Crash of a Cessna 750 Citation X in Toluca

Date & Time: Aug 27, 2015 at 0015 LT
Type of aircraft:
Operator:
Registration:
XA-KYE
Flight Type:
Survivors:
Yes
MSN:
750-0204
YOM:
2002
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was apparently completing a positioning flight to Toluca Airport. Following a night landing on runway 15, the crew started the braking procedure when the aircraft deviated to the left. The crew applied full brake but the aircraft veered off runway. While contacting soft ground, the nose gear collapsed and the aircraft came to rest about 2,700 metres from the runway threshold. Both pilots escaped uninjured and the aircraft was damaged beyond repair.

Crash of a Cessna S550 Citation II in Charallave

Date & Time: Aug 26, 2015 at 2230 LT
Type of aircraft:
Operator:
Registration:
YV3125
Survivors:
Yes
Schedule:
Oranjestad – Barcelona – Charallave
MSN:
S550-0085
YOM:
1986
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing a charter flight from Oranjestad (Aruba) to Charallave with an intermediate stop in Barcelona. While on a night approach to runway 10, the captain initiated a go-around procedure for unknown reasons. During the second attempt to land, the aircraft landed long and the touchdown point appeared to be half way down the runway 10 which is 2,000 meters long. Unable to stop within the remaining distance, the aircraft overran, went down an embankment and came to rest. All eight occupants evacuated safely while the aircraft was damaged beyond repair. The passengers were members of the pop band 'Los Cadillac's' accompanied by the Venezuelan singer and actor Arán de las Casas.

Crash of an Eclipse EA500 in Danbury

Date & Time: Aug 21, 2015 at 1420 LT
Type of aircraft:
Operator:
Registration:
N120EA
Flight Type:
Survivors:
Yes
Schedule:
Oshkosh – Danbury
MSN:
199
YOM:
2008
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7846
Captain / Total hours on type:
1111.00
Aircraft flight hours:
858
Circumstances:
**This report was modified on April 2, 2020. Please see the public docket for this accident to view the original report.**
After the airplane touched down on the 4,422-ft-long runway, the airline transport pilot applied the brakes to decelerate; however, he did not think that the brakes were operating. He continued "pumping the brakes" and considered conducting a go-around; however, there was insufficient remaining runway to do so. The airplane subsequently continued off the end of the runway, impacted a berm, and came to rest upright, which resulted in substantial damage to the right wing. During postaccident examination of the airplane, brake pressure was obtained on both sets of brake pedals when they were depressed, and there was no bleed down or reduction in pedal firmness when the brakes were pumped several times. Examination revealed no evidence off any preimpact anomalies with the brake system that would have precluded normal operation. In addition, the pilot indicated that he was not aware of and was not trained on the use of the ALL INTERRUPT button, which is listed as a step in the Emergency Procedures section of the airplane flight manual and is used to disable the anti-skid brake system functions and restore normal braking when the brakes are ineffective; thus, the pilot did not follow proper checklist procedures. According to data downloaded from the airplane's diagnostic storage unit (DSU), the airplane touched down 1,280 ft beyond the runway threshold, which resulted in 2,408 ft of runway remaining (the runway had a displaced threshold of 734 ft) and that it traveled 2,600 ft before coming to rest about 200 ft past the runway. The airplane's touchdown speed was about 91 knots. Comparing DSU data from previous downloaded flights revealed that the airplane's calculated deceleration rate during the accident landing was indicative of braking performance as well as or better than the previous landings. Estimated landing distance calculations revealed that the airplane required about 3,063 ft when crossing the threshold at 50 ft above ground level. The target touchdown speed was 76 knots. However, the airplane touched down with only 2,408 ft of remaining runway faster than the target touchdown speed, which resulted in the runway overrun.
Probable cause:
The pilot's failure to attain the proper touchdown point and exceedance of the target touchdown speed, which resulted in a runway overrun.
Final Report:

Crash of a Beechcraft A100 King Air in Margaree

Date & Time: Aug 16, 2015 at 1616 LT
Type of aircraft:
Operator:
Registration:
C-FDOR
Survivors:
Yes
Schedule:
Halifax – Margaree
MSN:
B-103
YOM:
1972
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1723
Captain / Total hours on type:
298.00
Copilot / Total flying hours:
532
Copilot / Total hours on type:
70
Aircraft flight hours:
14345
Circumstances:
On 16 August 2015, a Maritime Air Charter Limited Beechcraft King Air A100 (registration C-FDOR, serial number B-103) was on a charter flight from Halifax Stanfield International Airport, Nova Scotia, to Margaree Aerodrome, Nova Scotia, with 2 pilots and 2 passengers on board. At approximately 1616 Atlantic Daylight Time, while conducting a visual approach to Runway 01, the aircraft touched down hard about 263 feet beyond the threshold. Almost immediately, the right main landing gear collapsed, then the right propeller and wing contacted the runway. The aircraft slid along the runway for about 1350 feet, then veered right and departed off the side of the runway. It came to rest about 1850 feet beyond the threshold and 22 feet from the runway edge. There were no injuries and there was no post-impact fire. The aircraft was substantially damaged. The occurrence took place during daylight hours. The 406-megahertz emergency locator transmitter did not activate.
Probable cause:
Findings:
Findings as to causes and contributing factors:
1. Neither pilot had considered that landing on a short runway at an unfamiliar aerodrome with known high terrain nearby and joining the circuit directly on a left base were hazards that may create additional risks, all of which would increase the crew’s workload.
2. The presence of the tower resulted in the pilot not flying focusing his attention on monitoring the aircraft’s location, rather than on monitoring the flight or the actions of the pilot flying.
3. The crew’s increased workload, together with the unexpected distraction of the presence of the tower, led to a reduced situational awareness that caused them to omit the Landing Checks checklist.
4. At no time during the final descent was the engine power increased above about 400 foot-pounds of torque.
5. Using only pitch to control the rate of descent prevented the pilot flying from precisely controlling the approach, which would have ensured that the flare occurred at the right point and at the right speed.
6. Neither pilot recognized that the steep rate of descent was indicative of an unstable approach.
7. Advancing the propellers to full would have increased the drag and further increased the rate of descent, exacerbating the already unstable approach.
8. The aircraft crossed the runway threshold with insufficient energy to arrest the rate of descent in the landing flare, resulting in a hard landing that caused the right main landing gear to collapse.
Findings as to risk:
1. If data recordings are not available to an investigation, then the identification and communication of safety deficiencies to advance transportation safety may be precluded.
2. If organizations do not use modern safety management practices, then there is an increased risk that hazards will not be identified and risks will not be mitigated.
3. If passenger seats installed in light aircraft are not equipped with shoulder harnesses, then there is an increased risk of passenger injury or death in the event of an accident.
4. If the experience and proficiency of pilots are not factored into crew selection, then there is a risk of suboptimal crew pairing, resulting in a reduction of safety margins.
5. If pilots do not carry out checklists in accordance with the company’s and manufacturer’s instructions, then there is a risk that a critical item may be missed, which could jeopardize the safety of the flight.
6. If crew resource management is not used and continuously fostered, then there is a risk that pilots will be unprepared to avoid or mitigate crew errors encountered during flight.
7. If organizations do not have a clearly defined go-around policy, then there is a risk that flight crews will continue an unstable approach, increasing the risk of an approach-and-landing accident.
8. If pilots are not prepared to conduct a go-around on every approach, then there is a risk that they may not respond to situations that require a go-around.
9. If operators do not have a stable approach policy, then there is a risk that an unstable approach will be continued to a landing, increasing the risk of an approach-andlanding accident.
10. If an organization’s safety culture does not fully promote the goals of a safety management system, then it is unlikely that it will be effective in reducing risk.
Other findings:
1. There were insufficient forward impact forces to automatically activate the emergency locator transmitter.
Final Report:

Crash of a Rockwell Sabreliner 60SC in San Diego: 4 killed

Date & Time: Aug 16, 2015 at 1103 LT
Type of aircraft:
Operator:
Registration:
N442RM
Flight Type:
Survivors:
No
Schedule:
San Diego - San Diego
MSN:
306-073
YOM:
1974
Flight number:
Eagle 1
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
4485
Captain / Total hours on type:
347.00
Copilot / Total flying hours:
6400
Aircraft flight hours:
13418
Circumstances:
The Cessna 172 (N1285U) was conducting touch-and-go landings at Brown Field Municipal Airport (SDM), San Diego, California, and the experimental North American Rockwell NA265-60SC Sabreliner (N442RM, call sign Eagle1) was returning to SDM from a mission flight. SDM has two parallel runways, 8R/26L and 8L/26R; it is common in west operations for controllers to use a right traffic pattern for both runways 26R and 26L due to the proximity of Tijuana Airport, Tijuana, Mexico, to the south of SDM. On the morning of the accident, the air traffic control tower (ATCT) at SDM had both control positions (local and ground control) in the tower combined at the local control position, which was staffed by a local controller (LC)/controller-in-charge, who was conducting on-the-job training with a developmental controller (LC trainee). The LC trainee was transmitting control instructions for all operations; however, the LC was monitoring the LC trainee's actions and was responsible for all activity at that position. About 13 minutes before the accident, the N1285U pilot contacted the ATCT and requested touch-andgo landings in the visual flight rules (VFR) traffic pattern. About that time, another Cessna 172 (N6ZP) and a helicopter (N8360R) were conducting operations in the VFR traffic pattern, and a Cessna 206 Stationair (N5058U) was inbound for landing. Over the next 5 minutes, traffic increased, with two additional aircraft inbound for landing. (Figure 1 in the factual report for this accident shows the aircraft in the SDM traffic pattern about 8 minutes before the accident.) The LC trainee cleared the N1285U pilot for a touch-and-go on runway 26R; the pilot acknowledged the clearance and then advised the LC trainee that he was going to go around. The LC trainee advised the N1285U pilot to expect runway 26L on the next approach. At that time, three aircraft were using runway 26R (Global Express [N18WZ] was inbound for landing, N6ZP was on a right base for a touch-and-go, and a Cessna Citation [XALVV] was on short final) and three aircraft were using runway 26L (N1285U was turning right downwind for the touch-and-go, a Skybolt [N81962] was on a left downwind for landing, and N8360R was conducting a touch-and-go landing). After N1285U completed the touch-andgo on runway 26L, the pilot entered a right downwind for runway 26R. Meanwhile, Eagle1 was 9 miles west of the airport and requested a full-stop landing; the LC trainee instructed the Eagle1 flight crew to enter a right downwind for runway 26R at or above an altitude of 2,000 ft mean sea level. At this time, about 3 minutes before the accident, the qualified LC terminated the LC trainee's training and took over control of radio communications. From this time until the collision occurred, the LC was controlling nine aircraft. (Figure 2 and Figure 4 in the factual report for this accident show the total number of aircraft under ATCT control shortly before the accident.) During the next 2 minutes, the LC made several errors. For example, after N6ZP completed a touch-andgo on runway 26R, the pilot requested a right downwind departure from the area, which the LC initially failed to acknowledge. The LC also instructed the N5058U pilot, who had been holding short of runway 26L, that he was cleared for takeoff from runway 26R. Both errors were corrected. In addition, the LC instructed the helicopter pilot to "listen up. turn crosswind" before correcting the instruction 4 seconds later to "turn base." (Figure 2 in the factual report for this accident shows the aircraft in the traffic pattern about 2 minutes before the accident.) About 1 minute before the collision, the Eagle1 flight crew reported on downwind midfield and stated that they had traffic to the left and right in sight. At that time, N1285U was to Eagle1's right, between Eagle1 and the tower, and established on a right downwind about 500 ft below Eagle1's position. N6ZP was about 1 mile forward and to the left of Eagle1, heading northeast and departing the area. Mistakenly identifying the Cessna to the right of Eagle1 as N6ZP, the LC instructed the N6ZP pilot to make a right 360° turn to rejoin the downwind when, in fact, N1285U was the airplane to the right of Eagle1. (The LC stated in a postaccident interview that he thought the turn would resolve the conflict with Eagle1 and would help the Cessna avoid Eagle1's wake turbulence.) The N6ZP pilot acknowledged the LC's instruction and began turning; N1285U continued its approach to runway 26R. However, the LC never visually confirmed that the Cessna to Eagle1's right (N1285U) was making the 360° turn. Ten seconds later, the LC instructed the Eagle1 flight crew to turn base and land on runway 26R, which put the accident airplanes on a collision course. The LC looked to ensure that Eagle1 was turning as instructed and noticed that the Cessna on the right downwind (which he still mistakenly identified as N6ZP) had not begun the 360° turn that he had issued. The LC called the N6ZP pilot, and the pilot responded that he was turning. In the first communication between the LC and the N1285U pilot (and the first between the controllers in the ATCT and that airplane's pilot in almost 6 minutes), the LC transmitted the call sign of N1285U, which the pilot acknowledged. N1285U and Eagle1 collided as the LC tried to verify N1285U's position. A postaccident examination of both airplanes did not reveal any mechanical anomalies that would have prevented the airplanes from maneuvering to avoid an impact.
Probable cause:
The local controller's (LC) failure to properly identify the aircraft in the pattern and to ensure control instructions provided to the intended Cessna on downwind were being performed before turning Eagle1 into its path for landing. Contributing to the LC's actions was his incomplete situational awareness when he took over communications from the LC trainee due to the high workload at the time of the accident. Contributing to the accident were the inherent limitations of the see-and-avoid concept, resulting in the inability of the pilots involved to take evasive action in time to avert the collision.
Final Report:

Crash of a Cessna 441 Conquest II in Cape Town: 5 killed

Date & Time: Aug 16, 2015 at 0629 LT
Type of aircraft:
Operator:
Registration:
V5-NRS
Flight Type:
Survivors:
No
Site:
Schedule:
Oranjemund - Cape Town
MSN:
441-0288
YOM:
1983
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
6353
Captain / Total hours on type:
1357.00
Copilot / Total flying hours:
1394
Copilot / Total hours on type:
1
Aircraft flight hours:
7605
Circumstances:
On 15 August 2015 at 2351Z a Cessna 441 aeroplane, with two crew and a paramedic on board took off from Eros Airport (FYWE) on a medical evacuation flight with their intended final destination Cape Town International Airport (FACT). The aircraft landed at Oranjemund (FYOG) to pick up a male patient and his daughter. At 0206Z the aircraft departed from FYOG on a mercy flight to FACT. At 0343Z the aircraft made the first contact with FACT area and the aircraft was put under radar control. At 0355Z, area control advised the crew that there was a complete radar failure. The aircraft was on a descent to 6500 ft when approach advised them to prepare for a VOR approach for runway 19. At 0429Z, while on approach for landing at FACT, all contact was lost with the aircraft. At approximately 0556Z the aircraft’s wreckage was located approximately 8 nm to the north of FACT. All five occupants on board were fatally injured and the aircraft was destroyed by impact and post impact fire. The investigation revealed the aircraft collided with terrain during instrument meteorological condition (IMC) conditions while on the VOR approach for Runway 19 at FACT. At the time the ILS was working, however the approach controller offered a VOR approach for separation with an outbound aircraft as the radar was unserviceable.
Probable cause:
The aircraft collided with terrain during instrument meteorological flight conditions while on the VOR approach Runway 19.
Final Report:

Crash of a Pacific Aerospace PAC750XL in Ninia: 1 killed

Date & Time: Aug 12, 2015 at 0748 LT
Operator:
Registration:
PK-KIG
Survivors:
Yes
Schedule:
Wamena – Ninia
MSN:
170
YOM:
2010
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1537
Captain / Total hours on type:
395.00
Aircraft flight hours:
757
Aircraft flight cycles:
1315
Circumstances:
On 12 August 2015, a PAC-750XL aircraft, registered PK-KIG, was being operated by PT. Komala Indonesia on an unscheduled passenger flight from Wamena Airport (WAJW) Papua to Ninia Airstrip , Yahukimo, Papua that was located on radial 127° from Wamena with a distance of approximately 26 Nm. At 0733 LT (2233 UTC), the aircraft departed from Wamena Airport with an estimated time of arrival at Ninia of 2248 UTC. The flight was uneventful until approaching Ninia. On board the aircraft were one pilot, one engineer and 4 passengers. According to the pilot statement, an airspeed indicator malfunction occurred during flight. Video footage taken by a passenger showed that, during the approach at an altitude of approximately 6,500 feet, the airspeed indicators indicated zero and the aural stall warning activated. The aircraft then flew on the left side and parallel to the runway. Thereafter the aircraft climbed, turned left and impacted the ground about 200 meters south-west of the runway. The engineer on board was fatally injured, one passenger had minor injuries and the other occupants, including the pilot, were seriously injured. Two occupants were evacuated to a hospital in Jayapura Airport and four others, including the fatally injured, were evacuated to a hospital in Wamena.
Probable cause:
The following findings were identified:
1. Continuing the flight with both airspeed indicators unserviceable increased the complexity of the flight combined with high-risk aerodrome increased the pilot workload.
2. The improper corrective action at the time of the aural stall warning activating on the final approach, and the aircraft flew to insufficient area for a safe maneuver.
3. The unfamiliarity to the airstrip resulted in inappropriate subsequent escape maneuver and resulted in the aircraft stalling.
4. The pilot was not provided with appropriate training and familiarization to fly into a high-risk airstrip
Final Report:

Crash of a Cessna 421B Golden Eagle II in Clovis

Date & Time: Aug 9, 2015 at 0925 LT
Registration:
N726JB
Flight Type:
Survivors:
Yes
Schedule:
Melrose – Clovis
MSN:
421B-0020
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3700
Captain / Total hours on type:
300.00
Circumstances:
The private pilot reported that he was approaching the airport for landing in the multi-engine airplane when both engines began to surge. The pilot attempted to switch to the auxiliary fuel tanks, but inadvertently switched the left engine fuel selector to the off position. The left engine subsequently experienced a total loss of engine power. On final approach for landing, the airplane impacted terrain and was subsequently consumed by a postimpact fire; the fuel onboard the airplane at the time of the accident could not be determined. An examination of the airplane's engines and systems revealed no mechanical anomalies that would have precluded normal operation.
Probable cause:
The pilot's improper management of fuel to the left engine during approach for landing, which resulted in a total loss of left engine power due to fuel starvation, and his subsequent failure to maintain control during the final landing approach, which resulted in collision with terrain.
Final Report:

Crash of a Cessna 402B in Cajicá: 3 killed

Date & Time: Aug 8, 2015 at 1003 LT
Type of aircraft:
Operator:
Registration:
HK-4990
Flight Type:
Survivors:
No
Schedule:
Guaymaral - Guaymaral
MSN:
402B-1219
YOM:
1977
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
5539
Captain / Total hours on type:
0.00
Copilot / Total flying hours:
2594
Copilot / Total hours on type:
59
Aircraft flight hours:
8985
Circumstances:
The twin engine airplane departed Bogotá-Guaymaral Airport on a local training flight, carrying one passenger, one instructor and one pilot who was following his initial training. While descending to the airport from the north for an approach to runway 11, the crew encountered technical problems with the engine and declared an emergency. While trying to make an emergency landing, the aircraft collided with power cables and crashed in a garden located about 12 km north of Bogotá-Guaymaral Airport. The aircraft was destroyed by impact forces and all three occupants were killed. There was no fire.
Probable cause:
Double engine failure on approach due to fuel exhaustion. The following contributing factors were identified:
- Poor Crew Resources Management in decision making, team work and communications in the cockpit,
- Low level of alert of the crew while completing a training mission,
- The crew failed to follow the emergency procedures,
- Limited experience of the instructor to proceed with an initial training,
- Poor flight planning.
Final Report:

Crash of a Beechcraft C90B King Air in Georgetown

Date & Time: Aug 1, 2015 at 2100 LT
Type of aircraft:
Operator:
Registration:
N257CQ
Flight Type:
Survivors:
Yes
Schedule:
Dayton – Somerset
MSN:
LJ-1419
YOM:
1995
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3182
Captain / Total hours on type:
1122.00
Aircraft flight hours:
2324
Circumstances:
The airplane was fueled with 140 gallons of fuel before the second of three flight segments. The pilot reported that, while en route on the third segment, a fuel crossfeed light illuminated. He reset the indicator and decided to land the airplane to troubleshoot. He requested to divert to the nearest airport, which was directly beneath the airplane. Subsequently, the right engine lost power, and the autofeather system feathered the right engine propeller. He reduced power on the left engine, lowered the nose, and extended the landing gear while entering the traffic pattern. The pilot indicated that, after the landing gear was extended, the electrical system "failed," and shortly after, the left engine would not respond to power lever inputs. As the flight was on a base leg approach, the airplane was below the intended flightpath to reach the runway. The pilot stated that he pulled "gently on the control wheel"; however, the airplane impacted an embankment and came to rest on airport property, which resulted in substantial damage to both wings and the fuselage. Postaccident examination of the engines and airframe revealed no evidence of mechanical malfunctions or abnormalities that would have precluded normal operation. Signatures on the left propeller indicated that the engine was likely producing power at the time of impact; however, actual power settings could not be conclusively determined. Signatures on the right propeller indicated that little or no power was being produced. The quantity of fuel in the airplane's fuel system, as well as the configuration of the fuel system at the time of the accident, could not be determined based on the available evidence. Although the position of the master switch (which includes the battery, generator 1, and generator 2) was found in the OFF position, the airplane had been operating for about 30 minutes when the electrical power was lost; thus, it is likely that the airplane had been operating on battery power throughout the flight. This could have been the result of the pilot's failure to activate, or his inadvertent deactivation of, the generator 1 and 2 switch. If the flight were operating on battery power, it would explain what the pilot described as an electrical system failure after the landing gear extension due to the exhaustion of the airplane's battery. The postaccident examination of the left engine and propeller revealed that the engine was likely producing some power at the time of impact, and an explanation for why the engine reportedly did not respond to the pilot's throttle movements could not be determined. Additionally, given the available evidence, the reason for the loss of power to the right engine could not be determined.
Probable cause:
Undetermined based on the available evidence.
Final Report: