Crash of a Raytheon 390 Premier I in South Bend: 2 killed

Date & Time: Mar 17, 2013 at 1623 LT
Type of aircraft:
Operator:
Registration:
N26DK
Survivors:
Yes
Site:
Schedule:
Tulsa - South Bend
MSN:
RB-226
YOM:
2008
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
613
Captain / Total hours on type:
171.00
Copilot / Total flying hours:
1877
Copilot / Total hours on type:
0
Aircraft flight hours:
457
Circumstances:
According to the cockpit voice recorder (CVR), during cruise flight, the unqualified pilot-rated passenger was manipulating the aircraft controls, including the engine controls, under the supervision and direction of the private pilot. After receiving a descent clearance to 3,000 feet mean sea level (msl), the pilot told the pilot-rated passenger to reduce engine power to maintain a target airspeed. The cockpit area microphone subsequently recorded the sound of both engines spooling down. The pilot recognized that the pilot-rated passenger had shutdown both engines after he retarded the engine throttles past the flight idle stops into the fuel cutoff position. Specifically, the pilot stated "you went back behind the stops and we lost power." According to air traffic control (ATC) radar track data, at the time of the dual engine shutdown, the airplane was located about 18 miles southwest of the destination airport and was descending through 6,700 feet msl. The pilot reported to the controller that the airplane had experienced a dual loss of engine power, declared an emergency, and requested radar vectors to the destination airport. As the flight approached the destination airport, the cockpit area microphone recorded a sound similar to an engine starter spooling up; however, engine power was not restored during the attempted restart. A review of the remaining CVR audio did not reveal any evidence of another attempt to restart an engine. The CVR stopped recording while the airplane was still airborne, with both engines still inoperative, while on an extended base leg to the runway. Subsequently, the controller told the pilot to go-around because the main landing gear was not extended. The accident airplane was then observed to climb and enter a right traffic pattern to make another landing approach. Witness accounts indicated that only the nose landing gear was extended during the second landing approach. The witnesses observed the airplane bounce several times on the runway before it ultimately entered a climbing right turn. The airplane was then observed to enter a nose low, rolling descent into a nearby residential community. The postaccident examinations and testing did not reveal any anomalies or failures that would have precluded normal operation of the airplane. Although the CVR did not record a successful engine restart, the pilot was able to initiate a go-around during the initial landing attempt, which implies that he was able to restart at least one engine during the initial approach. The investigation subsequently determined that only the left engine was operating at impact. Following an engine start, procedures require that the respective generator be reset to reestablish electrical power to the Essential Bus. If the Essential Bus had been restored, all aircraft systems would have operated normally. However, the battery toggle switch was observed in the Standby position at the accident site, which would have prevented the Essential Bus from receiving power regardless of whether the generator had been reset. As such, the airplane was likely operating on the Standby Bus, which would preclude the normal extension of the landing gear. However, the investigation determined that the landing gear alternate extension handle was partially extended. The observed position of the handle would have precluded the main landing gear from extending (only the nose landing gear would extend). The investigation determined that it is likely the pilot did not fully extend the handle to obtain a full landing gear deployment. Had he fully extended the landing gear, a successful single-engine landing could have been accomplished. In conclusion, the private pilot's decision to allow the unqualified pilot-rated passenger to manipulate the airplane controls directly resulted in the inadvertent dual engine shutdown during cruise descent. Additionally, the pilot's inadequate response to the emergency, including his failure to adhere to procedures, resulted in his inability to fully restore airplane systems and ultimately resulted in a loss of airplane control.
Probable cause:
The private pilot's inadequate response to the dual engine shutdown during cruise descent, including his failure to adhere to procedures, which ultimately resulted in his failure to
maintain airplane control during a single-engine go-around. An additional cause was the pilot's decision to allow the unqualified pilot-rated passenger to manipulate the airplane controls, which directly resulted in the inadvertent dual engine shutdown.
Final Report:

Crash of an Embraer EMB-820C Carajá in Almeirim: 10 killed

Date & Time: Mar 12, 2013 at 2030 LT
Operator:
Registration:
PT-VAQ
Survivors:
No
Schedule:
Belém - Almeirim
MSN:
820-140
YOM:
1986
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
1300
Captain / Total hours on type:
70.00
Circumstances:
The twin engine aircraft departed Belém-Val de Cans-Júlio Cezar Ribeiro Airport at 1907LT on a flight to Almeirim, carrying one pilot and nine employees of a company taking part to the construction of a hydro-electric station in the area. Following an eventful flight at FL85, the pilot started the descent to Almeirim and contacted ground at 2023LT. On final approach by night, the aircraft descended too low, impacted ground and crashed 5 km short of runway, bursting into flames. The aircraft was destroyed and all 10 occupants were killed.
Probable cause:
The following findings were identified:
- The pilot took the risks inherent to that flight when he accepted to be the only crewmember on a night-time flight with an aircraft in which he lacked enough experience. It is therefore considered that the pilot was complacent when he accepted to fly the aircraft under those circumstances, taking the risks associated with the operation.
- The fact that the pilot made a phone call to his father, to tell that he was feeling insecure for conducting the flight, may be considered an indication that he was not confident, and this condition may have influenced negatively his operational performance during the descent procedure.
- It is possible that the motivation of the pilot in making a fast progress in his career contributed to his acceptance of the challenge to operate the flight, even if he was not feeling fully confident.
- It is possible that the characteristics related to the type of flight, regions, time of the day, in addition to the fact that the pilot was flying the aircraft alone for the first time, contributed to an unclear perception of the relevant elements around him, leading him to a mistaken comprehension, which resulted in the deterioration of his ability to foresee the events.
- The operational progress of the pilot in the company was expedited and, therefore, it is possible that for this reason he did not gather the necessary experience for conducting that type of flight.
- It is possible that the way the work was organized within the company, with designation of pilots not readapted in the aircraft for night-time flights without artificial horizon, and for takeoffs with an aircraft weight above the one prescribed in the manual contributed to the event that resulted in the accident.
- It is possible that the prioritization of the financial sector, in detriment of operational safety, contributed to the designation of a single pilot with short experience for transporting nine passengers.
- It is probable that the pilot, during the preparation of the aircraft for landing, allowed the its speed and power to drop to a value below the minima required for maintenance of level flight on the downwind leg.
- It is possible that the location of the runway in an isolated area of the Amazonian jungle region, without visual references in a night-time flight, contributed to the pilot’s difficulty maintaining a sustained flight.
- It is possible that the training done by the pilot in a shortened manner deprived him from the knowledge and other technical abilities necessary for flying the aircraft.
- The decisions of the company operation sector to designate a short-experienced pilot without a copilot for a night flight destined for an aerodrome located in a jungle region without visual reference with the terrain increased the risk of the operation. Therefore, the risk management process was probably inappropriate.
- It was the first time the pilot was flying the aircraft on a night-time flight without a copilot. Since he had only little experience in the aircraft, it is possible that his operational performance was hindered in the management of tasks, weakening his situational awareness.
- It was not possible to determine whether the company chose to dispense with the copilot on account of the need to transport a ninth passenger and, thus, did not consider in a conservative manner the prescription contained in the aircraft airworthiness certificate by designating just one pilot for the flight.
Final Report:

Crash of a Beechcraft 1900C-1 near Dillingham: 2 killed

Date & Time: Mar 8, 2013 at 0815 LT
Type of aircraft:
Operator:
Registration:
N116AX
Flight Type:
Survivors:
No
Site:
Schedule:
King Salmon - Dillingham
MSN:
UC-17
YOM:
1988
Flight number:
AER51
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5770
Captain / Total hours on type:
5470.00
Copilot / Total flying hours:
470
Copilot / Total hours on type:
250
Aircraft flight hours:
29827
Circumstances:
Aircraft was destroyed when it impacted rising terrain about 10 miles east of Aleknagik, Alaska. The airplane was operated as Flight 51, by Alaska Central Express, Inc., Anchorage, Alaska, as an on demand cargo flight under the provisions of 14 Code of Federal Regulations (CFR) Part 135. The airline transport certificated captain and the commercial certificated first officer sustained fatal injuries. Instrument meteorological conditions were reported in the area at the time of the accident, and the airplane was operating on an instrument flight rules (IFR) flight plan. The flight had originally departed Anchorage about 0544, and made a scheduled stop at King Salmon, Alaska, before continuing on to the next scheduled stop, Dillingham, Alaska. According to Federal Aviation Administration (FAA) personnel, as the airplane approached Dillingham, the flight crew requested the RNAV GPS 19 instrument approach to the Dillingham Airport about 0757 from controllers at the Anchorage Air Route Traffic Control Center (ARTCC). The ARTCC specialist on duty subsequently granted the request by issuing the clearance, with instructions to proceed direct to the Initial Approach Fix (IAF) to begin the approach, and to maintain an altitude of 2,000 feet or above. A short time later the flight crew requested to enter a holding pattern at the IAF so that they could contact the Flight Service Station (FSS) for a runway conditions report, and the ARTCC specialist granted that request. The ARTCC specialist then made several attempts to contact the aircraft, but was unsuccessful and subsequently lost radar track on the aircraft. When the airplane failed to arrive at the Dillingham Airport, ARTCC personnel initiated a radio search to see if the airplane had diverted to another airport. Unable to locate the airplane, the FAA issued an alert notice (ALNOT) at 0835. Search personnel from the Alaska State Troopers, Alaska Air National Guard, and the U.S. Coast Guard, along with several volunteer pilots, were dispatched to conduct an extensive search effort. Rescue personnel aboard an Air National Guard C-130 airplane tracked 406 MHz emergency locater transmitter (ELT) signal to an area of mountainous terrain about 20 miles north of Dillingham, but poor weather prohibited searchers from reaching the site until the next morning. Once the crew of a HH-60G helicopter from the Air National Guard's 210th Air Rescue Squadron, Anchorage, Alaska, reached the steep, snow and ice-covered site, they confirmed that both pilots sustained fatal injuries.
Probable cause:
The flight crew's failure to maintain terrain clearance, which resulted in controlled flight into terrain in instrument meteorological conditions. Contributing to the accident were the flight crew's failure to correctly read back and interpret clearance altitudes issued by the air traffic controller, their failure to adhere to minimum altitudes depicted on the published instrument approach chart, and their failure to adhere to company checklists. Also contributing to the accident were the air traffic controller's issuance of an ambiguous clearance to the flight crew, which resulted in the airplane's premature descent, his failure to address the pilot's incorrect read back of the assigned clearance altitudes, and his failure to monitor the flight and address the altitude violations and issue terrain-based safety alerts.
Final Report:

Crash of a Partenavia P.68 Observer in Roskilde: 2 killed

Date & Time: Mar 6, 2013 at 1727 LT
Type of aircraft:
Operator:
Registration:
OY-CAG
Survivors:
No
Schedule:
Billund - Roskilde
MSN:
243-03-0B
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
13973
Aircraft flight hours:
8370
Aircraft flight cycles:
8400
Circumstances:
The aircraft was engaged in a bird control mission over the center of Denmark and departed Billund Airport in the afternoon with one passenger and one pilot on board. While returning to Roskilde, on approach to runway 03, the pilot initiated a go-around procedure due to the presence of a slower aircraft on the runway. While climbing, the twin engine aircraft stalled and crashed near runway 03. Both occupants were killed.
Probable cause:
The final approach and the go-around procedures were non-standard. The accident was caused by a stall during the climb, and the distance between the aircraft and the ground was insufficient to expect recovery. Weather conditions were not considered as a contributing factor.
Final Report:

Crash of a Beechcraft B200 Super King Air in Pias: 9 killed

Date & Time: Mar 6, 2013 at 0741 LT
Operator:
Registration:
OB-1992-P
Survivors:
No
Schedule:
Lima - Pias
MSN:
BB-1682
YOM:
1999
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
4509
Captain / Total hours on type:
312.00
Copilot / Total flying hours:
994
Copilot / Total hours on type:
425
Aircraft flight hours:
3859
Aircraft flight cycles:
4318
Circumstances:
The twin engine aircraft departed Lima-Jorge Chávez Airport at 0625LT on a charter flight to Pias, carrying two pilots and seven employees of the Peruvian company MARSA (Minera Aurífera Retamas) en route to Pias gold mine. On approach to Pias Airport, the crew encountered limited visibility due to foggy conditions. Heading 320° on approach, the crew descended too low when the aircraft collided with power cables, stalled and crashed on the slope of a mountain located 4,5 km from the airport, bursting into flames. The aircraft was destroyed by impact forces and a post crash fire and all 9 occupants were killed.
Probable cause:
Loss of control following the collision with high power cables after the crew lost visual references during an approach completed in poor weather conditions. The following contributing factors were identified:
- Inadequate meteorological information provided by the Pias Airport flight coordinator that did not reflect the actual weather condition in the area,
- Lack of a procedure card to carry out the descent, approach, landing and takeoff at Pias Airport, considering the visual and operational meteorological limitations in the area,
- The copilot training was limited and did not allow the crew to develop skills for an effective CRM in normal and emergency procedures.
Final Report:

Crash of a Fokker 50 in Goma: 7 killed

Date & Time: Mar 4, 2013 at 1744 LT
Type of aircraft:
Operator:
Registration:
9Q-CBD
Flight Type:
Survivors:
Yes
Site:
Schedule:
Kananga - Lodja - Goma
MSN:
20270
YOM:
1992
Location:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The aircraft was completing a cargo flight from Kananga to Goma with an intermediate stop in Lodja, carrying four passengers, 6 crew members and a load of various goods. On final approach to Goma Airport Runway 36, the crew encountered poor weather conditions with limited visibility due to heavy rain falls. On final, the aircraft contacted the roof of a house and crashed in the garden of a residential area, coming to rest upside down. Three passengers were seriously injured while seven other occupants were killed.

Crash of a Let L-410UVP-E9 in Wau

Date & Time: Feb 28, 2013
Type of aircraft:
Operator:
Registration:
LZ-CCJ
Flight Type:
Survivors:
Yes
MSN:
02 26 34
YOM:
2002
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing a humanitarian flight on behalf of the United Nations Organisation (UNO). Upon landing at Wau Airport, the nose gear collapsed. The aircraft slid on runway for few dozen metres before coming to rest, bursting into flames. Both pilots evacuated safely and the aircraft was partially destroyed by fire.

Crash of a Beechcraft A60 Duke in Abilene

Date & Time: Feb 24, 2013 at 1020 LT
Type of aircraft:
Registration:
N7466D
Survivors:
Yes
Schedule:
Fort Smith – Abilene
MSN:
P-139
YOM:
1970
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7500
Captain / Total hours on type:
800.00
Aircraft flight hours:
3725
Circumstances:
The pilot reported that he had added fuel at the previous fuel stop and that he was using a fuel totalizer to determine the quantity of fuel onboard. After climbing to a cruise altitude of 14,000 feet above ground level, he discovered that the fuel mixture control was frozen and that he was unable to lean the mixture to a lower fuel flow setting. The pilot reported that because of the increased fuel consumption, he briefly considered an en route stop for additional fuel but decided to continue. During descent, the airplane experienced a complete loss of power in both engines, and the pilot made an emergency off-field, gear-up landing about 7 miles from the destination. The airplane impacted terrain and thick scrub trees, which resulted in substantial damage to both wings, both engine mounts, and the fuselage. A postaccident examination found that only a trace of fuel remained. The pilot also reported that there was no mechanical malfunction or failure and that his inadequate fuel management was partly because he had become overconfident in his abilities after 50 years of flying.
Probable cause:
The pilot’s improper fuel management, which resulted in a loss of engine power due to fuel exhaustion.
Final Report:

Crash of an Antonov AN-24RV in Donetsk: 5 killed

Date & Time: Feb 13, 2013 at 1809 LT
Type of aircraft:
Operator:
Registration:
UR-WRA
Survivors:
Yes
Schedule:
Odessa - Donetsk
MSN:
3 73 087 09
YOM:
1973
Flight number:
YG8971
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
44
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
3245
Captain / Total hours on type:
560.00
Copilot / Total flying hours:
175
Aircraft flight hours:
51136
Aircraft flight cycles:
32645
Circumstances:
On final approach to Donetsk-Sergei Prokofiev Airport, during the last segment, the aircraft banked right to a angle of 48°, causing the right wing to struck the ground. The aircraft overturned and crashed in a grassy area to the left of runway 08, coming to rest upside down. Five passengers were killed while all other occupants were injured. The aircraft was destroyed. It was performing a charter flight from Odessa with 44 football fans on their way to a match between Shakhtar Donetsk and Borussia Dortmund. At the time of the accident, the visibility was poor due to the night and foggy conditions. The horizontal visibility was reported to be 250 metres with an RVR of 750 metres for runway 08 and vertical visibility of 200 feet.
Probable cause:
It was planned that an instructor should perform the flight with the crew but he did not show up, so the captain decided to do the flight without him. On final approach to Donetsk, the visibility was limited and the captain was authorized to descent until 1,000 feet on approach where he should establish a visual contact with runway 08 or the approach lights. At this decision height, he continued the approach without any calls to the rest of the crew despite he did not establish any visual contact with the runway. During the last segment, the aircraft banked right due to a too low approach speed of 103 knots, stalled and crashed. The crew failed to monitor the approach speed, and the captain decided to continue the approach despite the visibility was below minimums. At the decision height, he should abandon the approach for a go-around procedure.
Final Report:

Crash of a Boeing 737-33A in Muscat

Date & Time: Feb 11, 2013 at 1325 LT
Type of aircraft:
Operator:
Registration:
AP-BEH
Survivors:
Yes
Schedule:
Sialkot - Muscat
MSN:
25504/2341
YOM:
1992
Flight number:
PK259
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
107
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Sialkot, the crew completed the approach to Muscat-Seeb Runway 26L. After touchdown, while decelerating, the left main gear collapsed, causing the left engine to struck the ground. The aircraft slid for few dozen metres before coming to rest on the left edge of the runway. All 114 occupants evacuated uninjured while the aircraft was damaged beyond repair.