Crash of a Beechcraft C90 King Air in Rockford

Date & Time: Dec 5, 2017 at 1802 LT
Type of aircraft:
Registration:
N500KR
Flight Type:
Survivors:
Yes
Schedule:
Kissimmee - Rockford
MSN:
LJ-708
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2500
Aircraft flight hours:
9856
Circumstances:
The private pilot departed on a cross-country flight in his high-performance, turbine-powered airplane with full tanks of fuel. He landed and had the airplane serviced with 150 gallons of fuel. He subsequently departed on the return flight. As the airplane approached the destination airport, the pilot asked for priority handling and reported that the airplane "lost a transfer pump and had a little less fuel than he thought," and he did not want to come in with a single engine. When asked if he needed assistance, he replied "negative." The pilot was cleared to perform a visual approach to runway 19 during night conditions. As the airplane approached the airport, the pilot requested the runway lights for runway 25 be turned on and reported that the airplane lost engine power in one engine. The controller advised that the lights on runway 25 were being turned on and issued a landing clearance. The airplane impacted terrain before the threshold for runway 25. During examination of the recovered wreckage, flight control continuity was established. No useable amount of fuel was found in any of the airplane's fuel tanks; however, fuel was observed in the fuel lines. All transfer pumps and boost pumps were operational. The engine-driven fuel pumps on both engines contained fuel in their respective fuel filter bowls. Both pumps were able to rotate when their input shafts were manipulated by hand. Disassembly of both pumps revealed that their inlet filters were free of obstructions. Bearing surfaces in both pumps exhibited pitting consistent with pump operation with inadequate fuel lubrication and fuel not reaching the pump. The examination revealed no evidence of airframe or engine preimpact malfunctions or failures that would have precluded normal operation of the airplane. Performance calculations using a flight planning method described in the airplane flight manual indicated that the airplane could have made the return flight with about 18 gallons (119 lbs) of fuel remaining. However, performance calculations using a fuel burn simulation method developed from the fuel burn and data from the airplane flight manual indicated that the airplane would have run out of fuel on approach. Regulations require that a flight depart with enough fuel to fly to the first point of intended landing and, assuming normal cruising speed, at night, to fly after that for at least 45 minutes. The calculated 45-minute night reserves required about 56 gallons (366 lbs) of fuel using a maximum recommended cruise power setting or about 37.8 gallons (246 lbs) of fuel using a maximum range power setting. Regardless of the flight planning method he could have used, the pilot did not depart on the accident flight with the required fuel reserves and exhausted all useable fuel while on approach to the destination. The airplane was owned by Edward B. Noakes III.
Probable cause:
The pilot's inadequate preflight planning and his decision to depart without the required fuel reserve, which resulted in fuel exhaustion during a night approach and subsequent loss of engine power.
Final Report:

Crash of a Raytheon 390 Premier I in Johannesburg

Date & Time: Nov 22, 2017 at 1623 LT
Type of aircraft:
Registration:
ZS-CBI
Flight Type:
Survivors:
Yes
Schedule:
Cape Town - Johannesburg
MSN:
RB-214
YOM:
2007
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3048
Captain / Total hours on type:
649.00
Copilot / Total flying hours:
4718
Copilot / Total hours on type:
305
Aircraft flight hours:
963
Circumstances:
On 22 November 2017, the pilot-in-command (PIC) accompanied by the first officer (FO) took off from the Cape Town International Airport (FACT) on a private flight to the Rand Airport (FAGM). The flight was conducted under instrument flight rules (IFR) by day and the approach was conducted under visual flight rules (VFR). The PIC was the pilot flying (PF) and was seated on the left seat and the FO was occupying the right seat. The air traffic controller (ATC) on duty at FAGM tower stated that the FO reported in-bound for a fullstop landing at FAGM. The last wind direction data for Runway 29 was transmitted to the FO as 230°/11 knots (kts) and Query Nautical Height (QNH): 1021. The FO acknowledged the transmission and the crew elected to land on Runway 11. The PIC stated that the approach for landing was stable and that the touchdown was near the first taxiway exit point. According to the FO, the aircraft floated for a while before touchdown. This was confirmed during the investigation. During the landing rollout, the PIC applied the brakes and the brakes responded for a short while, however, the aircraft continued to roll without slowing down. At approximately 300 metres (m) beyond the intersection of Runway 35 and Runway 11, the PIC requested the FO to apply emergency brakes. The FO applied the emergency brakes gradually and the aircraft continued to roll before the brakes locked and the tyres burst. The aircraft skidded on the main wheels and continued for approximately 180m until it overshot the runway. The undercarriage went over a ditch of approximately 200 millimetres in depth at the end of the runway into the soft ground and the aircraft came to a stop approximately 10m from the threshold facing slightly left off the extended centre line Runway 11. The aircraft was substantially damaged during the impact sequence and none of the occupants sustained injuries. The crash alarm was activated by the tower and the fire services responded to the scene.
Probable cause:
The investigation revealed that the aircraft was unstable on approach (hot and high), resulting in deep landing, probably near the second exit point, leading to a runway excursion. Contributing factors were attributed to the lift dumps not being deployed and the incorrect application of the emergency brakes.
Final Report:

Crash of a Grumman C-2A(R) Greyhound in the Philippines Sea: 3 killed

Date & Time: Nov 22, 2017 at 1445 LT
Type of aircraft:
Operator:
Registration:
162175
Flight Type:
Survivors:
Yes
Schedule:
Iwakuni - USS Ronald Reagan
MSN:
55
Flight number:
Password 33
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The aircraft was on its way from Iwakuni Airbase to the USS Ronald Reagan (CVN-76) cruising in the Philippines Sea on behalf of the 7th Fleet. It is believed that while approaching the supercarrier, the airplane stalled and crashed in the sea, apparently following an engine failure. Eight crew members were rescued while three were still missing two days after the accident. The wreckage was localized on 29 December 2017 at a depth of 5,640 meteres.
Those killed were:
Lt Steven Combs, Aviation Boatswain’s Mate (Equipment),
Airman Matthew Chialastri,
Aviation Ordnance Airman Apprentice Bryan Grosso.

Crash of a Let L-410UVP-E20 in Nelkan: 6 killed

Date & Time: Nov 15, 2017 at 1309 LT
Type of aircraft:
Operator:
Registration:
RA-67047
Survivors:
Yes
Schedule:
Khabarovsk - Chumikan - Nelkan
MSN:
15 30 10
YOM:
2015
Flight number:
RNI463
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
12076
Captain / Total hours on type:
1243.00
Copilot / Total flying hours:
1220
Copilot / Total hours on type:
837
Aircraft flight hours:
1693
Aircraft flight cycles:
1071
Circumstances:
On 14.11.2017, Khabarovsk Airlines' representative submitted the flight request for L-410UVP-E20 RA-67047 A/C flight to Joint ATM System Khabarovsk regional unit; the flight (NI 463) was planned along the route Khabarovsk – Nikolayevsk-on-Amur – Nelkan. On 14.11.2017 at 22:00 (local time: on 15.11.2017 at 08:00) at Khabarovsk airport, the preflight preparation was started including the medical examination. While the preflight preparation was being performed, new information was received that Nikolayevsk-on-Amur airport was closed due to the RWY snow removal. In coordination with ATC of Nikolayevsk-on-Amur airport, it was decided to change the route as follows: Khabarovsk – Chyumican – Nelkan. Before coming onboard the crew passed all mandatory preflight procedures as required by the normative documentation. On 15.11.2017, before the departure, Khabarovsk Airlines' technicians provided the line maintenance check in accordance with the F-A Form (Maintenance Job Card #687). No findings in relation to the aircraft and/or systems' operation were reported. The total amount of fuel on board was 1250 kg. The flight crew obtained all the necessary weather information (actual and forecast) during of the preflight weather briefing. The actual weather and the weather forecast for the departure aerodrome, on route weather, the weather forecast for the destination and alternate aerodromes – all met the FAP-128 (Russian FAR) requirements stated in items 5.30 and 5.38, and did not preclude the PIC's decision for departure. There were 2 crew members, 5 passengers and 410 kg of cargo (personal luggage and mail) onboard. The A/C takeoff mass was 6368 kg and the A/C center of gravity was at 25.5% MAC, which was within the AFM limits for the flight. The takeoff from Khabarovsk airport was performed at 23:33. 50 minutes before the approach to Chyumikan aerodrome, the flight crew checked the remaining fuel and requested the Khabarovsk ATC controller for the route change (AFIL): after passing of the OGUMI waypoint to follow the B226 airway to Nelkan destination airport without a stop at Chyumikan. According the initial flight plan, the stop at Chyumikan was intended only for refueling. On 15.11.2017 at 01:47 the Khabarovsk ATC approved the AFIL. At 02:35 the crew contacted the Nelkan Tower controller and received the approach conditions and the actual weather at the landing site. During the approach, at the true height of about 100 m and IAS of about 100 knots, developing the aggressive right roll and losing its altitude, the aircraft left the descending glidepath, collided with the ground and was destroyed. The crew and 4 passengers were killed. A 3-and-half year old child was taken to hospital with serious injuries. Nobody was killed on ground and there was no on-ground damage. The accident area is mountainous, marshy, with broad-leaved and needle-leaved trees. In winter, the area is covered with snow which is about 50-100 cm deep. The accident place ASL elevation is 304 m, the magnetic dip is minus 15°.
Probable cause:
The direct cause of the L410UVP-E20 RA-67047 A/C accident was the uncommanded inflight RH engine propeller blades setting to the angle of minus 1.8° which is significantly below the
minimum inflight pitch angle (13.5°) with TCLs set to forward thrust. It caused the significant rolling and turning moments, the A/C loss of speed and controllability, and the subsequent with the ground collision. The propeller blades' setting to the negative angles was caused by the failures of two systems: the BETA Feedback system and the Pitch Lock system. As the Propeller Pitch Lock system components that are to be tested during the PITCH LOCK TEST most probably did not contribute to the system malfunction, then it is unlikely that the crews' deviation of the PITCH LOCK TEST procedure could have make any difference in the detection of the said system malfunction before the flight. The said situation had been classified as extremely improbable during the aircraft type certification, so, there was no required crew actions in AFM for such situations, and the respective crew training was not required.
Final Report:

Crash of a PZL-Mielec AN-2 in Ekimchan: 1 killed

Date & Time: Nov 7, 2017 at 0825 LT
Type of aircraft:
Operator:
Registration:
RA-02305
Flight Type:
Survivors:
Yes
Schedule:
Ekimchan - Udskoye
MSN:
1G240-07
YOM:
1990
Flight number:
SHA9001
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5253
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
13550
Copilot / Total hours on type:
10000
Aircraft flight hours:
2483
Aircraft flight cycles:
8807
Circumstances:
The single engine airplane depart Ekimchan Airport at 0834LT on a cargo flight to Udskoye, carrying two pilots and a load of 1,199 kilos of various goods. Six minutes after takeoff, while climbing to an altitude of 1,600 metres, the crew noticed a strong smell of fuel in the cockpit and decided to return. During the descent, flames came out from the engine that started to rough and eventually stopped on short final. The airplane stalled, impacted a birch tree and crashed in a wooded area located 132 metres short of runway 06, bursting into flames. The copilot was killed and the captain was seriously injured. The aircraft was totally destroyed by a post crash fire.
Probable cause:
The crash of An-2 RA-02305 aircraft occurred during the forced landing. The necessity of the forced landing was caused by the engine stopping in flight due to the destruction of the cylinder head No.1 of the ASH62-IR engine No.K16509153. The destruction of cylinder head No. 1 is of fatigue nature and occurred due to exhaustion of fatigue life of the cylinder head material and reaching its limit state. Most likely, during the last repair of the engine the crack in the cylinder head was present, but was not through and was not revealed during the inspection. The most likely contributing factor to stopping the engine in flight was the impoverishment of the fuel-air mixture due to icing of the BAC filter mesh and the presence of a rubber plug on the filter flange of the corrector.
Final Report:

Crash of a Socata TBM-850 in Las Vegas

Date & Time: Nov 5, 2017 at 1145 LT
Type of aircraft:
Operator:
Registration:
N893CA
Flight Type:
Survivors:
Yes
Schedule:
Tomball – Las Vegas
MSN:
393
YOM:
2007
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3000
Captain / Total hours on type:
1850.00
Aircraft flight hours:
2304
Circumstances:
The pilot of the turbine-powered airplane reported that, while landing in a gusting crosswind, it was "obvious" the wind had changed directions. He performed a go-around, but "the wind slammed [the airplane] to the ground extremely hard." Subsequently, the airplane veered to the right off the runway and then back to the left before coming to rest. The airplane sustained substantial damage to the fuselage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The automated weather observation system located at the accident airport reported that, about the time of the accident, the wind was from 270° at 19 knots, gusting to 25 knots. The pilot landed on runway 20.
Probable cause:
The pilot's inadequate compensation for gusting crosswind conditions during the go-around.
Final Report:

Crash of a Swearingen SA227AC Metro III in Thompson

Date & Time: Nov 2, 2017 at 1920 LT
Type of aircraft:
Operator:
Registration:
C-FLRY
Flight Type:
Survivors:
Yes
Schedule:
Gods River – Thompson
MSN:
AC-756
YOM:
1990
Flight number:
PAG959
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1400
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
950
Copilot / Total hours on type:
700
Aircraft flight hours:
24672
Circumstances:
On 02 November 2017, a Perimeter Aviation LP Fairchild SA227-AC Metro III (serial number AC-756B, registration C-FLRY) was operating as flight 959 (PAG959) from Gods River Airport, Manitoba, to Thompson Airport, Manitoba, with 2 flight crew members on board. When the aircraft was approximately 40 nautical miles southeast of Thompson Airport, the crew informed air traffic control that they had received a low oil pressure indication on the left engine that might require the engine to be shut down. The crew did not declare an emergency, but aircraft rescue and firefighting services were put on standby. After touchdown on Runway 24 with both engines operating, the aircraft suddenly veered to the right and exited the runway. The aircraft came to rest in snow north of the runway. The captain and first officer exited the aircraft through the left side over-wing emergency exit and were taken to hospital with minor injuries. The aircraft was substantially damaged. The 406-MHz emergency locator transmitter did not activate. The occurrence took place during the hours of darkness, at 1920 Central Daylight Time.
Probable cause:
Findings as to causes and contributing factors:
1. The left engine low oil pressure indications during the previous and the occurrence flights were likely the result of a steady oil leak past the rear turbine air-oil seal assembly.
2. The loss of engine oil pressure resulted in a loss of propeller control authority on landing and the upset of the aircraft.
3. After consultation with maintenance, the crew considered the risks associated with landing single engine and without hydraulic pressure for the nose-wheel steering, and decided to continue the flight with both engines running, even though this was not consistent with the QRH procedures for low oil pressure indications.
4. Carbon deposits that accumulated within the inside diameter of the bellows convolutions interfered with the bellows’ ability to expand and to provide a positive seal against the rotor seal.

Findings as to risk:
1. If Canadian Aviation Regulations (CARs) subparts 703 and 704 operators do not provide initial or recurrent crew resource management training to pilots, these pilots may not be prepared to avoid, trap, or mitigate crew errors encountered during flight.
2. If operators of the SA227-AC Metro III aircraft rely solely on the emergency procedures listed in the aircraft flight manual, continued engine operation with low oil pressure may result in loss of control of the aircraft.
3. If an engine is not allowed to sufficiently cool down prior to shutdown, oil that remains trapped within hot areas of the engine may heat up to a point where the oil decomposes, creating a carbon deposit.
4. If flight data, voice, and video recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded.

Other findings:
1. The investigation was unable to determine the length of cooldown periods for the occurrence aircraft. However, a random sampling of engine shutdowns for similar company aircraft showed that 50% had not completed the full 3-minute cooldown period.
2. Despite having received limited crew resource management (CRM).
Final Report:

Crash of a Cessna 208B Grand Caravan in Lobo

Date & Time: Oct 25, 2017 at 1430 LT
Type of aircraft:
Operator:
Registration:
5H-THR
Survivors:
Yes
Schedule:
Lake Manyara - Lobo
MSN:
208B-0571
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown at Lobo Airstrip deserving the Lobo Wildlife Lodge located in the Serengeti National park, the single engine aircraft went out of control, veered off runway to the left and came to rest against a tree. The pilot and two passengers were injured while eight other occupants were unhurt. The aircraft was damaged beyond repair. There was no fire.

Crash of a Cessna 402B in St Petersburg

Date & Time: Oct 18, 2017 at 1545 LT
Type of aircraft:
Operator:
Registration:
N900CR
Survivors:
Yes
Site:
Schedule:
Tampa – Sarasota
MSN:
402B-1356
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
654
Captain / Total hours on type:
38.00
Aircraft flight hours:
8971
Circumstances:
The pilot departed on the non-scheduled passenger flight with one passenger onboard; the flight was the 3rd leg of a 4-leg trip. About 13 minutes after departure, he advised air traffic control that the airplane was “fuel critical” and requested vectors to the nearest airport, which was about 7 miles away. Both engines subsequently lost total power and the pilot performed a forced landing on a street about 2 miles from the airport, during which the airplane collided with two vehicles. Examination of the airplane revealed substantial damage to the fuel tanks, with evidence of a small fire near the left wingtip fuel tank. Fuel consumption calculations revealed that the airplane would have used about 100 gallons of fuel since its most recent refueling, which was the capacity of the main (wingtip) tanks. Both fuel selectors were found in their respective main tank positions. Given the available information, it is likely that the pilot exhausted all the fuel in the main fuel tanks and starved the engines of fuel. Although the total amount of fuel on board at the start of the flight could not be determined, had all tanks been full, the airplane would have had about 63 gallons remaining in the two auxiliary tanks at the time of the accident. The auxiliary fuel tanks were breached during the accident and quantity of fuel they contained was not determined. Examination of the engines revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation.
Probable cause:
The pilot's mismanagement of the onboard fuel, which resulted in fuel starvation, a total loss of power to both engines, and a subsequent forced landing.
Final Report:

Crash of a Cessna 208A Caravan I in the Anavilhanas Archipelago: 1 killed

Date & Time: Oct 17, 2017 at 1240 LT
Type of aircraft:
Operator:
Registration:
PR-MPE
Flight Type:
Survivors:
Yes
Schedule:
Manaus - Anavilhanas Archipelago
MSN:
208A-0510
YOM:
2009
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8535
Captain / Total hours on type:
660.00
Circumstances:
The single engine aircraft departed Manaus-Eduardo Gomes Airport at 1220LT on a flight to the Anavilhanas Archipelago, carrying cargo, four passengers and one pilot. Upon landing on the Rio Negro, the airplane struck the water surface and crashed upside down before coming to rest partially submerged. The pilot and three passengers were rescued while a fourth passenger was killed.
Probable cause:
The aircraft landed on the water with the landing gear in the down position.
Contributing factors:
- Attitude – a contributor
Failure to comply with the checklist during the pre-flight inspection and the flight itself favored the landing with inadequate configuration. This attitude may have been triggered by the pilot's confidence in his operational capability, because of his long experience in aviation.
- Flight indiscipline – a contributor
Failure to comply with the checklist indicated, in addition to the low level of situational awareness, a low level of concern for the safe conduction of the flight by failing to follow basic procedures set forth in the manufacturer's manuals and current regulations.
- Piloting judgement – a contributor
The pilot's choice not to use the checklist during the flight phases revealed an inadequate evaluation of parameters related to the operation of the aircraft. Improper compliance with the items in the Pre-Flight Inspection Sheet prevented the AMPHIB PUMP 1 and 2 circuit breakers from being rearmed.
- Aircraft maintenance – a contributor
After performing the test of landing gear extension and retraction by the emergency system, the AMPHIB PUMP 1 and 2 circuit breakers were not rearmed, being the aircraft delivered to fly in this condition. The setting recorded on the AIRSPEED switch of the landing gear position warning system computer demonstrated that the scheduled speed of 74kt was not in accordance with the recommended in the 9600-1A installation manual of Wipaire Inc. in its revision G.
- Memory – undetermined
The AMPHIB PUMP 1 and 2 circuit breakers were found disarmed after the occurrence, indicating that, after the completion of the maintenance service, the executor of the tasks probably forgot to comply with the procedures for reconfiguring the aircraft. In addition, it is possible that the pilot's automatism in relation to his way of carrying out the air operations, without the use of the checklist, has prevented the correct perception of the circuit breakers condition and the erroneous positioning of the landing gear.
- Perception – a contributor
The accomplishment of the landing on the water with the aircraft in inadequate configuration for the situation denotes a decrease in the level of situational awareness of the pilot, considering that the necessary factors and conditions for the safety of the operation were not observed.
Final Report: