Crash of a Beechcraft A100 King Air in Itapaci

Date & Time: Sep 6, 2018 at 0830 LT
Type of aircraft:
Operator:
Registration:
PT-LJN
Survivors:
Yes
Schedule:
Goiânia – Ceres
MSN:
B-121
YOM:
1972
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane departed Goiânia-Santa Genoveva Airport at 0810LT on a charter flight to Ceres, carrying nine passengers and one pilot. En route, it was decided to change the itinerary and to land in Itapaci where there was no suitable terrain for landing. On final approach, the aircraft impacted ground, lost its undercarriage and veered to the right. It collided with a fence and made a 180 turn before coming to rest. All 10 occupants evacuated safely and the aircraft was damaged beyond repair. On board was the candidate for governor of the state of Goiás and his campaign team.
Probable cause:
The pilot intentionally changed his routing for Itapaci where the landing zone was not approved for flight operations. During the landing, the plane struck the ground before the planned zone and crashed. The pilot violated the rules established by the authority.
Final Report:

Crash of a Beechcraft C90GTi King Air in Vila Rica

Date & Time: Sep 5, 2018 at 1120 LT
Type of aircraft:
Registration:
PR-GVJ
Flight Type:
Survivors:
Yes
Schedule:
Belo Horizonte – Confresa
MSN:
LJ-2145
YOM:
2017
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane departed Belo Horizonte-Pampulha-Carlos Drummond de Andrade Airport at 0820LT on a private flight to Confresa, carrying five passenger and one pilot. While descending to Confresa, the pilot decided to fly directly to the farm of the owner (Fazenda Angola) located in Vila Rica, about 80 km northeast of Confresa Airport. On final approach, the aircraft was too low when it struck the surface of a lake then its bank. On impact, the undercarriage were torn off and the aircraft crash landed and came to rest on its belly. There was no fire. All six occupants were injured, one seriously. The aircraft was damaged beyond repair.
Probable cause:
The pilot descended too low on approach to an umprepared terrain.
Contributing Factors:
- Attitude,
- Command application,
- Pilot judgment,
- Decision making process,
- Lack of adherence to regulations established by the authority of Brazilian civil aviation.
Final Report:

Crash of a Boeing 737-8AS in Sochi

Date & Time: Sep 1, 2018 at 0258 LT
Type of aircraft:
Operator:
Registration:
VQ-BJI
Survivors:
Yes
Schedule:
Moscow - Sochi
MSN:
29937/1238
YOM:
2002
Flight number:
UT579
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
164
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13995
Captain / Total hours on type:
6391.00
Copilot / Total flying hours:
12277
Copilot / Total hours on type:
5147
Aircraft flight hours:
45745
Aircraft flight cycles:
23434
Circumstances:
On 31.08.2018 Boeing 737-800 VQ-BJI operated by UTAir Airlines conducted the scheduled flight UT 579 from Moscow (Vnukovo airport) to Sochi (Adler airport). During the preflight briefing (at 19:50) the crew was provided with the necessary weather information. At 20:15, the crew had passed the medical examination at Vnukovo airport mobile RWY medical unit. The Daily Check line maintenance (DY) was done on 30.08.2018 at Vnukovo airport by UTG aviation services, ZAO; job card # 11465742. The A/C takeoff weight was 68680 kg and the MAC was 26.46 %, that was within the AFM limitations for the actual conditions. At 21:33 the takeoff from Vnukovo airport was performed. The flight along he prescribed route was performed on FL350 in auto mode and without any issues. The F/O acted as the pilot flying (PF). When approaching the Sochi aerodrome traffic control area, the flight crew was provided by the aerodrome approach control with the approach and descending conditions, as well as with the weather conditions near the aerodrome. After descending to the height specified by Sochi Approach, the pilot contacted Sochi Radar, waited for the weather that met his minimum and was cleared for landing. In course of the first approach to landing (from the altitude about 30 m) when RVR got down because of heavy showers, the PIC took controls and performed the go-around. In course of the second approach, the crew performed the landing but failed to keep the airplane within the RWY. The airplane had landed at about 1285 m from the RWY threshold, overrun the threshold, broke through the aerodrome fencing, and came to rest in Mzymta river bed. This ended with the fire outbreak of fuel leaking from the damaged LH wing fuel tank. The crew performed the passenger evacuation. The aerodrome alert measures were taken and the fire was brought under control. Eighteen occupants were injured while all other occupants were unhurt. The aircraft was damaged beyond repair.
Probable cause:
The aircraft overrun, destroying and damage by fire were caused by the following factors:
- repeated disregarding of the windshear warnings which when entered a horizontal windshear (changing from the head wind to tail one) at low altitude resulted in landing at distance of 1285 m from the RWY threshold (overrunning the landing zone by 385 m) with the increased IAS and tail wind;
- landing to the runway, when its normative friction coefficient was less than 0.3 that according to the regulations in force, did not allow to land.
The factors contributed the accident:
- the crew violation of the AFM and Operator's OM requirements in regards to the actions required a forecasted or actual wind shear warning;
- use of the automatic flight mode (autopilot, autothrottle) in the flight under the windshear conditions which resulted in the aircraft being unstable (excess thrust) when turning to the manual control;
- lack of prevention measures taken by the Operator when the previous cases of poor crew response to windshear warning were found;
- insufficient crew training in regards to CRM and TEM that did not allow to identify committed mistakes and/or violations in good time;
- the crew members' high psychoemotional state caused by inconsistency between the actual landing conditions and the received training as well as the psychological limit which was determined by the individual psychological constitution of each member;
- insufficient braking both in auto and manual mode during the aircraft rollout caused by the insufficient tyre-to-ground friction aiming to achieve the specified rate of braking. Most probably the insufficient tyre-to-ground friction was caused by the significant amount of water on the RWY surface;
- the aerodrome services' noncompliance of Sochi International Aerodrome Manual requirements related to the RWY after heavy showers inspection which resulted in the crew provision of wrong normative friction coefficients. In obtaining of the increased overrun speed of about ≈75 kt (≈140 km/h) the later setting of engines into reverse mode was contributed (the engines were set into reverse mode 16 s later than the aircraft landed at distance of about ≈200 m from the runway end).
Final Report:

Crash of a Beechcraft 60 Duke in Destin: 4 killed

Date & Time: Aug 30, 2018 at 1030 LT
Type of aircraft:
Registration:
N1876L
Flight Type:
Survivors:
No
Schedule:
Toledo - Destin
MSN:
P-386
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2427
Captain / Total hours on type:
100.00
Aircraft flight hours:
4167
Circumstances:
The commercial pilot and three passengers departed on a cross-country flight in a twin-engine airplane. As the flight neared the destination airport, the pilot canceled his instrument flight rules (IFR) clearance. The approach controller transferred the flight to the tower controller, and the pilot reported to the tower controller that the airplane was about 2 miles from the airport. However, the approach controller contacted the tower controller to report that the airplane was 200 ft over a nearby joint military airport at the time. GPS data revealed that, when pilot reported that the airplane was 2 miles from the destination airport, the airplane's actual location was about 10 miles from the destination airport and 2 miles from the joint military airport. The airplane impacted a remote wooded area about 8 miles northwest of the destination airport. At the time of the accident, thunderstorm cells were in the area. A review of the weather information revealed that the pilot's view of the airport was likely obscured because the airplane was in an area of light precipitation, restricting the pilot's visibility. A review of airport information noted that the IFR approach course for the destination airport passes over the joint military airport. The Federal Aviation Administration chart supplement for the destination airport noted the airport's proximity to the other airport. However, it is likely that the pilot mistook the other airport for the destination airport due to reduced visibility because of weather. The accident circumstances were consistent with controlled flight into terrain. The ethanol detected in the pilot's blood specimens but not in his urine specimens was consistent with postmortem bacteria production. The carbon monoxide and cyanide detected in the pilot's blood specimens were consistent with inhalation after the postimpact fire.
Probable cause:
The pilot's controlled flight into terrain after misidentifying the destination airport during a period of restricted visibility due to weather.
Final Report:

Cras of a De Havilland DHC-6 Twin Otter in Mojo: 18 killed

Date & Time: Aug 30, 2018 at 1030 LT
Operator:
Registration:
ET-AIU
Survivors:
No
Schedule:
Dire Dawa – Debre Zeit
MSN:
822
YOM:
1985
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
18
Circumstances:
The twin engine airplane departed Dire Dawa in the morning on a flight to Harar Meda Airbase located in Debre Zeit, carrying 15 Army officers and three civilians on behalf of the Ethiopian Army. While descending to Harar Meda, the airplane crashed in unknown circumstances in a wooded area located in Mojo, some 17 km southeast of the airfield. The aircraft was totally destroyed and all 18 occupants were killed, among them two children. Operated on behalf of the Ethiopian Army with dual registration ET-AIU/808.

Crash of a Piper PA-31-310 Navajo in Limoges

Date & Time: Aug 21, 2018 at 1525 LT
Type of aircraft:
Operator:
Registration:
F-HGPS
Flight Type:
Survivors:
Yes
Schedule:
Limoges - Limoges
MSN:
31-245
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1250
Circumstances:
The twin engine airplane, owned by IMAO specialized in aerial photo missions, departed Limoges-Bellegarde Airport at 1009LT with one pilot (the Director of the Company, aged 58) and a female operator in charge of the aerial photo program. The goal of the mission was to fly over the sector of Peyrelevade at 7,000 feet then a second sector over Ussel at an altitude of 6,500 feet. Following an uneventful flight, the pilot return to Limoges, contacted ATC and was instructed to recall for a right base leg approach for a landing on runway 03. Two minutes after passing the altitude of 3,000 feet on approach, the pilot informed ATC he was short of fuel and that he was attempting an emergency landing. The airplane impacted trees and crashed in a field located near Verneuil-sur-Vienne, some 3,6 short of runway 03. Both occupants were seriously injured and the aircraft was damaged beyond repair.
Probable cause:
Emergency landing due to fuel exhaustion following a flight of five hours and 15 minutes.
Final Report:

Crash of a Boeing 737-85C in Manila

Date & Time: Aug 16, 2018 at 2355 LT
Type of aircraft:
Operator:
Registration:
B-5498
Survivors:
Yes
Schedule:
Xiamen – Manila
MSN:
37574/3160
YOM:
2010
Flight number:
MF8667
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
157
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On August 16, 2018, about 1555UTC/2355H local time, a Boeing 737-800 type of aircraft with Registry No. B-5498 operating as flight CXA 8667 sustained substantial damage following a runway excursion after second approach while landing on Runway 24 of Ninoy Aquino International Airport (NAIA), Manila, Philippines. The flight was a scheduled commercial passenger from Xiamen, China and operated by Xiamen Airlines. The one hundred fifty-seven (157) passengers and two (2) pilots together with the five (5) cabin crew and one air security officer did not sustain any injuries while the aircraft was substantially damaged. An instrument flight rules flight plan was filed. Instrument Meteorological Conditions (IMC) prevailed at the time of the accident. During the first approach, the Captain who was the pilot flying aborted the landing at 30 feet Radio Altitude (RA) due to insufficient visual reference. A second approach was considered and carried out after briefing the First Officer (FO) of the possibility of another aborted landing should the flight encounter similar conditions. The briefing included a diversion to their planned alternate airfield. The flight was “stabilized” on the second approach with flaps set at 30 degrees landing position, all landing gears extended and speed brake lever appropriately set in the ARM position. On passing 1,002 feet Radio Altitude (RA), the autopilot was disengaged; followed by the disengagement of the auto-throttle, three (3) seconds later. The ILS localizer lateral path and Glide slope vertical path were accurately tracked and no deviations were recorded. The “reference” landing speed for flaps 30 for the expected aircraft gross weight at the time of landing was 145 knots and a target speed of 150 knots was set on the Mode Control Panel (MCP). The vertical descent rate recorded during the approach was commensurate with the recommended descent rate for the profile angle and ground speed; and was maintained throughout the approach passing through the Decision Altitude (DA) of 375 feet down to 50 feet radio altitude (RA). As the aircraft passed over the threshold, the localizer deviation was established around zero dot but indicated the airplane began to drift to the left of the centerline followed by the First Officer (FO) making a call out of “Go-Around” but was answered by the Captain “No”. The throttle levers for both engines were started to be reduced to idle position at 30 feet RA and became fully idle while passing five (5) feet RA. At this point, the aircraft was in de-crab position prior to flare. At 13 feet RA, the aircraft was rolling left and continuously drifting left of the runway center line. At 10 feet RA another call for go-around was made by the FO but was again answered by the Captain with “No” and “It’s Okay”. At this point, computed airspeed was approximately 6 knots above MCP selected speed and RA was approaching zero feet. Just prior to touchdown, computed airspeed decreased by 4 knots and the airplane touched down at 151 knots (VREF+6). The wind was recorded at 274.7 degrees at 8.5 knots. Data from the aircraft’s flight data recorder showed that the aircraft touched down almost on both main gears, to the left of the runway centerline, about 741 meters from the threshold of runway 24. Deployment of the speed brakes was recorded and auto brakes engagement was also recorded. The auto brakes subsequently disengaged but the cause was undetermined. Upon touchdown, the aircraft continued on its left-wards trajectory while the aircraft heading was held almost constant at 241 degrees. After the aircraft departed the left edge of the runway, all landing gears collided with several concrete electric junction boxes that were erected parallel outside the confines of the runway pavement. The aircraft was travelling at about 147 knots as it exited the paved surface of the runway and came to rest at approximately 1,500 meters from the threshold of Runway 24, with a geographical position of 14°30’23.7” N; 121°0’59.1” E and a heading of 120 degrees. Throughout the above sequence of events from touchdown until the aircraft came to a full stop, the CVR recorded 2 more calls of “GO-AROUND” made by the FO. Throughout the landing sequence, the thrust reversers for both engines were not deployed. Throttle Lever Position (TLP) were recorded and there was no evidence of reverse thrust being selected or deployment of reversers. After the aircraft came to a complete stop, the pilots carried out all memory items and the refence items in the evacuation non-normal checklist, which includes extending the flaps to a 40 degrees position. The aircraft suffered total loss of communication and a failure in passenger address system possibly due to the damage caused by the nose gear collapsing rearwards and damaging the equipment in the E/E compartment or the E-buss wires connecting the Very High Frequency (VHF) 1 radio directly to the battery was broken. The Captain then directed the FO to go out of the cockpit to announce the emergency evacuation. The cabin crew started the evacuation of the passengers utilizing the emergency slides of the left and right forward doors. There were no reported injuries sustained by the passengers, cabin crew, flight crew or the security officer.
Probable cause:
Primary causal factors:
a. The decision of the Captain to continue the landing on un-stabilized approach and insufficient visual reference.
- The Captain failed to maintain a stabilized landing approach moments before touchdown, the aircraft was rolling left and continuously drifting left of the runway centerline.
- The Captain failed to identify correctly the aircraft position and status due to insufficient visual reference caused by precipitation.
b. The Captain failed to apply sound CRM practices.
- The Captain did not heed to the First Officer call for a Go-Around.
Contributory factors:
a. Failure to apply appropriate TEM strategies. Failure of the Flight Crew to discuss and apply appropriate Threat and Error Management (TEM) strategies for the following:
- Inclement weather.
- Cross wind conditions during approach to land.
- Possibility of low-level wind shear.
- NOTAM information on unserviceable runway lights.
b. Inadequate Company Policy on Go-Around:
- Company’s Standard Operation Procedures were less than adequate in terms of providing guidance to the flight crew for call out of "Go-Around" during landing phase of the flight.
c. Runway strip inconsistent with CAAP MOS for Aerodrome and ICAO Annex 14:
- The uneven surface and concrete obstacles contributed to the damage sustained by the aircraft.
Final Report:

Crash of a Pacific Aerospace PAC 750XL near Oksibil: 8 killed

Date & Time: Aug 11, 2018 at 1420 LT
Operator:
Registration:
PK-HVQ
Survivors:
Yes
Site:
Schedule:
Tanah Merah – Oksibil
MSN:
144
YOM:
2009
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
13665
Captain / Total hours on type:
1468.00
Aircraft flight hours:
4574
Aircraft flight cycles:
5227
Circumstances:
On 11 August 2018, a PAC 750XL aircraft registered PK-HVQ was being operated by PT. Marta Buana Abadi (Dimonim Air) on unscheduled passenger flight from Tanah Merah to Oksibil. At the day of the occurrence the meteorological condition at Oksibil was below the requirement of Visual Flight Rule (VFR) weather minima and did not improve. Being aware that some flights had performed flight to Tanah Merah to Oksibil and returned, the pilot decided to fly to Oksibil. At 1342 LT, on daylight condition the PK-HVQ aircraft departed from Tanah Merah to Oksibil, on board the aircraft were one pilot, one observer pilot and 7 passengers. According to the passenger and cargo manifest, the total weight of passenger and the baggage were 473 kg. Prior to the departure, there was no record or report of aircraft system malfunction. At 1411 LT, the PK-HVQ pilot made initial contact to Oksibil Tower controller and reported that the aircraft was maintaining altitude of 7,000 feet over and the estimate time arrival at Oksibil would be 0520 UTC (1420 LT). The Oksibil Tower controller advised the pilot of the latest meteorological condition that the visibility was 1 up to 2 km and most of the area were covered by cloud. At 1416 LT, the pilot reported that the aircraft position was over Oksibil Aiport and the Oksibil Tower controller instructed the pilot to continue the flight to the final runway 11 and to report when the runway had in sight. The Oksibil Tower controller and pilots of other aircraft called the pilot but no reply. On the following day, the aircraft was found on a ridge of mountain about 3.8 Nm north west of Oksibil on bearing 331° with elevation about 6,800 feet. Eight occupants were fatally injured and one occupant was seriously injured.
Probable cause:
The KNKT concluded the contributing factors as follows:
- The VFR weather minimum requirement that was not implemented properly most likely had made the pilot did not have a clear visual to the surrounding area.
- Considering that the Pilot in Command (PIC) had lack knowledge of the terrain surrounding the Oksibil area, and the absence of voice alert from the TAWS when the aircraft flying close to terrain, resulted in the PIC did not have adequate awareness to the surrounding terrain while flying into clouds and continued to fly below the terrain height until the aircraft impacted the terrain.
Final Report:

Crash of a Dassault Falcon 20D in San Luis Potosí

Date & Time: Aug 7, 2018 at 0110 LT
Type of aircraft:
Operator:
Registration:
N961AA
Flight Type:
Survivors:
Yes
Schedule:
Santiago de Querétaro - Laredo
MSN:
205
YOM:
1969
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Santiago de Querétaro Airport on a night cargo flight to Laredo, Texas, carrying two pilots and a load consisting of automotive parts. En route, the crew encountered engine problems and was clearted to divert to San Luis Potosí-Ponciano Arriaga Airport for an emergency landing. On approach, the crew realized he could not make it and decided to attempt an forced landing. The airplane struck the ground, lost its undercarriage and came to rest in an agricultural area located in Peñasco, about 6 km northeast of runway 14 threshold. The left wing was bent and partially torn off. Both crew members escaped with minor injuries and the aircraft was damaged beyond repair.

Crash of a Cessna 414 Chancellor in Santa Ana: 5 killed

Date & Time: Aug 5, 2018 at 1229 LT
Type of aircraft:
Registration:
N727RP
Flight Type:
Survivors:
No
Site:
Schedule:
Concord – Santa Ana
MSN:
414-0385
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
980
Captain / Total hours on type:
120.00
Aircraft flight hours:
3963
Circumstances:
The pilot and four passengers were nearing the completion of a cross-county business flight. While maneuvering in the traffic pattern at the destination airport, the controller asked the pilot if he could accept a shorter runway. The pilot said he could not, so he was instructed to enter a holding pattern for sequencing; less than a minute later, the pilot said he could accept the shorter runway. He was instructed to conduct a left 270° turn to enter the traffic pattern. The pilot initiated a left bank turn and then several seconds later the bank increased, and the airplane subsequently entered a steep nose-down descent. The airplane impacted a shopping center parking lot about 1.6 miles from the destination airport. A review of the airplane's flight data revealed that, shortly after entering the left turn, and as the airplane’s bank increased, its airspeed decreased to about 59 knots, which was well below the manufacturer’s published stall speed in any configuration. Postaccident examination of the airframe and engines revealed no anomalies that would have precluded normal operation. It is likely that the pilot failed to maintain airspeed during the turn, which resulted in an exceedance of the aircraft's critical angle of attack and an aerodynamic stall.
Probable cause:
The pilot’s failure to maintain adequate airspeed while maneuvering in the traffic pattern which resulted in an aerodynamic stall and subsequent spin at a low altitude, which the pilot was unable to recover from.
Final Report: