Landing (descent or approach)

Flight Type:

Private

Survivors:

Site:

Swearingen SA227 Metro III

Schedule:

Tomball – Las Vegas

MSN:

393

YOM:

2007

Location:

Las Vegas-Municipal

New Mexico

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

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 Phase:

Flight Type:

Positioning

Survivors:

Site:

Cessna 208B Grand Caravan

Schedule:

Gods River – Thompson

MSN:

AC-756

YOM:

1990

Flight number:

PAG959

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

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

Flight Phase:

Charter/Taxi (Non Scheduled Revenue Flight)

Flight Type:

Survivors:

Site:

Schedule:

Lake Manyara - Lobo

MSN:

208B-0571

YOM:

1996

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

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:

Cessna 402

Operator:

Registration:

N900CR

Flight Phase:

Charter/Taxi (Non Scheduled Revenue Flight)

Flight Type:

Survivors:

Saint Petersburg-Albert Whitted

Site:

City

Schedule:

Tampa – Sarasota

MSN:

402B-1356

YOM:

1978

Location:

Florida

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

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:

Cessna 208A Caravan

Operator:

Registration:

PR-MPE

Flight Phase:

Flight Type:

Cargo

Survivors:

Site:

Lake, Sea, Ocean, River

Schedule:

Manaus - Anavilhanas Archipelago

MSN:

208A-0510

YOM:

2009

Location:

Anavilhanas Archipelago

Amazonas

Country:

Brazil

Region:

South America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

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:

Crash of an Antonov AN-26-100 off Abidjan: 4 killed

Date & Time: Oct 14, 2017 at 0823 LT

Type of aircraft:

Antonov AN-26

Operator:

Registration:

ER-AVB

Flight Phase:

Flight Type:

Cargo

Survivors:

Rockwell Aero Commander 500

Site:

Lake, Sea, Ocean, River

Schedule:

Ouagadougou – Abidjan

MSN:

32 04

YOM:

1975

Flight number:

Kondor 26

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

23766

Captain / Total hours on type:

10133.00

Copilot / Total flying hours:

2250

Copilot / Total hours on type:

2080

Circumstances:

The airplane departed Ouagadougou on a flight to Abidjan, carrying seven passengers, three crew members and military equipment on behalf of the French Army (antiterrorist operation 'Barkhane'). On approach to Abidjan-Félix Houphouët-Boigny Airport, the crew encountered poor visibility due to heavy rain falls. On short final, the aircraft descended below MDA, impacted water and crashed in the sea few hundred metres short of runway 03. Six occupants were rescued while four others including all three crew members were killed. The aircraft was destroyed. At the time of the accident, weather conditions were below minimums.

Probable cause:

The probable cause of this accident is the continuation of the approach below minimums without having established formal visual contact with runway references and without adequate monitoring of the aircraft's glide path. The rigorous application of the company SOPs should have necessarily led to a go-around.
The following factors contributed to the accident:
- Underestimation of adverse weather conditions below minimums;
- A lack of knowledge of the environment of Abidjan airport and insufficient awareness of the aircraft's vertical position;
- Inadequate monitoring of aircraft instruments and flight path (altitude and speed) in degraded weather conditions;
- A high workload due to continued final approach training and distraction from tasks not related to flight operations;
- Disabling EGPWS audible alerts due to unwanted alarms;
- Crew resource management (CRM) probably unbalanced by the authority of the PNF over the rest of the crew.
- Strict non-compliance with company SOPs.

Final Report:

Crash of a Rockwell Aero Commander 500 in Dabajuro: 1 killed

Date & Time: Sep 26, 2017

Type of aircraft:

Operator:

Registration:

HI-560

Flight Phase:

Flight Type:

Private

Survivors:

Site:

MSN:

500-778-69

YOM:

1959

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

Apparently following technical issues, the pilot was forced to attempt an emergency landing at Dabajuro Airport. The twin engine aircraft crash landed near the runway and struck two motorcyclists. One of them was killed while the second was injured. The airplane was damaged beyond repair and the pilot was uninjured.

Crash of a Cessna 650 Citation VII in Istanbul

Date & Time: Sep 21, 2017 at 2116 LT

Type of aircraft:

Cessna 650 Citation VII

Operator:

Registration:

TC-KON

Flight Phase:

Charter/Taxi (Non Scheduled Revenue Flight)

Flight Type:

Survivors:

Site:

Marmara Region (Marmara Bölgesi)

Schedule:

Istanbul - Ercan

MSN:

650-7084

YOM:

1998

Location:

Istanbul-Atatürk

Country:

Turkey

Region:

Asia

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The aircraft departed Atatürk Airport in Istanbul at 2105LT bound for Ercan with a crew of three and one passenger on board. Shortly after takeoff, an unexpected situation forced the crew to return for an emergency landing. After touchdown on runway 35L, the twin engine aircraft went out of control, veered off runway, struck a concrete drainage ditch and came to rest, broken in two and bursting into flames. All four occupants evacuated safely while the aircraft was destroyed by a post crash fire.

Crash of an Antonov AN-26B in Goma

Date & Time: Sep 10, 2017 at 1130 LT

Type of aircraft:

Antonov AN-26

Operator:

Registration:

9S-AFL

Flight Phase:

Flight Type:

Cargo

Survivors:

Site: