Crash of a Beechcraft 200 Super King Air in Oscoda: 1 killed

Date & Time: Sep 25, 2018 at 0613 LT
Operator:
Registration:
N241CK
Flight Type:
Survivors:
No
Schedule:
Detroit - Oscoda
MSN:
BB-272
YOM:
1977
Flight number:
K985
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3806
Captain / Total hours on type:
201.00
Aircraft flight hours:
13933
Circumstances:
The airline transport pilot of the multiengine airplane was cleared for the VOR approach. The weather at the airport was reported as 400 ft overcast with 4 miles visibility in drizzle. When the airplane failed to arrive at the airport as scheduled, a search was initiated, and the wreckage was located soon thereafter. Radar data indicated that the pilot was provided vectors to intercept the final approach course. The last radar return indicated that the airplane was at 2,200 ft and 8.1 miles from the runway threshold. It impacted terrain 3.5 miles from the runway threshold and left of the final approach course. According to the published approach procedure, the minimum descent altitude was 1,100 feet, which was 466 ft above airport elevation. Examination of the wreckage revealed that the airplane had impacted the tops of trees and descended at a 45° angle to ground contact; the airplane was destroyed by a postcrash fire, thus limiting the examination; however, no anomalies were observed that would have precluded normal operation. The landing gear was extended, and approach flaps had been set. Impact and fire damage precluded an examination of the flight and navigation instruments. Autopsy and toxicology of the pilot were not performed; therefore, whether a physiological issue may have contributed to the accident could not be determined. The location of the wreckage indicates that the pilot descended below the minimum descent altitude (MDA) for the approach; however, the reason for the pilot's descent below MDA could not be determined based on the available information.
Probable cause:
The pilot's descent below minimum descent altitude during the non precision instrument approach for reasons that could not be determined based on the available information.
Final Report:

Crash of a Honda HA-420 HondaJet in Foz do Iguaçu

Date & Time: Sep 24, 2018 at 1342 LT
Type of aircraft:
Operator:
Registration:
PR-TLZ
Survivors:
Yes
Schedule:
Curitiba – Foz do Iguaçu
MSN:
420-00068
YOM:
2017
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5600
Captain / Total hours on type:
77.00
Copilot / Total flying hours:
660
Copilot / Total hours on type:
14
Circumstances:
The airplane departed Curitiba-Afonso Pena Airport at 1240LT on an executive flight to Foz do Iguaçu, carrying one passenger and two pilots. Following an uneventful flight, the crew started the descent to Foz do Iguaçu-Cataratas Airport. The aircraft was stabilized and landed on wet runway 32. After touchdown, the crew encountered difficulties to stop the aircraft that overran and came to rest into a ravine. All three occupants evacued safely and the aircraft was damaged beyond repair.
Probable cause:
The following findings were identified:
- The approach was considered stabilized;
- The required landing distance of 6,431t (1,960m) was compatible for the operation, since the LDA of runway 32 at SBFI was 7,201ft (2,195m);
- There was no evidence of malfunction of the aircraft brake system that could have caused the runway excursion;
- At the time of landing, the runway was wet with a significant amount of water on the pavement;
- The estimated deceleration corresponded to what would be expected on a very wet runway (> 3mm of water) with hydroplaning of the tires at higher speeds;
- The friction and macrotexture measurements had normal parameters and did not contribute to the aircraft's poor deceleration;
- The characteristics of the precipitation over threshold 14 associated with the large variations in wind direction and intensity were consistent with the windshear phenomenon, resulting from a microburst;
- The PR-TLZ sensors did not detect the occurrence of windshear during the landing approach;
- A sudden increase in the calibrated speed that peaked at 32kt altered the aircraft's lift and, consequently, reduced the tires' grip on the ground, resulting in poor braking in the parts where the ground speed was lower;
- The speedbrakes were not extended during the run after landing, contrary to what was prevised in the AFM;
- The aircraft ran the full length of the runway, overpassed its limits and crashed into a ravine;
- There was a windshear alert issued about 30 seconds after the landing of the PRTLZ by an aircraft that was at the threshold 32;
- The aircraft had substantial damage; and
- The crewmembers and the passenger left unharmed.
Contributing factors:
- Control skills – undetermined
Despite the low contribution of the speedbrakes to the reduction of the landing distance, this device represents a deceleration resource through aerodynamic drag that should not be neglected, especially during landing on wet runways, and could have contributed to avoiding runway excursion.
- Adverse meteorological conditions – a contributor
The large variation in wind intensity peaked at 32 kt. This variation lasted 13 seconds and raised the indicated speed from 76 kt to 108 kt. Considering that the speed of 108 kt was very close to the VREF (111 KCAS), it can be stated that this phenomenon altered the aircraft's lift and, consequently, reduced the tires' grip on the ground, leading to poor braking.
Final Report:

Crash of a Let L-410UVP off Yirol: 20 killed

Date & Time: Sep 9, 2018 at 0845 LT
Type of aircraft:
Operator:
Registration:
UR-TWO
Survivors:
Yes
Schedule:
Juba - Yirol
MSN:
84 13 28
YOM:
1984
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
20
Circumstances:
On approach to Yiral Airport in poor visibility due to fog, the twin engine aircraft descended too low, impacted the surface of the Yirol Lake and crashed about 2 km north of the airfield. The aircraft was destroyed upon impact and four occupants were rescued while 19 others were killed. A day later, one of the survivor died from his injuries. The three survivors are two children and a Italian doctor. The flight was completed on behalf of the Slaver Company based in Ukraine.
Probable cause:
The committee for the investigations of Slav air let410 aircraft registration UR-TWO has finally concluded that the cause of the accident at Yirol Eastern Lake State Republic of South Sudan was caused by a combination of the following factors:
1. Severely bad weather in the morning of the accident.( Not making a decision to return back to Juba or diverting to the nearest airportRumbek).
2. Pilot incompetency and error in setting the altimeter for Yirol airstrip before the crash. (Causing variations in altitude- flying at false altitude actually below the actual flight level).
3. Replacement of a faulty propeller in Pibor and not informing the safety department of the changes and not being given the release document for operations.
Final Report:

Crash of a Cessna 340A in Saint Clair County: 1 killed

Date & Time: Sep 6, 2018 at 2347 LT
Type of aircraft:
Operator:
Registration:
C-GLKX
Flight Type:
Survivors:
No
Schedule:
Saint Thomas - Saint Clair County
MSN:
340A-1221
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
690
Captain / Total hours on type:
51.00
Aircraft flight hours:
4038
Circumstances:
The private pilot of the multi-engine airplane was conducting an instrument approach during night visual meteorological conditions. About 1.3 nautical miles (nm) from the final approach fix, the right engine lost total power. The pilot continued the approach and notified air traffic control of the loss of power about 1 minute and 13 seconds later. Subsequently, the pilot contacted the controller again and reported that he was unable to activate the airport's pilot-controlled runway lighting. In the pilot's last radio transmission, he indicated that he was over the airport and was going to "reshoot that approach." The last radar return indicated that the airplane was about 450 ft above ground level at 72 kts groundspeed. The airplane impacted the ground in a steep, vertical nose-down attitude about 1/2 nm from the departure end of the runway. Examination of the wreckage revealed that the landing gear and the flaps were extended and that the right propeller was not feathered. Data from onboard the airplane also indicated that the pilot did not secure the right engine following the loss of power; the left engine continued to produce power until impact. The airplane's fuel system held a total of 203 gallons. Fuel consumption calculations estimated that there should have been about 100 gallons remaining at the time of the accident. The right-wing locker fuel tank remained intact and contained about 14 gallons of fuel. Fuel blight in the grass was observed at the accident site and the blight associated with the right wing likely emanated from the right-wing tip tank. The elevator trim tab was found in the full nose-up position but was most likely pulled into this position when the empennage separated from the aft pressure bulkhead during impact. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Although there was adequate fuel on board the airplane, the pilot may have inadvertently moved the right fuel selector to the OFF position or an intermediate position in preparation for landing instead of selecting the right wing fuel tank, or possibly ran the right auxiliary fuel tank dry, which resulted in fuel starvation to the right engine and a total loss of power. The airplane manufacturer's Pilot Operating Handbook (POH) stated that the 20-gallon right- and left-wing locker fuel tanks should be used after 90 minutes of flight. However, 14 gallons of fuel were found in the right-wing locker fuel tank which indicated that the pilot did not adhere to the POH procedures for fuel management. The fuel in the auxiliary fuel tank should be used when the main fuel tank was less than 180 pounds (30 gallons) per tank. As a result of not using all the fuel in the wing locker fuel tanks, the pilot possibly ran the right auxiliary fuel tank empty and was not able to successfully restart the right engine after he repositioned the fuel selector back to the right main fuel tank. Postaccident testing of the airport's pilot-controlled lighting system revealed no anomalies. The airport's published approach procedure listed the airport's common traffic advisory frequency, which activated the pilot-controlled lighting. It is possible that the pilot did not see this note or inadvertently selected an incorrect frequency, which resulted in his inability to activate the runway lighting system. In addition, the published instrument approach procedure for the approach that the pilot was conducting indicated that the runway was not authorized for night landings. It is possible that the pilot did not see this note since he gave no indication that he was going to circle to land on an authorized runway. Given that the airplane's landing gear and flaps were extended, it is likely that the pilot intended to land but elected to go-around when he was unable to activate the runway lights and see the runway environment. However, the pilot failed to reconfigure the airplane for climb by retracting the landing gear and flaps. The pilot had previously failed to secure the inoperative right engine following the loss of power, even though these procedures were designated in the airplane's operating handbook as "immediate action" items that should be committed to memory. It is likely that the airplane was unable to climb in this configuration, and during the attempted go-around, the pilot exceeded the airplane's critical angle of attack, which resulted in an aerodynamic stall. Additionally, the pilot had the option to climb to altitude using singleengine procedures and fly to a tower-controlled airport that did not have any landing restrictions, but instead, he decided to attempt a go-around and land at his destination airport.
Probable cause:
The pilot's improper fuel management, which resulted in a total loss of right engine power due to fuel starvation; the pilot's inadequate flight planning; the pilot's failure to secure the right engine following the loss of power; and his failure to properly configure the airplane for the go-around, which resulted in the airplane's failure to climb, an exceedance of the critical angle of attack, and an aerodynamic stall.
Final Report:

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: