Crash of a Piper PA-31-310 Navajo in Schefferville: 2 killed

Date & Time: Apr 30, 2017 at 1756 LT
Type of aircraft:
Operator:
Registration:
C-FQQB
Survivors:
No
Schedule:
Schefferville - Schefferville
MSN:
31-310
YOM:
1968
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
461
Captain / Total hours on type:
110.00
Copilot / Total flying hours:
1693
Copilot / Total hours on type:
650
Aircraft flight hours:
20180
Circumstances:
The Piper PA-31 (registration C-FQQB, serial number 31-310) operated by Exact Air Inc., with 2 pilots on board, was conducting its 2nd magnetometric survey flight of the day, from Schefferville Airport, Quebec, under visual flight rules. At 1336 Eastern Daylight Time, the aircraft took off and began flying toward the survey area located 90 nautical miles northwest of the airport. After completing the magnetometric survey work at 300 feet above ground level, the aircraft began the return flight segment to Schefferville Airport. At that time, the aircraft descended and flew over the terrain at an altitude varying between 100 and 40 feet above ground level. At 1756, while the aircraft was flying over railway tracks, it struck power transmission line conductor cables and crashed on top of a mine tailings deposit about 3.5 nautical miles northwest of Schefferville Airport. Both occupants were fatally injured. The accident occurred during daylight hours. Following the impact, there was no fire, and no emergency locator transmitter signal was captured.
Probable cause:
Findings:
Findings as to causes and contributing factors:
- Sensation seeking, mental fatigue, and an altered risk perception very likely contributed to the fact that, immediately after completing the magnetometric survey work, the pilot flying descended to an altitude varying between 100 and 40 feet above ground level and maintained this altitude until the aircraft collided with the wires.
- It is highly likely that the pilots were unaware that there was a power transmission line in their path.
- The pilot flying did not detect the power transmission line in time to avoid it, and the aircraft collided with the wires, which were 70 feet above the ground.
- Despite the warning regarding low-altitude flying in the Transport Canada Aeronautical Information Manua, and in the absence of minimum-altitude restrictions imposed by the company, the pilot chose to descend to a very low altitude on the return flight; as a result, this flight segment carried an unacceptable level of risk.

Findings as to risk:
- If pilots fly at low altitude, there is a risk that they will collide with wires, given that these are extremely difficult to see in flight.
- If lightweight flight data recording systems are not used to closely monitor flight operations, there is a risk that pilots will deviate from established procedures and limits, thereby reducing safety margins.
- If Transport Canada does not take concrete measures to facilitate the use of lightweight flight data recording systems and flight data monitoring, there is a risk that operators will be unable to proactively identify safety deficiencies before they cause an accident.
- If safety management systems are not required, assessed, and monitored by Transport Canada in order to ensure continual improvement, there is an increased risk that companies will be unable to effectively identify and mitigate the hazards involved in their operations.
- Not wearing a safety belt increases the risk of injury or death in an accident.
- The current emergency locator transmitter system design standards do not include a requirement for a crashworthy antenna system. As a result, there is a risk that potentially life-saving search‑and‑rescue services will be delayed if an emergency locator transmitter antenna is damaged during an occurrence.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Huntsville: 1 killed

Date & Time: Apr 25, 2017 at 1038 LT
Registration:
N421TK
Flight Type:
Survivors:
No
Schedule:
Conroe – College Station
MSN:
421C-0601
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1567
Captain / Total hours on type:
219.00
Aircraft flight hours:
7647
Circumstances:
While conducting a post maintenance test flight in visual flight rules conditions, the private pilot of the multi-engine airplane reported an oil leak to air traffic control. The controller provided vectors for the pilot to enter a right base leg for a landing to the south at the nearest airport, about 7 miles away. The pilot turned toward the airport but indicated that he did not have the airport in sight. Further, while maneuvering toward the airport, the pilot reported that the engine was "dead," and he still did not see the airport. The final radar data point recorded the airplane's position about 3.5 miles west-northwest of the approach end of the runway; the wreckage site was located about 4 miles northeast of the runway, indicating that the pilot flew past the airport rather than turning onto a final approach for landing. The reason that the pilot did not see the runway during the approach to the alternate airport, given that the airplane was operating in visual conditions and the controller was issuing guidance information, could not be determined. Regardless, the pilot did not execute a precautionary landing in a timely manner and lost control of the airplane. Examination of the airplane's left engine revealed that the No. 2 connecting rod was broken. The connecting rod bearings exhibited signs of heat distress and discoloration consistent with a lack of lubrication. The engine's oil pump was intact, and the gears were wet with oil. Based on the available evidence, the engine failure was the result of oil starvation; however, examination could not identify the reason for the starvation.
Probable cause:
The pilot's failure to identify the alternate runway, to perform a timely precautionary landing, and to maintain airplane control. Contributing to the accident was the failure of the left engine due to oil starvation for reasons that could not be determined based on the post accident examination.
Final Report:

Ground fire of a GippsAero GA8 Airvan in Gibb River

Date & Time: Apr 22, 2017 at 1255 LT
Type of aircraft:
Operator:
Registration:
VH-AJZ
Flight Type:
Survivors:
Yes
Schedule:
Derby - Gibb River
MSN:
GA8-05-96
YOM:
2005
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 22 April 2017, a Gippsland Aeronautics GA-8 aircraft, registered VH-AJZ, was being used to conduct incendiary bombing aerial work operations in the Prince Regent River area of northern Western Australia (WA). On board were a pilot, a navigator seated in the co-pilot seat and a bombardier in the rear of the aircraft cabin. While conducting the incendiary bombing operations, the bombardier advised the pilot that he was suffering from motion sickness. The pilot elected to land at Gibb River aircraft landing area (ALA), WA, to take a lunch break and provide the bombardier with time to recover from the motion sickness. At about 1255 Western Standard Time (WST), the aircraft landed on runway 07 at Gibb River. During the landing roll, the engine failed. The aircraft had sufficient momentum to enable the pilot to turn the aircraft around on the runway and begin to taxi to the parking area at the western end of runway 07. Shortly after turning around, the aircraft came to rest on the runway. The pilot attempted to restart the engine, but the engine did not start. The pilot waited about 10–20 seconds before again attempting to restart the engine. While attempting the second restart of the engine, the pilot heard a loud noise similar to that of a backfire. The navigator then observed flames and smoke coming from around the front of the engine and immediately notified the pilot. After being notified of the fire, the pilot immediately shut down the engine and switched off the aircraft electrical system. As the pilot switched off the aircraft electrical system, the navigator located the aircraft fire extinguisher and evacuated from the aircraft through the co-pilot door. After evacuating from the aircraft, the navigator observed fire on the aircraft nose wheel. The navigator had difficulty preparing the fire extinguisher for use and was unable to discharge the fire extinguisher onto the fire. While the navigator was attempting to extinguish the fire, the pilot exited the aircraft through the pilot door and assisted the bombardier to exit the aircraft. After assisting the bombardier, the pilot moved to the front of the aircraft to assist the navigator with the firefighting. The pilot was able to activate the fire extinguisher and extinguished the fire on the nose wheel. The pilot observed fire continuing to burn within the engine compartment. Due to the heat of the fire, the pilot was unable to access the engine compartment to extinguish this fire. The pilot determined that no more could be done to contain the fire, and therefore, the pilot, navigator and bombardier moved clear of the aircraft to a safe location as the fire continued. The crew members were not injured. As a result of the fire, the aircraft was destroyed.
Probable cause:
These findings should not be read as apportioning blame or liability to any particular organisation or individual.
- The cause of the engine failure and fire could not be determined.
- After the fire was identified, two steps in the emergency procedure were omitted. This included not closing the fuel shutoff valve, which likely resulted in the fire not being extinguished and subsequently intensifying.
Final Report:

Crash of a Piper PA-46-310P Malibu in Harrisburg: 4 killed

Date & Time: Apr 7, 2017 at 1048 LT
Registration:
N123SB
Flight Type:
Survivors:
No
Schedule:
Van Nuys – Eugene
MSN:
46-8508023
YOM:
1985
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
5060
Captain / Total hours on type:
163.00
Aircraft flight hours:
3681
Circumstances:
The commercial pilot and three passengers departed on an instrument flight rules crosscountry flight. While on approach to the destination airport, the pilot indicated to the air traffic controller that the airplane was passing through areas of moderate-to-extreme precipitation. After clearing the airplane for the approach, the controller noted that the airplane descended below its assigned altitude; the controller issued a low altitude alert, but no response was received from the pilot. The airplane subsequently impacted terrain in a level attitude about 12 miles from the airport. Examination of the airframe, engine, and system components revealed no evidence of preimpact mechanical malfunction that would have precluded normal operation. An area of disturbed, flattened, tall grass was located about 450 ft southwest of the accident site. Based on the images of the grass, the National Weather Service estimated that it would take greater than 35 knots of wind to lay over tall grass as the images indicated, and that a downburst/microburst event could not be ruled out. A downburst is an intense downdraft that creates strong, often damaging winds. About 6 hours before the flight, the pilot obtained weather information through a mobile application. Review of weather data indicated the presence of strong winds, heavy precipitation, turbulence, and low-level wind shear (LLWS) in the area at the time of arrival, which was reflected in the information the pilot received. Given the weather conditions, it is likely that the airplane encountered an intense downdraft, or downburst, which would have resulted in a sudden, major change in wind velocity. The airplane was on approach for landing at the time and was particularly susceptible to this hazardous condition given its lower altitude and slower airspeed. The downburst likely exceeded the climb performance capabilities of the airplane and resulted in a subsequent descent into terrain. It is unknown if the accident pilot checked or received additional weather information before or during the accident flight. While the flight was en route, several PIREPs were issued for the area of the accident site, which also indicated the potential of LLWS near the destination airport; however, the controller did not provide this information to the pilot, nor did he solicit PIREP information from the pilot. Based on published Federal Aviation Administration guidance for controllers and the widespread adverse weather conditions in the vicinity of the accident site, the controller should have both solicited PIREP information from the pilot and disseminated information from previous PIREPs to him; this would have provided the pilot with more complete information about the conditions to expect during the approach and landing at the destination.
Probable cause:
An encounter with a downburst during an instrument approach, which resulted in a loss of control at low altitude. Contributing to the accident was the air traffic controller's failure to
solicit and disseminate pilot reports from arriving and departing aircraft in order to provide pilots with current and useful weather information near the airport.
Final Report:

Crash of a Piper PA-42-720 Cheyenne III in Sorocaba: 2 killed

Date & Time: Mar 31, 2017 at 1445 LT
Type of aircraft:
Operator:
Registration:
PP-EPB
Flight Type:
Survivors:
No
Schedule:
Manaus - Sorocaba
MSN:
42-8001035
YOM:
1980
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3382
Captain / Total hours on type:
118.00
Circumstances:
The twin engine aircraft departed Manaus-Aeroclub de Flores Airport on a flight to Barra do Garças, carrying one passenger and one pilot. After takeoff from Manaus, the pilot changed his mind and decided to fly to Sorocaba. On final approach to Sorocaba-Bertram Luiz Leupolz Airport in good weather conditions, the aircraft impacted trees and crashed in a wooded area located about one km short of runway 18. The aircraft was destroyed and both occupants were killed. There was no fire.
Probable cause:
Contributing factors:
- Flight indiscipline – a contributor
The pilot failed to comply with the minimum fuel requirements laid down in the regulations, providing conditions for both engines to stop operating in flight, due to lack of fuel.
- Piloting judgment – a contributor
It was found in this flight an inadequate evaluation for certain parameters related to aircraft operation, particularly with regard to the influence of the chosen flight level on fuel consumption. This misjudgment led to the decision to proceed with the flight to the Aerodrome where it was intended to land, to the detriment of the more conservative option of finding a suitable place for an intermediate landing and a refueling, which led to the depletion of usable fuel in flight.
- Flight planning – a contributor
Inadequate flight preparation work, especially with regard to fuel calculation and cruise level selection, has degraded the safety level and also contributed to the actual accident.
- Decision-making process – undetermined
Difficulties in perceiving, analyzing, choosing alternatives, and acting appropriately due to inadequate judgment, may have resulted in poor assessment of flight parameters (available fuel, distance to destination, verified consumption, etc.), which may have favored the occurrence of lack of fuel failure.
Final Report:

Crash of a Boeing 737-3M8 in Jauja

Date & Time: Mar 28, 2017 at 1628 LT
Type of aircraft:
Operator:
Registration:
OB-2036-P
Survivors:
Yes
Schedule:
Lima - Jauja
MSN:
25071/2039
YOM:
1991
Flight number:
P9112
Location:
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
142
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13504
Copilot / Total flying hours:
7604
Aircraft flight hours:
62817
Aircraft flight cycles:
44025
Circumstances:
The aircraft departed Lima-Jorge Chavez Airport on a 20-minute flight to Jauja, carrying 142 passengers and 7 seven crew members. The approach to Jauja-Francisco Carlé was uneventful and completed in good weather conditions. Two seconds after the nose gear touched down on runway 31, the crew activated the reverse systems when he felt strong vibrations and oscillations. The aircraft started to bounce and became uncontrollable. The right main gear collapsed then the aircraft veered off runway to the right, lost its right engine and came to rest in a grassy area, bursting into flames. All 149 occupants evacuated safely and the aircraft was totally destroyed by fire.
Probable cause:
Failure of the mechanical components of the shimmy damper system in each of the main landing gears which, being out of tolerance range, did not allow the correct damping of the vibrations and lateral oscillations of the wheels after touchdown, generating sequential shimmy events in both gears and causing their collapse.
Contributing factors:
- Incorrect and probable absence of measurements on mechanical components of the 'cimmetic chain for shimmy damper operation', as indicated by the operator's PM AMM Task, which would have allowed for the timely detection and replacement of out-of-tolerance components, ensuring their integrity and correct operation.
- The Service Letter 737-SL-32-057-E 'broken torsion link', does not provide for mandatory actions, it only recommends maintenance practices to prevent fractures in mechanical components of the 'cimmetic chain for shimmy damper operation'.
- Service Letter 737-SL-32-057-E 'fractures in lower torsion link', makes a proper interpretation difficult; that could induce errors to choose the corresponding AMM Task and determine its scope.
Final Report:

Crash of a Britten Norman BN-2A-3 Islander near Mutare: 6 killed

Date & Time: Mar 27, 2017 at 0815 LT
Type of aircraft:
Operator:
Registration:
C9-AOV
Survivors:
No
Site:
Schedule:
Beira - Mutare - Harare
MSN:
624
YOM:
1970
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The twin engine aircraft was performing a charter flight from Beira to Harare with an intermediate stop in Mutare on behalf of the Mozambican company Cornelder. Ten minutes before its ETA in Mutare Airport, while descending to the altitude of 5,200 feet, the crew encountered marginal weather conditions when the aircraft hit obstacles and crashed on the slope of a mountain located in the Vumba Botanical Reserve. The wreckage was found 23 km southeast from the airport. It appears that a passenger survived but later died from his injuries. Among the passengers were Adelino Mesquita, brother of the Minister of Transport and Communications of the Republic of Mozambique.
Probable cause:
Controlled flight into terrain.

Crash of a Cessna 500 Citation I in Marietta: 1 killed

Date & Time: Mar 24, 2017 at 1924 LT
Type of aircraft:
Registration:
N8DX
Flight Type:
Survivors:
No
Site:
Schedule:
Cincinnati – Atlanta
MSN:
500-0303
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6000
Aircraft flight hours:
9299
Circumstances:
The private pilot departed on an instrument flight rules flight plan in his twin-engine turbojet airplane. The flight was uneventful until the air traffic controller amended the flight plan, which required the pilot to manually enter the new routing information into the GPS. A few minutes later, the pilot told the controller that he was having problems with the GPS and asked for a direct route to his destination. The controller authorized the direct route and instructed the pilot to descend from 22,000 ft to 6,000 ft, during which time the sound of the autopilot disconnect was heard on the cockpit voice recorder (CVR). During the descent, the pilot told the controller that the airplane had a steering problem and was in the clouds. The pilot was instructed to descend the airplane to 4,100 ft, which was the minimum vectoring altitude. The airplane continued to descend, entered visual meteorological conditions, and then descended below the assigned altitude. The controller queried the pilot about the airplane's low altitude and instructed the pilot to maintain 4,100 ft. The pilot responded that he was unsure if he would be able to climb the airplane back to that altitude due to steering issues. The controller issued a low altitude warning and again advised the pilot to climb back to 4,100 ft. The pilot responded that the autopilot was working again and that he was able to climb the airplane to the assigned altitude. The controller then instructed the pilot to change to another radio frequency, but the pilot responded that he was still having a problem with the GPS. The pilot asked the controller to give him direct routing to the airport. A few minutes later, the pilot told the controller that he was barely able to keep the airplane straight and its wings level. The controller asked the pilot if he had the airport in sight, which he did not. The pilot then declared an emergency and expressed concerns related to identifying the landing runway. Afterward, radio contact between the controller and the pilot was lost. Shortly before the airplane impacted the ground, a witness saw the airplane make a complete 360° roll to the left, enter a steep 90° bank to the left, roll inverted, and enter a vertical nose-down dive. Another witness saw the airplane spiral to the ground. The airplane impacted the front lawn of a private residence, and a postcrash fire ensued.The pilot held a type rating for the airplane, but the pilot's personal logbooks were not available for review. As a result, his overall currency and total flight experience in the accident airplane could not be determined. The airplane was originally certified for operations with a pilot and copilot. To obtain an exemption to operate the airplane as a single pilot, a pilot must successfully complete an approved single-pilot exemption training course annually. The accident airplane was modified, and the previous owner was issued a single-pilot conformity certificate by the company that performed the modifications. However, there was no record indicating that the accident pilot received training under this exemption. Several facilities that have single-pilot exemption training for the accident airplane series also had no record of the pilot receiving training for single-pilot operations in the accident airplane. Therefore, unlikely that the pilot was properly certificated to act as a single-pilot. The GPS was installed in the airplane about 3.5 years before the accident. A friend of the pilot trained him on how to use the GPS. The friend said that the pilot generally was confused about how the unit operated and struggled with pulling up pages and correlating data. The friend of the pilot had flown with him several times and indicated that, if an air traffic controller amended a preprogrammed flight plan while en route, the pilot would be confused with the procedure for amending the flight plan. The friend also said the pilot depended heavily on the autopilot, which was integrated with the GPS, and that he would activate the autopilot immediately after takeoff and deactivate it on short final approach to a runway. The pilot would not trim the airplane before turning on the autopilot because he assumed that the autopilot would automatically trim the airplane, which led to the autopilot working against the mis-trimmed airplane. The friend added that the pilot was "constantly complaining" that the airplane was "uncontrollable." A postaccident examination of the airplane and the autopilot system revealed no evidence of any preimpact deficiencies that would have precluded normal operation. This information suggests that pilot historically had difficulty flying the airplane without the aid of the autopilot. When coupled with his performance flying the airplane during the accident flight without the aid of the autopilot, it further suggests that the pilot was consistently unable to manually fly the airplane. Additionally, given the pilot's previous experience with the GPS installed on the airplane, it is likely that during the accident flight the pilot became confused about how to operate the GPS and ultimately was unable to properly control of the airplane without the autopilot engaged. Based on witness information, it is likely that during the final moments of the flight the pilot lost control of the airplane and it entered an aerodynamic stall. The pilot was then unable to regain control of the airplane as it spun 4,000 ft to the ground.
Probable cause:
The pilot's failure to maintain adequate airspeed while manually flying the airplane, which resulted in the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall. Contributing to the accident was the pilot's inability control the airplane without the aid of the autopilot.
Final Report:

Crash of an Antonov AN-26B in Wau

Date & Time: Mar 20, 2017 at 1525 LT
Type of aircraft:
Operator:
Registration:
S9-TLZ
Survivors:
Yes
Schedule:
Juba - Wau
MSN:
133 10
YOM:
1983
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
40
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Juba, the crew initiated the approach to Wau Airport when he encountered poor weather conditions and limited visibility. On short final, during the last segment, the aircraft collided with a fire truck and near the runway 27 threshold, bursting into flames. All 45 occupants were rescued, among them 18 were injured. The airplane was totally destroyed by a post crash fire.

Crash of a Pilatus U-28A at Cannon AFB: 3 killed

Date & Time: Mar 14, 2017 at 1835 LT
Type of aircraft:
Operator:
Registration:
08-0724
Flight Type:
Survivors:
No
Schedule:
Cannon - Cannon
MSN:
724
YOM:
2006
Flight number:
Demise 25
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
3400
Captain / Total hours on type:
3199.00
Copilot / Total flying hours:
448
Copilot / Total hours on type:
213
Circumstances:
On 14 Mar 17, at 1835 local time (L), a U-28A, tail number 0724, crashed one-quarter mile south of Clovis Municipal Airport (KCVN), New Mexico (NM). This aircraft was operated by the 318th Special Operations Squadron, 27th Special Operations Wing, Cannon Air Force Base (AFB), NM. The aircraft was destroyed and all three crewmembers died upon impact. The Mishap Aircraft (MA) departed Cannon AFB at 1512L for tactical training over Lubbock, Texas, followed by pilot proficiency training at KCVN. The Mishap Crew (MC) entered Lubbock airspace at 1545L, completed their tactical training, and departed Lubbock airspace at 1735L enroute to KCVN. The MC entered the KCVN traffic pattern at 1806L, where they conducted multiple approaches and landings prior to executing the mishap maneuver, a practice turnback Emergency Landing Pattern (ELP). The MC entered the practice turnback ELP with 0° flaps led to increased aircraft nose-down attitudes and higher descent rates required to maintain a safe angle of attack versus a comparative 15° flap approach. In addition, 0° flap stall speeds are higher than 15° flap stall speeds – 15 to 25 knots higher for the range of bank angles flown by the MC during the practice turnback ELP. The MC was also late to achieve the bank angle required to enable the MA to align with the extended centerline for the runway resulting in an overshoot condition. The MC attempted to arrest their excessive nose-down attitude, descent rate, and shallow bank angle by pulling back on the aircraft yoke and increasing bank angle. The g-load from the MC pull back, coupled with the MA's increased bank angle, slowed the MA airspeed below 0° flap stall speed and it departed controlled flight. Subsequent power increase and flight control inputs would not have enabled the aircraft to recover from the stall within remaining altitude. After entering the stall, the MC increased power; however, it was not enough to overcome the MA descent rate. At no point during the practice turnback ELP did the MA performance reflect a MC intent to abort the maneuver. The MA impacted the ground with a 13° nose-high, 7° left-wing low attitude. The aircraft was destroyed upon impact and all three occupants were killed.
Crew:
Cpt Andrew Becker, pilot,
1st Lt Frederick Dellecker, copilot,
Cpt Kenneth Dalga, combat systems officer.
Probable cause:
By a preponderance of the evidence, the Accident Investigation Board concluded the aircrew lost control of the aircraft when it entered a stall at low altitude during a turn back Emergency Landing Pattern procedure. There were no indications of mechanical malfunction. The board also surmised the crew delayed actions necessary to prevent the aircraft from entering the stall envelope and failed to accurately assess increasing risk throughout execution of the practice turn back Emergency Landing Pattern, thereby substantially contributing to the mishap.
Final Report: