Crash of a Learjet 24D in Rønne

Date & Time: Sep 15, 2012 at 1340 LT
Type of aircraft:
Operator:
Registration:
D-CMMM
Flight Type:
Survivors:
Yes
Schedule:
Strausberg - Rønne
MSN:
24-328
YOM:
1976
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The accident occurred during a private IFR flight from Strausberg Airport (EDAY), Germany, to Bornholm Airport (EKRN), Denmark. Before the flight, an ATS flight plan was filed. Before takeoff at EDAY, the aircraft was refueled with 200 liters of jet fuel. According to the ATS flight plan, the pilot stated the total endurance to be 01:30 hrs and the Estimated Elapsed Time (EET) to be 00:30 hrs. The pilot informed the AIB DK that the estimated total endurance before takeoff at EDAY was approximately 01:00 hrs. The aircraft departed EDAY at 10:58. Enroute, the pilot observed a low fuel quantity warning light. Otherwise, the flight was uneventful until the approach to EKRN. At 11:32:00 hrs and at a distance of approximately18 nm southwest of EKRN, the pilot cancelled the IFR flight plan and continued VFR for a visual approach to runway 29. While descending inbound EKRN, the airspeed was decreasing. At 11:37:08 hrs, the pilot reported to Roenne Tower that the aircraft was turning final for runway 29. The aircraft was cleared to land. The wind conditions were reported to be 280° 19 knots maximum 29 knots. The aircraft was configured for landing (the landing gear was down and the flaps extended to 40°). On a left base to runway 29, both engines suffered from fuel starvation. At 11:39:18 hrs, the pilot three times declared an emergency. The aircraft entered a stall and impacted terrain in a field of sweet corn. A search and rescue mission was immediately initiated.
Probable cause:
CONCLUSION:
Inadequate en route fuel management resulted in fuel starvation of both engines, while the aircraft was flying at low altitude and the airspeed was decreasing. The dual engine flame out and the subsequent aircraft speed control led to an unrecoverable stall and consequently caused the accident.
FINDINGS:
On board the aircraft in the pilot’s personal belongings, the AIB DK found 2 Airline Transport Pilot Licenses (ATPL) issued by the US Federal Aviation Administration (FAA). The 2 US ATPL licenses had the same FAA license number but the names of the license holders were different. The names of the license holders were inconsistent with the pilot’s Iranian identity.
The BFU informed the AIB DK that the pilot was neither in possession of a valid German pilot license nor a German validation of an US license, which was required to operate a German registered aircraft.
The NTSB informed the AIB DK that the pilot was not in possession of a valid US pilot license.
It has not been possible for the AIB DK to determine whether or not the pilot was in possession of valid pilot license issued by another state.
The BFU informed the AIB DK that the certificate of aircraft registration was cancelled in 2009. Later on in the investigation, the BFU corrected this information. On February 2nd , 2012 and due to a missing airworthiness certificate, the Luftfahrt-Bundesamt (CAA - Germany) revoked the certificate of aircraft registration.
The latest valid airworthiness certificate was issued on the 8th of March 2004 and expired on the 31st of March 2005.
At the time of the accident, the aircraft was not recorded to be maintained by a JAR 145 maintenance organization, a maintenance program or a Continuing Airworthiness Management Organization (CAMO).
Final Report:

Crash of a PZL-Mielec AN-28 in Palana: 10 killed

Date & Time: Sep 12, 2012 at 1220 LT
Type of aircraft:
Operator:
Registration:
RA-28715
Survivors:
Yes
Schedule:
Petropavlovsk-Kamchatsky - Palana
MSN:
1AJ006-25
YOM:
1989
Flight number:
PTK251
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
8955
Captain / Total hours on type:
7732.00
Copilot / Total flying hours:
6543
Copilot / Total hours on type:
6347
Aircraft flight hours:
11947
Aircraft flight cycles:
8891
Circumstances:
Following an uneventful flight from Petropavlovsk-Kamchatsky, the crew started the descent to Palana Airport Runway 11 from the south. In marginal weather conditions, the twin engine aircraft descended too low, impacted trees and crashed in a wooded area located on Mt Pyatibratka. The wreckage was found at a height of 216 meters some 10 km south of the airport. Both pilots and 8 passengers were killed while four other passengers were seriously injured. Thea aircraft was destroyed by impact forces.
Probable cause:
The fatal accident with An-28 RA-28715 aircraft was caused by violation of specified approach pattern in Palan Airport resulted in outbound track and premature descending up to unauthorized low altitude performing flight in mountainous terrain in weather conditions excluding sustained visual reference with ground references resulted in aircraft collision with mountain slope, its destruction and crew and passengers fatality. Alcohol was detected in blood of both crew members.
Contributing factors were:
- Low level of discipline of personnel in Petropavlovsk-Kamchatsky Air Enterprise and inadequate flight methodical work in enterprises in a part of crew preflight training and approach patterns monitoring.
- Crew inaction when the radio altimeter altitude alert was actuated.
- Ground Proximity Warning System at An-28 aircraft could probably prevent the accident.
Final Report:

Crash of a Beechcraft King Air 90 in Lohegaon

Date & Time: Sep 7, 2012 at 2000 LT
Type of aircraft:
Operator:
Registration:
VT-KPC
Flight Type:
Survivors:
Yes
Schedule:
Lohegaon - Lohegaon
MSN:
LJ-1696
YOM:
2005
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a local training mission at Lohegaon Airport. On final approach to runway 28, the aircraft impacted ground, teared off several runway lights and came to rest. All three occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of an ATR42-500 in Lahore

Date & Time: Aug 31, 2012 at 1510 LT
Type of aircraft:
Operator:
Registration:
AP-BHJ
Survivors:
Yes
Schedule:
Islamabad - Lahore
MSN:
657
YOM:
2006
Flight number:
PK653
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
42
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Islamabad, the crew started the descent to runway 36R in marginal weather conditions. Upon touchdown on a wet runway, the right main gear collapsed. The aircraft slid for about 1,700 feet before exiting the runway to the right and coming to rest 60 feet further on. All 46 occupants were unhurt while the aircraft was considered as damaged beyond repair. Five minutes after the accident, the weather briefing was as follow: OPLA 311015Z 16009KT 3000 RA BKN040 OVC100 29/24 Q1003. But ten minutes prior to the crash, the weather briefing was as follow: OPLA 311000Z 33008KT 4000 -RA SCT040 BKN100 32/24 Q1002 TEMPO 31030KT 2000 TSRA FEW030CB. Thus, the conditions were considered as marginal with turbulences, wind to 30 knots and CB's at 3,000 feet. On 11SEP2012, the French BEA reported that the aircraft touched down just at the beginning of the paved surface (undershoot area) to the right of the extended runway 36R centerline, causing the right main gear to collapse. It was reported that the aircraft was unstable on short final and that the crew failed to initiate a go-around procedure while the aircraft was too low on the glide.

Crash of a De Havilland DHC-2 Beaver in Big River Lake

Date & Time: Aug 25, 2012 at 0800 LT
Type of aircraft:
Operator:
Registration:
N314HA
Survivors:
Yes
Schedule:
Soldotna - Big River Lake
MSN:
868
YOM:
1956
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1500
Captain / Total hours on type:
725.00
Aircraft flight hours:
20174
Circumstances:
The pilot of a float-equipped airplane was landing at a remote lake. The pilot stated that he was on a left base leg turning onto a short final approach when the left float struck the ground. The airplane sustained substantial damage to the wings and fuselage. The pilot indicated there were no preaccident mechanical malfunctions or anomalies that would have precluded normal operation. Accident occurred in Big River Lake, in the Kenai region.
Probable cause:
The pilot’s failure to maintain adequate ground clearance during his landing approach, which resulted in a collision with terrain.
Final Report:

Crash of an Antonov AN-26-100 in Talodi: 32 killed

Date & Time: Aug 19, 2012 at 0800 LT
Type of aircraft:
Operator:
Registration:
ST-ARL
Flight Type:
Survivors:
No
Site:
Schedule:
Khartoum - Talodi
MSN:
26 06
YOM:
1975
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
26
Pax fatalities:
Other fatalities:
Total fatalities:
32
Circumstances:
The aircraft was performing a flight from Khartoum to Talodi with a delegation of 26 members of the Sudanese Government, among them several Ministers, Generals and politicians. On approach to Talodi Airport in poor weather conditions due to a sand storm, the crew initiated a go-around procedure when the aircraft impacted the slope of Mt Hagar al Nar (244 metres high) located 1,500 metres south of the airport. The aircraft was destroyed by impact forces and a post crash fire and all 32 occupants were killed.
The official list of the passengers and crew, all of whom died in the crash, is as follows:
Guidance and Religious Endowments Minister Ghazi al-Sadiq Abdel Rahim,
Justice Party chairman Makki Ali Balayil,
State minister at the Youth and Sports Ministry Mahjub Abdel Rahim Tutu,
State minister at the Ministry of Tourism, Antiquities and Wildlife Issa Daifallah,
Maj. Gen. Salah Ismail – Air Forces
Maj. Gen. Ahmed Musa Ahmed – the Police Forces
Maj. Gen. Ahmed Al-Tayeb Abu-Guroon – Security and Intelligence Organ
Brigadier Lugman Omer – Second Commander of the People's Defence Forces
Al-Saddiq Abdul-Majid Al-Makkawi – the People's Defence Forces
Awadal-Karim Siral-Khatim – Deputy Coordinator of the People's Defence Forces
Waeez Salaha Omer – Headquarters of the People's Defence Forces
Omer Mahjoub Ahmed – Deputy Coordinator of the People's Defence Forces
Salah-Eddin Mustafa – People's Defence Forces – Jabal Aulia Locality
Several officials from Khartoum (including Hamid Al-Aghbash – the National Assembly)
Five media representatives
Six crew members.
Probable cause:
Despite the fact that rebels announced officially two days later they shot down the aircraft, the Sudanese Government confirmed that visibility was low at the time of the accident with clouds at low height and poor weather conditions. As a result, officials said the accident was the consequence of a controlled flight into terrain (CFIT) after the crew descended too low on final.

Crash of a Pilatus PC-6/B2-H2 Turbo Porter off Granville

Date & Time: Aug 18, 2012 at 1855 LT
Operator:
Registration:
F-GMJG
Survivors:
Yes
Schedule:
Granville - Granville
MSN:
659
YOM:
1967
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
13300
Circumstances:
The single engine aircraft departed Granville-Bréville Aerodrome on a local skydiving mission. After all skydivers left the aircraft, the pilot reduced his altitude to return to his base. On final approach to runway 07, the aircraft went out of control and crashed in the sea, few dozen metres offshore. A sailor went quickly to the scene and evacuated the pilot who was slightly injured while the aircraft sank by a depth of 5-6 metres. The wreckage was recovered and pulled on the beach a day later. The aircraft was damaged beyond repair.

Crash of an Embraer EMB-505 Phenom 300 in Altenrhein

Date & Time: Aug 6, 2012 at 1540 LT
Type of aircraft:
Operator:
Registration:
CN-MBR
Survivors:
Yes
Schedule:
Geneva - Altenrhein
MSN:
505-00025
YOM:
2011
Flight number:
DLI211
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7025
Captain / Total hours on type:
75.00
Copilot / Total flying hours:
5854
Copilot / Total hours on type:
465
Aircraft flight hours:
510
Circumstances:
On 6 August 2012 the Embraer EMB-505 Phenom 300 aircraft, registration CN-MBR, took off at 12:59 UTC from Geneva (LSGG) on a commercial flight to St. Gallen-Altenrhein (LSZR). After the initial call to the aerodrome control centre St. Gallen tower, the crew quickly decided, after an enquiry from the air traffic controller, on a direct approach on the runway 10 instrument landing system (ILS). Shortly thereafter, the landing gear and flaps were extended. The flaps jammed at approximately 10 degrees and the FLAP FAIL warning message was displayed. The crew carried out a go-around shortly before landing. The landing gear subsequently remained extended. The flaps remained jammed for the remainder of the flight. The crew decided immediately on a second ILS approach with jammed flaps, which according to the manufacturer's information required an increased approach speed. During the approach, the crew had difficulty in reducing the airspeed to this increased approach speed. At 13:40 UTC, the aircraft subsequently touched down on the wet runway at an indicated air speed of 136 kt, approximately 290 m after the runway threshold, and could not be brought to a standstill on the remaining length of runway. The aircraft then rolled over the end of runway 10, broke through the aerodrome perimeter fence and overrun the road named Rheinholzweg running perpendicular to the runway centreline, on which a public transport bus was travelling. The aircraft rolled very close behind the bus and came to a standstill in a maize field, approximately 30 m from the end of the runway. The female passenger and the two pilots were not injured in the accident. The aircraft was badly damaged. There was crop damage and damage to the aerodrome perimeter fence.
Probable cause:
The accident is attributable to the fact that the aircraft touched down late and at an excessively high speed on the wet runway after an unstabilized final approach and consequently rolled over the end of the runway.
The following factors contributed to the accident:
- The insufficient teamwork and deficient situation analysis by the crew.
- The flaps remained jammed at approximately 10 degrees, a position that is almost consistent with the flaps 1 position.
- Late initiation of full brake application after landing.
Final Report:

Crash of a Cessna 500 Citation I in Santiago de Compostela: 2 killed

Date & Time: Aug 2, 2012 at 0618 LT
Type of aircraft:
Operator:
Registration:
EC-IBA
Flight Type:
Survivors:
No
Schedule:
Oviedo - Santiago de Compostella
MSN:
500-0178
YOM:
1974
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3600
Captain / Total hours on type:
500.00
Copilot / Total flying hours:
678
Copilot / Total hours on type:
412
Aircraft flight hours:
9460
Circumstances:
Based on the information available, at 20:40 the ONT (National Transplant Organization) informed the Santiago Airport (LEST) that they were going to make a “hospital flight”. The aircraft was refueled at the Santiago Airport with 1062 liters of fuel. According to communications, the crew of aircraft EC-IBA contacted the Santiago tower at 21:46 to request permission to start up and information on the weather and the runway in use at Asturias. At 21:54 they were cleared to take off. According to the airport operations office, the aircraft landed in Asturias (LEAS) at 22:27. The hospital flight service commenced at 22:15. The RFFS accompanied the ambulance to the aircraft at 22:30 and at 22:44 the aircraft took off en route to Porto. The aircraft was transferred from Madrid control to Santiago approach at 22:52 at flight level 200 and cleared straight to Porto (LPPR). Based on the information provided by Porto Airport, the aircraft landed at 23:40. While waiting for the medical team to return, the crew remained in the airport’s facilities. According to some of the personnel there, the crew made some comments regarding the bad weather. There was fog, especially on the arrival route. At 01:34 and again at 02:01 the crew was supplied with the flight plan information, information from the ARO-LPPR office and updated weather data. The aircraft was refueled at the Porto Airport with 1,000 l of fuel and took off at 02:34. At 02:44 the aircraft contacted approach control at Santiago to report its position. Four minutes later the crew contacted the Santiago tower directly to ask about the weather conditions at the field (see Appendix C). The aircraft landed once more in Asturias at 03:28. At 03:26 the RFFS was again activated to escort the ambulance to the aircraft. The service was deactivated at 04:00. The crew requested updated weather information from the tower, which provided the information from the 03:00 METAR. According to the flight plan filed, the estimated off-block time (EOBT) for departing from the Asturias Airport was 03:45, with an estimated flight time to Santiago of 40 minutes. The alternate destination airport was Vitoria (LEVT). The aircraft took off from Asturias at 03:38. At 03:56 the crew established contact with Santiago approach control, which provided the crew with the latest METAR from 03:30, which informed that the runway in use was 17, winds were calm, visibility was 4,000 m with mist, few clouds at 600 ft, temperature and dew point of 13° and QNH of 1,019. The aircraft was then cleared to conduct an ILS approach to runway 17 at the Santiago Airport. At 04:15 the crew contacted the tower controller, who reported calm winds and cleared them to land on runway 17. At 04:18 the COSPAS-SARSAT system detected the activation of an ELT. The system estimated the position for the beacon as being in the vicinity of the LEST airport. At 04:38 the tower controller informed airport operations of a call he had received from SAR that a beacon was active in the vicinity of the airport, and requested that a marshaller go to the airport where the airplane normally parked to see if it was there. At 04:44 the marshaller confirmed that the aircraft was not in its hangar and the emergency procedure was activated, with the various parties involved in the search for the airplane being notified. At 05:10 the control tower called the airport to initiate the preliminary phase (Phase I) before activating the LVP. At 05:15 the RFFS reported that the aircraft had been found in the vicinity of the VOR. At 05:30 the LVP was initiated (Phase II). At 07:51 the LVP was terminated. The last flight to arrive at the Santiago Airport before the accident had landed at 23:33, and the next flight to arrive following the accident landed at 05:25.
Probable cause:
The ultimate cause of the accident could not be determined. In light of the hypothesis considered in the analysis, the most likely scenario is that the crew made a non-standard precision approach in manual based primarily on distances. The ILS frequency set incorrectly in the first officer’s equipment and the faulty position indicated on the DME switch would have resulted in the distance being shown on the captain’s HSI as corresponding to the VOR and not to the runway threshold. The crew shortened the approach maneuver and proceeded to a point by which the aircraft should already have been established on the localizer, thus increasing the crew’s workload. The crew then probably lost visual contact with the ground when the aircraft entered a fog bank in the valleys near the airport and did not realize they were making an approach to the VOR and not to the runway.
The contributing factors were:
- The lack of operational procedures of an aircraft authorized to be operated by a single pilot operated by a crew with two members.
- The overall condition of the aircraft and the instruments and the crew’s mistrust of the onboard instruments.
- The fatigue built up over the course of working at a time when they should have been sleeping after an unplanned duty period.
- The concern with having to divert to the alternate without sufficient fuel combined with the complacency arising from finally reaching their destination.
Final Report:

Crash of a Beechcraft B200 Super King Air in Juiz de Fora: 8 killed

Date & Time: Jul 28, 2012 at 0745 LT
Operator:
Registration:
PR-DOC
Survivors:
No
Schedule:
Belo Horizonte - Juiz de Fora
MSN:
BY-51
YOM:
2009
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
14170
Captain / Total hours on type:
2170.00
Copilot / Total flying hours:
730
Copilot / Total hours on type:
415
Aircraft flight hours:
385
Aircraft flight cycles:
305
Circumstances:
The twin engine aircraft departed Belo Horizonte-Pampulha Airport at 0700LT on a flight to Juiz de Fora, carrying six passengers and two pilots. In contact with Juiz de Fora Radio, the crew learned that the weather conditions at the aerodrome were below the IFR minima due to mist, and decided to maintain the route towards the destination and perform a non-precision RNAV (GNSS) IFR approach for landing on runway 03. During the final approach, the aircraft collided first with obstacles and then with the ground, at a distance of 245 meters from the runway 03 threshold, and exploded on impact. The aircraft was totally destroyed and all 8 occupants were killed, among them both President and Vice-President of the Vilmas Alimentos Group.
Probable cause:
The following factors were identified:
- The pilot may have displayed a complacent attitude, both in relation to the operation of the aircraft in general and to the need to accommodate his employers’ demands for arriving in SBJF. It is also possible to infer a posture of excessive self-confidence and confidence in the aircraft, in spite of the elements which signaled the risks inherent to the situation.
- It is possible that the different levels of experience of the two pilots, as well as the copilot’s personal features (besides being timid, he showed an excessive respect for the captain), may have resulted in a failure of communication between the crewmembers.
- It is possible that the captain’s leadership style and the copilot’s personal features resulted in lack of assertive attitudes on the part of the crew, hindering the exchange of adequate information, generating a faulty perception in relation to all the important elements of the environment, even with the aircraft alerts functioning in a perfect manner.
- The meteorological conditions in SBJF were below the minima for IFR operations on account of mist, with a ceiling at 100ft.
- The crew did not inform Juiz de Fora Radio about their passage of the MDA and, even without visual contact with the runway, deliberately continued in their descent, not complying with the prescriptions of the items 10.4 and 15.4 of the ICA 100-12 (Rules of the Air and Air Traffic Services).
- The crew judged that it would be possible to continue descending after the MDA, even without having the runway in sight.
Final Report: