Crash of a Casa NC-212-MP Aviocar 200 in Pitu

Date & Time: Nov 27, 2016 at 1000 LT
Type of aircraft:
Operator:
Registration:
U-623
Flight Type:
Survivors:
Yes
Schedule:
Manado - Pitu
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Pitu-Leo Wattimena Airport, the twin engine aircraft went out of control and veered off runway to the right. The left main landing gear collapsed and the right wing broke at the root. All 14 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a Beechcraft 200 Super King Air in Moorhead

Date & Time: Nov 23, 2016 at 1759 LT
Registration:
N80RT
Survivors:
Yes
Schedule:
Baudette - Moorhead
MSN:
BB-370
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5630
Captain / Total hours on type:
89.00
Circumstances:
The commercial pilot was conducting an on-demand passenger flight at night in instrument meteorological conditions that were at/near straight-in approach minimums for the runway. The pilot flew the approach as a non precision LNAV approach, and he reported that the approach was stabilized and that he did not notice anything unusual. A few seconds after leveling the airplane at the missed approach altitude, he saw the runway end lights, the strobe lights, and the precision approach path indicator. He then disconnected the autopilot and took his hand off the throttles to turn on the landing lights. However, before he could turn on the landing lights, the runway became obscured by clouds. The pilot immediately decided to conduct a missed approach and applied engine power, but the airplane subsequently impacted terrain short of the runway in a nose-up level attitude. The pilot reported that there were no mechanical anomalies with the airplane that would have precluded normal operation. It is likely the pilot lost sight of the runway due to the visibility being at/near the straight-in approach minimums and that the airplane got too low for a missed approach, which resulted in controlled flight into terrain. A passenger stated that he and the pilot were not wearing available shoulder harnesses. The passenger said that he was not informed that the airplane was equipped with shoulder harnesses or told how to adjust the seats. The pilot sustained injuries to his face in the accident.
Probable cause:
The pilot's failure to attain a positive climb rate during an attempted missed approach in night instrument meteorological conditions that were at/near approach minimums, which resulted in controlled flight into terrain.
Final Report:

Crash of a Swearingen SA227DC Metro 23 in Bogotá

Date & Time: Oct 28, 2016 at 2007 LT
Type of aircraft:
Operator:
Registration:
PNC-0226
Flight Type:
Survivors:
Yes
Schedule:
Pereira – Bogotá
MSN:
DC-811M
YOM:
1995
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Pereira, the twin engine airplane was cleared to land on Bogotá-El Dorado Airport Runway 13L. Apparently, the aircraft bounced three times before landing firmly. After touchdown, it went out of control, veered off runway, lost its nose gear and came to rest in a grassy area. All 11 occupants evacuated safely and the aircraft was damaged beyond repair. Among the passengers was Juan Fernando Cristo, Minister for Internal Affairs.

Crash of a Douglas DC-10-10 in Fort Lauderdale

Date & Time: Oct 28, 2016 at 1751 LT
Type of aircraft:
Operator:
Registration:
N370FE
Flight Type:
Survivors:
Yes
Schedule:
Memphis - Fort Lauderdale
MSN:
46608
YOM:
1972
Flight number:
FX910
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10000
Captain / Total hours on type:
1443.00
Copilot / Total flying hours:
6300
Copilot / Total hours on type:
1244
Aircraft flight hours:
84589
Aircraft flight cycles:
35606
Circumstances:
On October 28, 2016, about 1751 eastern daylight time, FedEx Express (FedEx) flight 910, a McDonnell Douglas MD-10-10F, N370FE, experienced a left main landing gear (MLG) collapse after landing on runway 10L at Fort Lauderdale–Hollywood International Airport (KFLL), Fort Lauderdale, Florida, and the left wing subsequently caught fire. The airplane came to rest off the left side of the runway. The two flight crew members evacuated the airplane. The captain reported a minor cut and abrasions from the evacuation, and the first officer was not injured. The airplane sustained substantial damage. The cargo flight was operating on an instrument flight plan under the provisions of Title 14 Code of Federal Regulation (CFR) Part 121 and originated at Memphis International Airport (KMEM), Memphis, Tennessee. The first officer was the pilot flying, and the captain was the pilot monitoring. Both flight crew members stated in post accident interviews that the departure from MEM and the en route portion of the flight were normal. About 1745, air traffic control (ATC) cleared the flight for final approach to the instrument landing system (ILS) approach to runway 10L at KFLL. Recorder data indicate that the first officer set the flaps at 35º about 1746 when the airplane was 3,000 ft above ground level (agl). The first officer disconnected the autopilot about 1749 when the airplane was 1,000 ft agl. Both flight crew members reported that the approach was stable at 500 ft agl. At 200 ft agl, the first officer began making airspeed corrections to compensate for the crosswind. About 1750, the first officer disconnected the autothrottles, as briefed, when the airplane was at 100 ft agl. At 50 ft agl, the first officer initiated the flare. The left MLG touched down about 1750:31 in the touchdown zone and left of the runway centerline. The first officer deployed the spoilers at 1750:34, and the nose gear touched down 3 seconds later. The thrust reversers were deployed at 1750:40. According to cockpit voice recorder (CVR) data, the captain instructed the first officer to begin braking about 1750:39 (the airplane was not equipped with autobrakes). FDR data indicate an increase in brake pedal position angle and increase in longitudinal deceleration (indicating braking) about 1750:41. In post accident interviews, the flight crew members reported hearing a "bang" as the first officer applied the brakes, and the airplane yawed to the left. About this time, the CVR recorded the sound of multiple thuds, consistent with the sound of a gear collapse. About 1750:48, the captain stated, "I have the airplane," and the first officer replied, "you got the airplane." The captain applied full right rudder without effect while the first officer continued braking. About 1750:53, the captain instructed the first officer to call and inform the tower about the emergency. An airport video of the landing showed that the No. 1 engine was initially supporting the airplane after the left MLG collapse when a fire began near the left-wing tip. The airplane eventually stopped off the left side of runway 10L, about 30º to 40º off the runway heading. About 1751, the flight crew began executing the evacuation checklist. The pilots reported that, as they were about to evacuate, they heard an explosion. The airport video showed a fireball erupted at the No. 1 engine. The captain attempted to discharge a fire bottle in the No. 1 engine, but it didn't discharge. They evacuated the airplane through the right cockpit window.
Probable cause:
The failure of the left main landing gear (MLG) due to fatigue cracking that initiated at a corrosion pit. The pit formed in the absence of a required protective cadmium coating the cause of which could not be determined from available evidence. Contributing to the failure of the left MLG was the operator's overhaul limit, which exceeded that recommended by the airplane manufacturer without sufficient data and analysis to ensure crack detection before it progressed to failure.
Final Report:

Crash of a Dornier DO328Jet-310 in Toluca

Date & Time: Oct 24, 2016 at 2029 LT
Type of aircraft:
Operator:
Registration:
XA-ALA
Flight Type:
Survivors:
Yes
Schedule:
Chetumal - Toluca
MSN:
3167
YOM:
2000
Location:
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14140
Captain / Total hours on type:
1699.00
Copilot / Total flying hours:
3623
Copilot / Total hours on type:
38
Aircraft flight hours:
13058
Aircraft flight cycles:
13493
Circumstances:
Following an uneventful positioning flight by night from Chetumal, the crew was cleared to land on runway 33 at Toluca Airport. Upon touchdown, the airplane went out of control and veered off runway to the right. While contacting soft grounf, the airplane lost its undercarriage and came to rest in a grassy area. All four occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
Loss of control upon landing due to the exhaust gases of the three turbofan engines and wake turbulences from an heavy category aircraft, causing a runway excursion, and an additional presence of crosswind, resulting in the aircraft rolling over uneven terrain of the safety strip resulting in severe damage.
Contributing factors:
- Safety strip in poor condition,
- Failure to attach times and separation distance between an aircraft taking off and landing on the same runway, to avoid the formation of wake turbulence and the presence of the exhaust gases of turbofan engines.
Final Report:

Crash of a Beechcraft D18S in Deming

Date & Time: Oct 23, 2016 at 1700 LT
Type of aircraft:
Operator:
Registration:
N644B
Flight Type:
Survivors:
Yes
Schedule:
Junction – Deming
MSN:
A-441
YOM:
1948
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18600
Captain / Total hours on type:
300.00
Aircraft flight hours:
5545
Circumstances:
The pilot of the multi-engine tailwheel-equipped airplane reported that during the landing roll, after the tailwheel had touched down, the airplane veered sharply to the left. The pilot further reported that the airplane was close to the left runway edge, so he allowed the airplane to continue off the runway, in effort not to overcorrect to the right. During the runway excursion, the right main landing gear collapsed in soft terrain. The right wing sustained substantial damage. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause:
The pilot's failure to maintain directional control during the landing roll, which resulted in a runway excursion.
Final Report:

Crash of an Airbus A300B4-230F in Recife

Date & Time: Oct 21, 2016 at 0630 LT
Type of aircraft:
Operator:
Registration:
PR-STN
Flight Type:
Survivors:
Yes
Schedule:
São Paulo – Recife
MSN:
236
YOM:
1983
Flight number:
STR9302
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11180
Captain / Total hours on type:
3000.00
Copilot / Total flying hours:
7300
Copilot / Total hours on type:
800
Circumstances:
Following an uneventful cargo service from São Paulo-Guarulhos Airport, the crew initiated the descent to Recife-Guararapes Airport. On final approach to runway 18, after the aircraft had been configured for landing, at an altitude of 500 feet, the crew was cleared to land. After touchdown, the thrust lever for the left engine was pushed to maximum takeoff power while the thrust lever for the right engine was simultaneously brang to the idle position then to reverse. This asymetric configuration caused the aircraft to veer to the right and control was lost. The airplane veered off runway to the right and, while contacting soft grounf, the nose gear collapsed. The airplane came to rest to the right of the runway and was damaged beyond repair. All four occupants evacuated safely.
Probable cause:
Contributing factors.
- Control skills - undetermined
Inadequate use of aircraft controls, particularly as regards the mode of operation of the Autothrottle in use and the non-reduction of the IDLE power levers at touch down, may have led to a conflict between pilots when performing the landing and the automation logic active during approach. In addition, the use of only one reverse (on the right engine) and placing the left throttle lever at maximum takeoff power resulted in an asymmetric thrust that contributed to the loss of control on the ground.
- Attitude - undetermined
The adoption of practices different from the aircraft manual denoted an attitude of noncompliance with the procedures provided, which contributed to put the equipment in an unexpected condition: non-automatic opening of ground spoilers and asymmetric thrust of the engines. These factors required additional pilot intervention (hand control), which may have made it difficult to manage the circumstances that followed the touch and led to the runway excursion.
- Crew Resource Management - a contributor
The involvement of the PM in commanding the aircraft during the events leading up to the runway excursion to the detriment of its primary responsibility, which would be to monitor systems and assist the PF in conducting the flight, characterized an inefficiency in harnessing the human resources available for the airplane operation. Thus, the improper management of the tasks assigned to each crewmember and the non-observance of the CRM principles delayed the identification of the root cause of the aircraft abnormal behavior.
- Organizational culture - a contributor
The reliance on the crew's technical capacity, based on their previous aviation experience, has fostered an informal organizational environment. This informality contributed to the adoption of practices that differed from the anticipated procedures regarding the management and operation of the aircraft. This not compliance with the procedures highlights a lack of safety culture, as lessons learnt from previous similar accidents (such as those in Irkutsk and Congonhas involving landing using only one reverse and pushing the thrust levers forward), have apparently not been taken into account at the airline level.
- Piloting judgment - undetermined
The habit of not reducing the throttle lever to the IDLE position when passing at 20ft diverged from the procedures contained in the aircraft-operating manual and prevented the automatic opening of ground spoilers. It is possible that the consequences of this adaptation of the procedure related to the operation of the airplane were not adequately evaluated, which made it difficult to understand and manage the condition experienced.
- Perception - a contributor
Failure to perceive the position of the left lever denoted a lowering of the crew's situational awareness, as it apparently only realized the real cause of the aircraft yaw when the runway excursion was already underway.
- Decision-making process - a contributor
An inaccurate assessment of the causes that would justify the behavior of the aircraft during the landing resulted in a delay in the application of the necessary power reduction procedure, that is, repositioning the left engine power lever.
Final Report:

Crash of a Piper PA-61P Aerostar (Ted Smith 601) in Karlsruhe

Date & Time: Oct 17, 2016 at 1243 LT
Operator:
Registration:
N20NR
Flight Type:
Survivors:
Yes
Schedule:
Bitburg - Karlsruhe
MSN:
61-0445-169
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1446
Captain / Total hours on type:
362.00
Aircraft flight hours:
2635
Circumstances:
Following an uneventful flight from Bitburg, the pilot was cleared for an approach to Karlsruhe-Baden Baden Airport Runway 21. On final approach, while completing a sharp turn to the left to join the runway, the twin engine airplane stalled and crashed in an open field, bursting into flames. The pilot was seriously injured and the aircraft was destroyed by a post crash fire. The wreckage was found about 500 metres from the runway threshold and 350 metres to the left of the runway extended centerline.
Probable cause:
The aircraft stalled on final approach while completing a sharp turn to the left at an insufficient speed with an insufficient distance with the ground, following an unstabilized approach. The limited visibility was considered as a contributing factor.
Final Report:

Crash of a Socata TBM-900 in Fairoaks

Date & Time: Oct 15, 2016 at 0732 LT
Type of aircraft:
Registration:
M-VNTR
Flight Type:
Survivors:
Yes
Schedule:
Douglas - Fairoaks
MSN:
1097
YOM:
2016
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5272
Captain / Total hours on type:
1585.00
Circumstances:
The accident occurred as the aircraft was preparing to land at Fairoaks Airport at the end of a private flight from Ronaldsway Airport on the Isle of Man. On board were the aircraft commander and a passenger who occupied the front right seat. As the aircraft neared Fairoaks, the pilot listened to the Farnborough ATIS broadcast, which reported a visibility of 4,000 m in mist. He and the passenger discussed the visibility, and agreed that they would proceed to Fairoaks while retaining the option to divert to Farnborough Airport (9 nm to the south-west) if a landing was not possible. The visibility at Fairoaks was recorded as 4,500 m, with ‘few’ clouds at 4,000 ft and a surface wind of 3 kt from 240°. Runway 24 was in use with a left-hand circuit. The circuit height, based on the Fairoaks QNH was 1,100 ft (the elevation of Fairoaks Airport is 80 ft amsl). Runway 24 is a hard runway, 813 m long and 27 m wide. The pilot identified the airfield visually, although there was low lying mist in the area. In order to maintain visual contact with the landing area he joined the circuit and flew a downwind leg that was closer to the runway than usual. He recalled carrying out the pre-landing checks while downwind, including lowering the landing gear and extending the flaps to the takeoff position2 . Based on a final approach with flaps at the landing setting, the pilot planned for an initial approach speed of 90 kt, reducing to a final approach speed of 80 kt. The pilot recalled the aircraft being slightly low as it turned from the downwind leg onto its final approach track. He believed he had selected flaps to the landing position, and recalled seeing the airspeed just below 90 kt, which prompted him to increase power slightly. The aircraft flew through the extended runway centreline and the pilot increased the bank angle to regain it. The pilot’s next recollection was of being in a right bank and seeing only sky ahead. He pushed forward on the control column and attempted to correct the bank with aileron. The aircraft then rolled quickly in the opposite direction and he again applied a correction. He became aware of being in an approximately wings-level attitude and seeing the ground approaching rapidly. He responded by pulling back hard on the control column, but was unable to prevent the aircraft striking the ground. He did not recall hearing a stall warning, or any other audio warning, before the loss of control occurred. The aircraft struck flat ground and slid for about 85 m before coming to rest against a treeline, about 500 m from Runway 24 and approximately on the extended centreline. The propeller was destroyed in the accident sequence and the landing gear legs detached, causing damage to the wings which included a ruptured fuel tank. In the latter stages of the slide the aircraft yawed right, coming to rest heading approximately in the direction from which it had come. The pilot and passenger remained conscious but had both suffered injury. The passenger saw flames from the region of the engine and warned the pilot that they needed to evacuate. He went to the rear of the cabin, opened the main door and left the aircraft. The pilot initially attempted to open his side door, but his right arm was injured and he was unable to open the door with only his left. He therefore followed the passenger out of the rear door.
Probable cause:
There were no indications that the aircraft had been subject to any defects or malfunctions that may have contributed to the accident. Reports from the two occupants, eye witness accounts and radar data all confirm that the aircraft commenced its final turn from a position closer to the runway than usual. This would have required a sustained moderate angle of bank through about 180° of turn. The radar data indicates that the turn onto the final approach was initially flown with less angle of bank than required. The pilot therefore either lost visual contact with the runway or did not fully appreciate the turn requirements. An explanation for the latter might be that the low height on the downwind leg combined with the relatively poor visibility to produce a runway visual aspect that gave a false impression that the aircraft spacing was not abnormal. As the finals turn progressed, there was a need to increase the angle of bank to a relatively high value. With the flaps remaining at the takeoff setting, and maintaining level flight, this placed the aircraft close to its stalling speed. Any increase in angle of bank or ‘g’ loading (as may have occurred when it became evident that the aircraft would fly through the extended centreline) risked a stall. The available evidence indicates that the aircraft stalled during the turn onto the final approach. Recovery actions taken by the occupants appear to have been partially successful, but there was evidently insufficient height in which to effect a full recovery.
Final Report:

Crash of an Antonov AN-26-100 in Belaya Gora

Date & Time: Oct 11, 2016 at 1638 LT
Type of aircraft:
Operator:
Registration:
RA-26660
Survivors:
Yes
Schedule:
Yakutsk - Belaya Gora
MSN:
8008
YOM:
1979
Flight number:
PI203
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
27
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11439
Captain / Total hours on type:
2697.00
Copilot / Total flying hours:
11142
Copilot / Total hours on type:
122
Aircraft flight hours:
34490
Aircraft flight cycles:
16367
Circumstances:
On final approach to Belaya Gora Airport, the aircraft was too low and hit the ground. On impact, the right main gear and the nose gear collapsed. The aircraft slid for several yards before coming to rest in a snow covered field about 400 meters short of runway threshold and 300 meters to the left of the approach path. The propeller on the right engine was torn off and it appears that the fuselage was bent as well. All 33 occupants were evacuated safely. At the time of the accident, weather conditions were marginal with limited visibility caused by snow falls. It was reported the visibility was about 2,5 km at the time of the accident while the crew needed at least 4 km on an NDB approach.
Probable cause:
The accident was caused by the combination of the following factors:
- Absence of standard operating procedures issued by the operator of how to conduct NDB approaches,
- Violation of procedures by tower who only transmitted information about snow fall and recommended to perform a low pass over the runway but did not transmit the actual visibility was 1900 meters below required minimum
- Absence of information that the visibility was below required minimum, the last transmission indicated minimum visibility was present,
- Presence of numerous landmarks (abandoned ships, ship cranes, fuel transshipment complex, ...) covered by snow within 700-1000 meters from the unpaved runway which could be taken as runway markers by flight crew,
- Presence of a number of "bald spots" due to the transitional period of year where the underlying surface became visible making it difficult to visualize and recognize the unpaved runway covered with snow (it was the first flight into Belaya Gora for the crew in the winter season, they had operated into the aerodrome only in summer so far),
- Insufficient use of the available nav aid on final approach which led to lack of proper control of the aircraft position relative to the glide path,
- Lack of possibility for tower to watch the aircraft performing the NDB approach from his work place.
Final Report: