 1526:44 hrs the Flugleiter addressed the pilot: “[…] do you have the field in sight?” The pilot responded: “Ah, not yet […].” At the time, the airplane was about 1,000 m south-west of threshold 08 at the western outskirts of Erzhausen flying a northeastern heading. The Flugleiter added: “I suggest to reduce, you are now in right base.” After the pilot had answered with “Roger”, the Flugleiter added: “You are number one to land. The wind is zero four zero, one zero knots.” At 1527:04 hrs, the airplane was about 300 m south of threshold 08 flying a northeastern heading, the radio message“[…] approach” of the pilot was recorded. From then on the airplane began to turn left. At 1527:11 hrs, the airplane crossed runway 08 with a ground speed of about 100 kt at very low altitude with northern heading. At 1527:24 hrs the pilot said: “[…] may I the […] make an orbit?” The Flugleiter answered: “Yes, do it to your left-hand side and do not overfly the highway westbound.” At 1527:31 hrs, the last radar target was recorded at approximately 600 m north-west of threshold 08 indicating an altitude of about 425 ft AMSL. About 100 m south-west of it the airplane crashed to the ground and caught fire. All three occupants suffered fatal injuries. At the time of the accident, three persons were in the Tower of the airfield. The Flugleiter, as tower controller, his replacement, and the apron controller. They observed that the airplane flew directly towards the tower coming from the DELTA approach in descent with north-eastern heading, i.e. diagonal to the landing direction. In this phase the landing gear extended. Two witnesses, who were at the airport close to the tower, stated that they had seen the airplane during the left-hand turn. They estimated the bank angle during the turn with 30-45°. The two occupants of a Piper PA-28, which had been on approach to runway 08, stated that they had become aware of the other airplane, before changing from downwind leg to final approach. They also stated that during the turn the airplane went into a dive and impacted the ground after about a half turn. Approximately 330 m north-east of the accident site, persons had been walking in a forest. One of them recorded a video. This recording was made available for investigation purposes. The video shows the shadow of the airplane moving west immediately prior to the accident. Consistent engine sounds and, 8 seconds after the shadow passed, the crash of the airplane can be heard. The aircraft was totally destroyed by a post crash fire and all three occupants were killed, among them Natalia Fileva, co-owner of the Russian Operator S7 Airlines.
Probable cause:
The accident was caused by the pilot steering the airplane during a turn in low altitude in an uncontrolled flight attitude, the airplane then banked over the wing and impacted the ground in a spinning motion.
Contributing factors:
- The decision of the pilot to conduct a non-standard approach to runway 08 without visual contact with the runway and contrary to the SOP and to continue the unstabilized approach,
- The complex airspace structure surrounding Frankfurt-Egelsbach Airfield,
- The late recognition of the airport and the pilot’s decision for an inappropriate manoeuvre close to the ground,
- The insufficient attention distribution of the pilot in combination with the missing stall warning of the airplane.
Final Report:

Crash of a Rockwell Sabreliner 60 near Bajamar

Date & Time: Mar 22, 2019
Type of aircraft:
Operator:
Registration:
N990PA
Flight Type:
Survivors:
Yes
MSN:
306-114
YOM:
1976
Location:
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft crashed in unknown circumstances in an isolated and uninhabited area located about 14 km east of Bajamar, Honduras. The airplane was engaged in an illegal mission (drug smuggling flight) as a pack of cocaine and a gun were found in the wreckage. The crew disappeared and was not recovered.

Crash of an IAI 1124 Westwind in Sundance: 2 killed

Date & Time: Mar 18, 2019 at 1531 LT
Type of aircraft:
Registration:
N4MH
Flight Type:
Survivors:
No
Schedule:
Panama City - Sundance
MSN:
232
YOM:
1978
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5872
Copilot / Total flying hours:
5259
Aircraft flight hours:
11030
Circumstances:
The two commercial pilots were conducting a personal, cross-country flight. A video surveillance camera at the airport captured their airplane’s approach. Review of the video revealed that, as the airplane approached the approach end of the landing runway, it began to climb, rolled left, became inverted, and then impacted terrain. The left thrust reverser (T/R) was found open and unlatched at the accident site. An asymmetric deployment of the left T/R would have resulted in a left roll/yaw. The lack of an airworthy and operable cockpit voice recorder, which was required for the flight, precluded identifying which pilot was performing pilot flying duties, as well as other crew actions and background noises, that would have facilitated the investigation. Postaccident examination of the airplane revealed that it was not equipped, nor was required to be equipped, with a nose landing gear (NLG) ground contact switch intended to preclude inflight operation of the thrust reverser (T/R). The left T/R door was found unlatched and open, and the right T/R door was found closed and latched. Further, electrical testing of the T/R left and right stow microswitches within the cockpit throttle quadrant revealed that the left stow microswitch did not operate within design specifications. Disassembly of the left and right stow microswitches revealed evidence of arc wear due to aging. Based on this information, it is likely that the airplane’s lack of an NLG ground contact switch and the age-related failure of the stow microswitches resulted in an asymmetric T/R deployment while on approach and a subsequent loss of airplane control. Also, there were additional T/R system components that were found to unairworthy that would have affected the control of the T/R system. Operational testing of the T/R system could not be performed due to the damage the airplane incurred during the accident. Toxicology testing results of the pilot’s specimens indicated that the pilot had taken diazepam, which is considered impairing at certain levels. However, the detected amounts of both diazepam and its metabolite nordiazepam were at subtherapeutic levels, and given the long half-life of these compounds, it appears that the medication was taken several days before the accident; therefore, it is unlikely that the pilot was impaired at the time of the accident and thus that his use of diazepam was a not factor in the accident.
Probable cause:
The airplane’s unairworthy thrust reverser (T/R) system due to inadequate maintenance that resulted in an asymmetric T/R deployment during an approach to the airport and the subsequent loss of airplane control.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Delaware: 1 killed

Date & Time: Mar 17, 2019 at 1745 LT
Registration:
N424TW
Flight Type:
Survivors:
No
Schedule:
Dayton - Delaware
MSN:
421B-0816
YOM:
1974
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3000
Captain / Total hours on type:
48.00
Aircraft flight hours:
8339
Circumstances:
The pilot departed on a short cross-country flight in the twin-engine airplane. Instrument meteorological conditions (IMC) were present at the time. While en route at an altitude of 3,000 ft mean sea level, the pilot reported that the airplane was "picking up icing" and that he needed to "pick up speed." The controller then cleared the pilot to descend, then to climb, in order to exit the icing conditions; shortly thereafter, the controller issued a low altitude alert. The pilot indicated that he was climbing; radar and radio contact with the airplane were lost shortly thereafter. The airplane impacted a field about 7 miles short of the destination airport. Examination of the airplane was limited due to the fragmentation of the wreckage; however, no pre-impact anomalies were noted during the airframe and engine examinations. Extensive damage to the pitot static and deicing systems precluded functional testing of the two systems. A review of data recorded from onboard avionics units indicated that, about the time the pilot reported to the controller that the airplane was accumulating ice, the airplane's indicated airspeed had begun to diverge from its ground speed as calculated by position data. However, several minutes later, the indicated airspeed was zero while the ground speed remained fairly constant. It is likely that this airspeed indication was the result of icing of the airplane's pitot probe. During the final 2 minutes of flight, the airplane was in a left turn and the pilot received several "SINK RATE" and "PULL UP PULL UP" annunciations as the airplane conducted a series of climbs and descents during which its ground speed (and likely, airspeed) reached and/or exceeded the airplane's maneuvering and maximum structural cruising speeds. It is likely that the pilot became distracted by the erroneous airspeed indication due to icing of the pitot probe and subsequently lost control while maneuvering.
Probable cause:
A loss of airspeed indication due to icing of the airplane's pitot probe, and the pilot's loss of control while maneuvering.
Final Report:

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: