Crash of a Piper PA-31-350 Navajo Chieftain in Grand Central

Date & Time: Nov 25, 2012 at 1027 LT
Registration:
ZS-JHN
Flight Type:
Survivors:
Yes
Schedule:
Grand Central – Tzaneen
MSN:
31-7405496
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1699
Captain / Total hours on type:
1.00
Aircraft flight hours:
8029
Circumstances:
On the morning of 25 November 2012 at 0902Z the pilot, sole occupant on board the aircraft, took off from FAGC to FATZ. He filed an IFR flight plan to cruise at F110 in controlled airspace. The take-off roll and initial climb from RWY 17 was uneventful and passing FL075 FAGC Tower Controller transferred the aircraft to Johannesburg Approach Control (Approach) on 124.5 MHz. On contact with Approach the pilot was cleared to climb to FL110. On the climb approaching FL090 the aircraft lost power on the left engine, oil pressure dropped and the cylinder head temperature increased. He then advised Approach of the problem and requested to level out at FL090 to attempt to identify the problem. He requested radar vectors from Approach to route direct to FAGC and proceeded to shut down the left engine. The pilot continued routing FAGC using the right engine but was unable to maintain height. He noticed the oil pressure and manifold pressure on the right engine dropping. The pilot also reported seeing fire through the cooling vents of the right engine cowling. The pilot requested distance to FAGC from Approach and was told it is 2.5nm (nautical miles) and the aircraft continued loosing height. An update from Approach seconds later indicated that the aircraft was 1nm from FAGC. The pilot decided to do a wheels up forced landing on an open field when he realized that the aircraft was too low. He landed wheels up in a wings level attitude. The aircraft impacted and skidded across an uneven field and came to a stop 5m from Donovan Street. The pilot disembarked the aircraft and attempted to put out the fire which had started inflight on the right engine but without success. Eventually the right wing and the fuselage were engulfed by fire. Minutes later the FAGC fire department using two vehicles extinguished the fire. The pilot escaped with no injuries and the aircraft was destroyed by the ensuing fire.
Probable cause:
An inspection the left wings outboard tank was full and the main tank was empty. Both fuel selectors were also found on main tanks (left and right) position. Unsuccessful forced landing due to fuel starvation and the cause of the fire was undetermined. The left engine failed because of fuel exhaustion and the cause of fire could not be determined.
Final Report:

Crash of an Antonov AN-26B-100 in Deputatsky

Date & Time: Nov 21, 2012 at 1431 LT
Type of aircraft:
Operator:
Registration:
RA-26061
Survivors:
Yes
Schedule:
Yakutsk - Deputatsky
MSN:
111 08
YOM:
1981
Flight number:
PI227
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
23
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8845
Captain / Total hours on type:
1150.00
Copilot / Total flying hours:
2566
Copilot / Total hours on type:
245
Aircraft flight hours:
22698
Aircraft flight cycles:
11257
Circumstances:
Following an uneventful flight from Yakutsk-Magan Airport, crew started the descent to runway 10. On touch down on a snow covered runway, aircraft landed slightly to the left of the centerline. After a course of 350 meters, left main gear hit a snow berm of 20-50 cm high. Aircraft continued to the left, veered off runway and came to rest in snow covered field with its right main gear and right wing severely damaged. All 29 occupants were evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
The non-fatal accident with An-26B RA-26061 aircraft was caused by its RWY overrun that resulted in aircraft structure damage. The accident was possible due to combination of the following factors:
- Pilot's error resulted in approach procedure correction up to the moment of landing resulted in offset approach towards unpaved RWY axis and considerably to the left from its axis;
- Non-compliance of unpaved RWY of "Deputatsky" Airport" condition with Civil aerodrome operation manual requirements RF-94, in part of interface between cleaned and uncleaned surface of unpaved RWY with slope no more than 1:10;
- Nose-left moment during main landing gear movement along interface from recent snow up to 30-50 cm as a result of both left landing gear wheels dipping into snow.
Final Report:

Crash of an Antonov AN-26B-100 in Yida

Date & Time: Nov 19, 2012
Type of aircraft:
Operator:
Registration:
3X-GFN
Flight Type:
Survivors:
Yes
Schedule:
Entebbe - Yida
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was completing a cargo flight from Entebbe, carrying four crew members and a load consisting of foodstuffs. After landing, the aircraft was unable to stop within the remaining distance. It overran, lost its left main gear and came to rest in bushes. While all four occupants escaped uninjured, the aircraft was damaged beyond repair.

Crash of a Piper PA-46-500TP Malibu Meridian in La Crete: 1 killed

Date & Time: Nov 17, 2012 at 1810 LT
Registration:
C-GWEI
Flight Type:
Survivors:
No
Schedule:
High Level – La Crete
MSN:
46-97351
YOM:
2008
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
While descending to La Crete Airport, the pilot encountered foggy conditions and the visibility dropped to 100 metres. By night, the single engine aircraft descended too low, impacted ground and crashed in a snow covered field located few km northeast of the airport. The aircraft was destroyed and the pilot, sole on board, was killed.
Probable cause:
It was determined that the pilot continued the descent under VFR mode in IMC conditions, resulting in a controlled flight into terrain.

Crash of a Cessna 550 Citation II in Greenwood

Date & Time: Nov 17, 2012 at 1145 LT
Type of aircraft:
Operator:
Registration:
N6763L
Flight Type:
Survivors:
Yes
Schedule:
Greenwood - Greenwood
MSN:
550-0673
YOM:
1991
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11592
Captain / Total hours on type:
903.00
Copilot / Total flying hours:
4501
Copilot / Total hours on type:
13
Aircraft flight hours:
8611
Circumstances:
The aircraft, registered to the United States Customs Service, and operated by Stevens Aviation, Inc., was substantially damaged during collision with a deer after landing on Runway 9 at Greenwood County Airport (GRD), Greenwood, South Carolina. The airplane was subsequently consumed by postcrash fire. The two certificated airline transport pilots were not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the maintenance test flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. According to the pilot, the purpose of the flight was to conduct a test of the autopilot and flight director systems on board the airplane, following a "cockpit modernization" their company had performed. The airplane completed the NDB/GPS RWY 27 instrument approach procedure and then circled to land on Runway 9. About 5 seconds into the landing rollout, a deer appeared from the wood line and ran into the path of the airplane. The deer struck the airplane at the leading edge of the left wing above the left main landing gear, and ruptured an adjacent fuel cell. The pilot was able to maintain directional control, and the airplane was stopped on the runway, spilling fuel and on fire. The crew performed an emergency shutdown of the airplane and egressed without injury.Greenwood County Airport did not have a fire station co-located on the airport facility. The fixed base operator called 911 at the time of the accident, and the fire trucks arrived approximately 10 minutes after notification.
Probable cause:
Collision with a deer during the landing roll, which resulted in a compromised fuel tank and a postimpact fire. In a telephone interview, the manager of the Greenwood County Airport explained that Greenwood was not an FAR Part 139 Airport, and while there was no published Wildlife Management Program for the airport, she had been very proactive about eradicating wildlife that could pose a hazard to safety on the airport property, primarily deer and wild turkey. She contacted the United States Department of Agriculture (USDA) for guidance and advice and she attended a wildlife management course. Among the suggestions offered by the USDA, was to remove the deer habitat. The manager proposed adding the area between the runway and taxiway to an approach clearing project in order to reduce the habitat. The manager worked with a local charity and local hunters with depredation permits to take deer on the airport property, and their efforts averaged 50 deer a year. The hunts were conducted in stands away from runways and on property not aviation related. The nearest deer stand was 1 mile from the runway, and the hunters fired only shotguns. The hunts were conducted between the hours of 0700 and 1000. On the morning of the accident, the last shot was fired at 0930.When asked why the hunters were still on the property at the time of the accident, the manager said they had stayed to eat lunch, and repeated that the hunt was long over and that the last shot was fired hours before the accident. She offered that the deer struck by the airplane was probably flushed from the woods by another deer or a coyote, whose population has also grown in recent years.After the accident, the Federal Aviation Administration contacted the state and had the Greenwood County Airport added to a list of airports where funding for improvements had been allotted. A second 10-foot perimeter fence was added around the existing 6-foot fence, and since its construction only 4 deer have been taken inside the perimeter, and no wild turkeys have been sighted
Final Report:

Crash of an Airbus A300B4-203F in Bratislava

Date & Time: Nov 16, 2012 at 0525 LT
Type of aircraft:
Operator:
Registration:
EI-EAC
Flight Type:
Survivors:
Yes
Schedule:
Leipzig - Bratislava
MSN:
250
YOM:
1983
Flight number:
DHL6321
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew took off from Leipzig Airport at 0438LT bound for Bratislava Airport (Slovakia). The approximately forty-five minutes flight took place without incident and the crew was cleared for the ILS approach to runway 22. The Captain was PF. During the descent, the controller informed the crew that the wind was from  120° at  7  kt. The crew selected the slats and flaps at 25°. The antiskid and the autobrake were armed in MED mode. The ILS 22 approach was stable until the wheels touched down. The main landing gear touched the runway about 700 m from the threshold of runway  22. The crew deployed the thrust reversers. About six seconds after the nose gear touched, the crew felt strong vibrations that increased as the speed dropped. At 85 kt, the thrust reversers were retracted. The aeroplane veered towards the left. The PF explained that he applied energetic braking and tried in vain to counter the rocking by using the rudder pedals then the nose gear steering control. He  added that the sequence occurred so quickly that he did not think to use differential braking to try to keep the aeroplane on the runway. The aeroplane exited the runway to the left at a speed of about 45 kt. Its nose gear struck a concrete inspection pit and collapsed. The aeroplane skidded for a few dozen metres before coming to a stop. The crew evacuated the aeroplane. Between the start of the vibrations and the aeroplane stopping, it had rolled about 400 metres.
Probable cause:
Incorrect installation of one or more washers on the nose gear torque link centre hinge made it impossible to lock the hinge shaft nut effectively. The unscrewing and the detachment of the latter in service caused the loss of nose gear steering. Free on its axle, the nose gear bogie began to shimmy, which made the aeroplane veer to the left. The aeroplane exited the runway and the nose gear collapsed during the collision with a concrete inspection pit for access to the runway lighting electric cables.The runway excursion was due to the incorrect and undetected re-assembly of the nose gear torque links. Despite the presence of a detailed diagram, the absence of clear and detailed instructions in the text of the manufacturer’s AMM, allowing the operator to ensure that the assembly was correct, contributed to the incorrect assembly. The failure of the nose gear was due to the collision with an obstacle in the runway  strip. The absence of any regulation requiring that equipment in the immediate vicinity of a runway or of a runway overrun area be designed so as to limit as much as possible any damage to aeroplanes, in case of a runway excursion, contributed to the accident.
Final Report:

Crash of a Fokker 50 in Aweil

Date & Time: Nov 15, 2012 at 1700 LT
Type of aircraft:
Operator:
Registration:
5Y-CAN
Survivors:
Yes
Schedule:
Khartoum - Aweil
MSN:
20175
YOM:
1990
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
53
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown at Aweil Airport, the left main gear collapsed. The aircraft veered off runway to the left, slid on soft ground for few dozen metres before coming to rest in bushes with its left wing torn off. There was no fire. All 57 occupants evacuated safely, only one passenger suffered minor injuries. The aircraft was damaged beyond repair. The plane was contracted by the International Organization for Migration (IOM) and the Government of South Sudan to airlift South Sudanese refugees back to Aweil.

Crash of a Cessna 525B Citation CJ3 in São Paulo

Date & Time: Nov 11, 2012 at 1721 LT
Type of aircraft:
Operator:
Registration:
PR-MRG
Survivors:
Yes
Schedule:
Florianópolis – São Paulo
MSN:
525B-0187
YOM:
2008
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4048
Captain / Total hours on type:
521.00
Copilot / Total flying hours:
648
Copilot / Total hours on type:
189
Circumstances:
Following an uneventful flight from Florianópolis, the crew started the approach to São Paulo-Congonhas Airport Runway 35R. After touchdown, the airplane was unable to stop within the remaining distance. It overran, went down an embankment and came to rest against a fence, broken in two. The passenger and the copilot were slightly injured and captain was seriously injured. The aircraft was destroyed.
Probable cause:
The following findings were identified:
- The commander was overconfident in himself and the aircraft which led him to lose the critical capacity to discern the risks involved in the procedure that was adopting. Corroborating was the fact that the pilot judged he had much knowledge in this operation and knew exactly how the aircraft responded. It can be inferred there was complacency by the copilot on the actions of the commander, during the approach at high speed, because even feeling uncomfortable, he did not make an incisive interference because he believed in the idea that the commander had done this kind of approach, with high speed, and so knowing what he was doing.
- The pilot failed to identify the location of touch down during landing and not knowing how much runway was remaining, he decided he should not rush, thus demonstrating low situational awareness and lack of awareness, impacting the proper reaction time for the situation (Rush), which was not performed , leading the occurrence in question.
- The crew failed to properly assess the information available like speed and the runway length for the realization of a safe landing, which led to a poor judgment of the situation at hand, making the decision not to adopt the missed approach procedure.
- The distance between the crew, caused unconsciously by the commander's position with excess knowledge in the operation and the aircraft, and the insecurity of the copilot in considering new and inexperienced, resulted in a lack of assertiveness of the copilot to inform, with little emphasis, the commander of his perception of excessive airspeed.
- The crew did not adopt good crew resource management, failing to communicate with assertiveness and share critical information in time prior to landing, allowing the speeding remained present until the touchdown.
- Despite having adequate experience and training, the commander did not use the resources available, such as speed brakes to reduce the aircraft approach speed.
- The variable wind direction and predominantly tail intensity equal to or greater than 10 knots, allowed excessive speed during landing.
- The crew did not adopt good crew resource management, allowing the high speed to remain present until the touchdown.
- The commander thought he would be able to perform the approach and landing with the speed above the expected.
Final Report:

Crash of a Piper PA-31T2 Cheyenne II XL in Curitiba: 4 killed

Date & Time: Nov 6, 2012 at 1725 LT
Type of aircraft:
Operator:
Registration:
PT-MFW
Survivors:
No
Schedule:
Dourados – Curitiba
MSN:
31-8166067
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
11088
Captain / Total hours on type:
618.00
Copilot / Total flying hours:
771
Copilot / Total hours on type:
16
Circumstances:
The twin engine aircraft departed Dourados-Francisco de Matos Pereira Airport on an on-demand flight to Curitiba, carrying two passengers, two pilots and a load consisting of valuables. On final approach to Curitiba-Bacacheri Airport, both engines failed simultaneously. The crew attempted an emergency landing when the aircraft crashed in a field and came to rest near trees. A passenger was seriously injured while three other occupants were killed. The following day, the only survivor died from his injuries.
Probable cause:
The following findings were identified:
- Fatigue is likely to have occurred, since there are reports of high workload, capable of affecting the perception, judgment, and decision making of the crew.
- In view of the fact that the captain displayed an attitude of gratefulness toward the company which hired him, working for consecutive hours and many times more than was prescribed for his daily routine, it is possible that such high motivation may have been present in the accident flight, harming his capacity to evaluate the conditions required for a safe flight.
- The crew neither gathered nor properly evaluated the available pieces of information for the correct refueling of the aircraft, something that led to their decision of not refueling the aircraft in SBDO.
- The company crews did not usually keep fuel records, and made approximate calculations based on the fuel remaining from previous flights, whose control parameters were not dependable. Such attitudes reflected a work-group culture that became apparent in this accident.
- The pilots were presumably undergoing a condition of stress on account of the company flight routine, in which they flew every day, with little time dedicated to rest or even holidays. Under such condition, the pilots may have had their cognitive processes affected, weakening their performance in flight.
- The flights had the objective of transporting valuables, causing concern in relation to security issues involving the aircraft on the ground. Thus, it is suspected that decisions made by the pilots may have been affected by this complexity, such as, for example, deciding not to refuel the aircraft on certain locations.
- The way the work was structured in the company was giving rise to overload due to the routine of many flights and few periods of rest or holidays. This situation may have affected the crew’s performance, interfering in the analysis of the conditions necessary for a safe flight.
- The company did not monitor the performance of its pilots for the identification of contingent deviations from standard procedures, such as non-compliance with the MGO.
- Failures in the application of operational norms, as well as in the communication between the crew members, may have occurred on account of inadequate management of tasks by each individual, such as, for example, the use of the checklist and the filling out of control forms relative to fuel consumption contained in the company MGO.
- The crew judged that the amount of fuel existing in the aircraft was sufficient for the flight in question.
- The fact that the fuel gauges were not indicating the correct quantity of fuel had direct influence on the flight outcome, since the planning factors and the pilots’ situational awareness were affected.
- The crew did not analyze appropriately the amount of fuel necessary for the flight leg between SBDO and SBBI. The Mission Order did not establish the minimum amount of fuel necessary for the flight legs, and the crew had to take responsibility for the decision.
- The company was not rigorous with the filling out of aircraft logbooks and cargo manifestos, resulting that it did not have control over the operational procedures performed by the crews, and this may have contributed to the aircraft taking off with an amount of fuel that was insufficient for the flight. Although the MGO had parameters established for calculating the endurance necessary for VFR/IFR flights, the company did not define the fuel necessary in the Mission Orders, transferring the responsibility for the decision to the aircraft captain.
Final Report:

Crash of a Cessna 208B Super Cargomaster in Wichita: 1 killed

Date & Time: Nov 6, 2012 at 0745 LT
Type of aircraft:
Operator:
Registration:
N793FE
Flight Type:
Survivors:
No
Schedule:
Wichita - Garden City
MSN:
208B-0291
YOM:
1991
Flight number:
FDX8588
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
15200
Aircraft flight hours:
10852
Circumstances:
The aircraft was substantially damaged when it collided with a hedgerow during a forced landing following a loss of engine power near Wichita, Kansas. The loss of engine power occurred about 4-1/2 minutes after departing Wichita Mid-Continent Airport (ICT), Wichita, Kansas. The commercial pilot, who was the sole occupant, was fatally injured. The airplane was registered to the Federal Express Corporation and operated by Baron Aviation Services Incorporated, under the provisions of 14 Code of Federal Regulations Part 135 while on an instrument flight plan. Day visual meteorological conditions prevailed for the cargo flight that had the intended destination of Garden City Regional Airport (GCK), Garden City, Kansas. According to air traffic control transmissions, at 0734:35 (hhmm:ss), the pilot requested an instrument flight rules clearance from ICT to GCK. Radar track data indicated that the airplane departed runway 19R approximately 0737:45. At 0738:18, the tower controller told the pilot to change to the departure control frequency. The departure controller then cleared the flight to proceed direct to GCK and to climb to 8,000 ft mean sea level (msl). The airplane continued to climb on a westerly heading until 0742:02, at which time the airplane began a left 180-degree turn back toward the departure airport. According to radar data, the airplane had reached 4,700 ft msl when it began the left turn. At 0742:13, the pilot transmitted that his airplane had experienced a loss of engine power and that he was attempting to return to the departure airport. At 0742:31, the pilot asked if there were any nearby airports because he was unable to reach ICT. The departure controller provided vectors toward an airstrip that was approximately 2.5 miles southeast of the airplane's position. At 0743:46, the pilot advised that he could not see the airstrip because the airplane's windshield was contaminated with oil. At 0744:57, the pilot's final transmission was that he was landing in a grass field. The airplane was located about 2.2 miles south of ICT at 1,600 feet msl, about 300 feet above ground level (agl) at the time of the last transmission. The radar data continued northeast another 1/2 mile before radar contact was lost at 0745:15. A witness to the accident reported that he was outside his residence when he observed the accident airplane overfly his position. He recalled that the airplane's propeller was not rotating and that he did not hear the sound of the engine operating. He stated that the airplane landed in a nearby agricultural field on a northeast heading. He reported that during the landing rollout the airplane impacted a hedgerow located at the northern edge of the field. The witness indicated that the pilot was unresponsive when he arrived at the accident site and that there was a small grass fire located 8 to 10 feet in front of the main wreckage.
Probable cause:
The total loss of engine power as a result of a fractured compressor turbine blade due to high-cycle fatigue.
Final Report: