Crash of an ATR72-500 in Pokhara: 72 killed

Date & Time: Jan 15, 2023 at 1057 LT
Type of aircraft:
Operator:
Registration:
9N-ANC
Survivors:
No
Schedule:
Kathmandu - Pokhara
MSN:
754
YOM:
2007
Flight number:
YT691
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
68
Pax fatalities:
Other fatalities:
Total fatalities:
72
Captain / Total flying hours:
21901
Captain / Total hours on type:
3300.00
Copilot / Total flying hours:
6396
Copilot / Total hours on type:
186
Aircraft flight hours:
28731
Aircraft flight cycles:
30104
Circumstances:
On 15 January 2023, an ATR 72-212A version 500 was operating scheduled flights between Kathmandu (VNKT) and Pokhara International Airport (VNPR). The same flight crew operated two sectors between VNKT to VNPR and VNPR to VNKT earlier in the morning. For first sector, the aircraft landed on runway 30 of VNPR and thereafter departed from VNPR using runway 12. The accident occurred during a visual approach for runway 12 at VNPR. This was the third flight by the crew members on that day. As per the CVR recordings it was understood that the flight was operated by two Captains, one Captain was in the process of obtaining aerodrome familiarization for operating into VNPR and the other Captain was an instructor pilot. The Captain being familiarized, who was occupying the left-hand seat, was the Pilot Flying (PF) and the instructor pilot, occupying the right-hand seat, was the Pilot Monitoring (PM). The take-off, climb, cruise and descent to VNPR was normal. The weather was compatible with VMC enroute to the destination airport. During the first contact with VNPR tower, the Air Traffic Controller (ATC) assigned runway 30 for the aircraft to land. But during the later phases of flight the flight crew, without mentioning any reason for changing the allocated runway, requested and received clearance from ATC to change runway 30 to 12 for landing. At 10:51:36, the aircraft descended from 6,500 feet at fifteen miles away from VNPR and joined the downwind track for Runway 12 to the north of the runway. The aircraft was visually identified by ATC during the approach. At 10:56:12, the pilots extended the flaps to the 15 degrees position and 46 seconds later they selected the landing gears lever to the down position. At 10:56:27, the PF disengaged the Autopilot System (AP) at an altitude of 721 feet Above Ground Level (AGL). The PF then called for “FLAPS 30” at 10:56:32, and the PM replied, “Flaps 30 and continue descent. The flight data recorder (FDR) data did not record any flap surface movement at that time. Instead, the propeller rotation speed (Np) of both engines decreased simultaneously to less than 25% and the torque (Tq) started decreasing to 0%, which is consistent with both propellers going into the feathered condition . The feather condition is not recorded in the FDR parameters. On the cockpit voice recorder (CVR) area microphone recording, a single Master Caution chime was recorded at 10:56:36. As per CVR readout, the flight crew then carried out the “Before Landing Checklist” without identifying the flaps were not to the 300 position, before starting the left turn onto the base leg. During that time, the power lever angle increased from 41% to 44%. At that point, Np of both propellers was recorded as Non-Computed Data (NCD) in the FDR and the torque (Tq) of both engines was at 0%. When propellers are in feather, they are not producing thrust. When both propellers were feathered both engines of 9N-ANC were running in flight idle condition during the event flight as per design to prevent overtorque. As per the FDR data, the engine turbo machine were functioning as expected considering the propeller were feathered. At 10:56:50 when the radio altitude callout for five hundred feet was annunciated, another “click” sound was heard . The aircraft turned to the left and reached a maximum bank angle of 30 degrees. The recorded Np and Tq data remained non-computed, in line with propellers being in feather condition. The yaw damper was disconnected four seconds later. The PF consulted the PM on whether to continue the left turn and the PM replied to continue the turn. Subsequently, the PF asked the PM on whether to continue descend and the PM responded it was not necessary and instructed to apply a little power. At 10:56:54, another click was heard, followed by the flaps moving to the 30 degrees position. When ATC gave the clearance for landing at 10:57:07, the crew did not respond to the tower, the PF mentioned twice that there was no power coming from the engines. The FDR data shows that at 10:57:11, the power levers were advanced first to 62 degrees then to the maximum power position in 2 seconds. It was followed by a “click” sound at 10:57:16. One second after the “click” sound, the aircraft was at the initiation of its last left turn at 368 feet AGL, the highpressure turbine speed (Nh) of both engines increased from 73% to 77%. It is noted that at 10:57:18, in the very last stage of flight, the PF handed over control of the aircraft to the PM. At 10:57:20, the PM (who was previously the PF) repeated again that there was no power from the engines. At 10:57:24 when the aircraft was at 311 feet AGL, the stick shaker5 was activated warning the crew that the aircraft Angle of Attack (AoA) increased up to the stick shaker threshold. At 10:57:26, a second sequence of stick shaker warning was activated when the aircraft banked towards the left abruptly. Three seconds later, the radio altitude alert for two hundred feet was annunciated, and the cricket sound and stick shaker ceased. At 10:57:32, sound of impact was heard in the CVR. The FDR and CVR stopped recording at 10:57:33 and 10:57:35 respectively. The airplane was totally destroyed and all 72 occupants were killed.
Probable cause:
The most probable cause of the accident is determined to be the inadvertent movement of both condition levers to the feathered position in flight, which resulted in feathering of both propellers and subsequent loss of thrust, leading to an aerodynamic stall and collision with terrain.
The following contributing factors were identified:
- High workload due to operating into a new airport with surrounding terrain and the crew missing the associated flight deck and engine indications that both propellers had been feathered;
- Human factor issues such as high workload and stress that appears to have resulted in the misidentification and selection of the propellers to the feathered position;
- The proximity of terrain requiring a tight circuit to land on runway 12. This tight circuit was not the usual visual circuit pattern and contributed to the high workload. This tight pattern also meant that the approach did not meet the stabilized visual approach criteria;
- Use of visual approach circuit for RWY 12 without any evaluation, validation and resolution of its threats which were highlighted by the SRM team of CAAN and advices proposed in flight procedures design report conducted by the consultant and without the development and approval of the chart by the operator and regulator respectively;
- Lack of appropriate technical and skill based training (including simulator) to the crew and proper classroom briefings (for that flight) for the safe operation of flight at new airport for visual approach to runway 12;
- Non-compliance with SOPs, ineffective CRM and lack of sterile cockpit discipline.
Final Report:

Crash of a Cessna 208B Grand Caravan in Mweya

Date & Time: Dec 31, 2022 at 1315 LT
Type of aircraft:
Operator:
Registration:
5X-GBR
Survivors:
Yes
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Mweya Airstrip located in the Queen Elizabeth National Park, the single engine airplane was unable to stop within the remaining distance. It overran and collided with a house. All five occupants escaped uninjured and the aircraft was damaged beyond repair. It just completed a charter flight with three European citizens and two pilots on board.

Crash of a Piper PA-46-350P Jetprop DLX in Goose Bay: 1 killed

Date & Time: Dec 14, 2022 at 1002 LT
Registration:
N5EQ
Flight Type:
Survivors:
Yes
Schedule:
Nashua – Goose Bay – Nuuk
MSN:
46-36051
YOM:
1996
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2260
Captain / Total hours on type:
1046.00
Circumstances:
The single engine airplane departed Nashua Airport, New Hampshire, on December 13 on a flight to Nuuk, Greenland, with an intermediate stop in Goose Bay. Due to poor weather conditions at destination, the pilot diverted to Seven Islands Airport, Quebec, where the couple passed the overnight. On the morning of December 14, the airplane departed Seven Islands Airport at 0820LT bound for Goose Bay. At about 0958LT, the aircraft crossed the final approach fix / final approach waypoint FAFKO at 2,800 feet ASL, travelling at a ground speed of 104 knots, and began the final descent. Although the descent remained steady on a 3° profile, the ground speed decreased continuously for about 60 seconds. At 1000:31, the occurrence pilot reported at waypoint SATAK, and the ground speed had increased to above 80 knots. The tower provided the pilot with updated wind information and cleared the aircraft to land on Runway 08. The pilot acknowledged the clearance at 1000:49. Soon after, the ground speed began to decrease at a rate similar to the previous rate. At 1002:47, it had decreased to 51 knots. The aircraft departed controlled flight and impacted terrain when it was about 2.5 NM southwest of the airport along the extended centreline for Runway 08. The 406 MHz emergency locator transmitter activated, and the signal was received by the Joint Rescue Coordination Centre in Halifax, Nova Scotia, at 1006. A helicopter search and rescue mission was launched from Canadian Forces Base 5 Wing Goose Bay at 1036; the helicopter arrived at the accident site 3 minutes later. Medical technicians extricated the 2 occupants, who were both seriously injured. The occupants were airlifted to a waiting ambulance and then transported to the local hospital. The pilot later died of his injuries. The aircraft was destroyed.
Probable cause:
Given the absence of data for the last minute of the occurrence flight, the investigation could not determine the complete sequence of events that led to the loss of control and collision with terrain.
Final Report:

Crash of a Piper PA-42-1000 Cheyenne 400LS in Lewistown

Date & Time: Dec 13, 2022 at 1006 LT
Type of aircraft:
Operator:
Registration:
C-GZPU
Survivors:
Yes
Schedule:
Great Falls – Lewistown
MSN:
42-5527011
YOM:
1984
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 08 at Lewistown Airport, the twin engine airplane started to skid then veered off runway to the left. While contact a snow covered terrain, it slid for few dozen metres and came to rest with its left wing severely damaged. All three occupants evacuated safely.

Crash of a Learjet 45 in Batesville

Date & Time: Nov 29, 2022 at 1910 LT
Type of aircraft:
Operator:
Registration:
N988MC
Survivors:
Yes
Schedule:
Waterloo – Batesville
MSN:
45-352
YOM:
2007
Flight number:
DHR003
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3910
Captain / Total hours on type:
1560.00
Copilot / Total flying hours:
505
Copilot / Total hours on type:
263
Aircraft flight hours:
2490
Circumstances:
The two pilots were conducting a business flight with six passengers when the accident occurred. During the night arrival the captain flew a visual approach with excessive airspeed
and the airplane crossed the runway threshold more than 50 knots above approach speed (Vref). The before-landing checklist was not completed, and the flaps were at an incorrect 20° position instead of 40°. The airplane touched down near the midfield point of the 6,022 ft non grooved runway, which was wet due to earlier precipitation. The captain initially applied intermittent braking, then applied continuous braking starting about 2,069 ft from the end of the runway. The captain did not deploy the thrust reversers. The airplane exited the runway above 100 knots ground speed, then continued into a ditch and airport perimeter fence, which resulted in substantial damage to the forward fuselage. Examination of the airplane revealed no mechanical anomalies that would have precluded normal operation. The operator’s flight manual directed that all approaches were to be flown using the stabilized approach concept. For a visual approach, this included establishing and maintaining the proper approach speed and correct landing configuration at least 500 ft above the airport elevation. Neither pilot recognized the requirement to execute a go-around due to the excessive approach speed or the long landing on a wet runway, which resulted in the runway excursion.
Probable cause:
The crew’s failure to execute a go-around during the unstable approach and long landing, which resulted in a runway excursion.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Decatur: 1 killed

Date & Time: Nov 18, 2022 at 1510 LT
Registration:
N6797L
Flight Type:
Survivors:
No
Schedule:
Denton – Decatur
MSN:
421C-1050
YOM:
1981
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The twin engine airplane departed Denton Enterprise Airport runway 36 at 1459LT and continued to the west at an altitude of 2,000 feet. Eight minutes later, the pilot initiated a left hand circuit to land at Decatur Airport. While descending on final, the speed decreased and the airplane crashed nearby a wooded area located 6 km short of runway 35. The aircraft was destroyed and the pilot, sole on board, was killed.

Crash of a Swearingen SA227AT Expediter in Waukesha

Date & Time: Nov 15, 2022 at 0900 LT
Operator:
Registration:
N247DH
Flight Type:
Survivors:
Yes
Schedule:
New Orleans – Waukesha
MSN:
AT-626B
YOM:
1985
Flight number:
AMF7141
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The airplane departed New Orleans-Lakefront Airport on a cargo flight to Waukesha, carrying three crew members and a load consisting of 53 dogs in dog crates. On final approach to Waukesha Airport, the crew encountered marginal weather conditions with limited visibility due to snow falls. The airplane crash landed into the third hole on the Western Lakes Golf Course located about 5,5 km short of runway 10 threshold. The airplane slid on its belly for few dozen metres on a snow covered ground before colliding with trees. There was no fire. All three crew members and all 53 dogs were uninjured. Both wings were severely damaged due to the collision with trees.

Crash of a Piper PA-46-500TP Malibu Meridian in North Platte: 2 killed

Date & Time: Nov 9, 2022 at 0934 LT
Registration:
N234PM
Flight Type:
Survivors:
No
Schedule:
Lincoln – North Platte
MSN:
46-97200
YOM:
2005
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
505
Captain / Total hours on type:
24.00
Aircraft flight hours:
649
Circumstances:
The pilot obtained a preflight weather briefing about 2.5 hours before departing on an instrument flight rules (IFR) cross-country flight. Automatic dependent surveillance-broadcast (ADS-B) and weather data indicated the flight encountered low IFR (LIFR) conditions during the approach to the destination airport. These conditions included low ceilings, low visibility, localized areas of freezing precipitation, low-level turbulence and wind shear. The ADS-B data revealed that during the last minute of data, the airplane’s descent rate increased from 500 ft per minute to 3,000 ft per minute. In the last 30 seconds of the flight the airplane entered a 2,000 ft per minute climb followed by a descent that exceeded 5,000 ft per minute. The last data point was located about 1,000 ft from the accident site. There were no witnesses to the accident. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The airplane’s flight instruments and avionics were destroyed during the accident and were unable to be functionally tested. The rapid ascents and descents near the end of the flight track were consistent with a pilot who was experiencing spatial disorientation, which resulted in a loss of control and high-speed impact with terrain. The pilot purchased the airplane about 3 weeks before the accident and received about 15 hours of transition training in the airplane, including 1 hour of actual instrument conditions during high-altitude training. The pilot’s logbook indicated he had 5.2 hours of actual instrument flight time. At the time of the pilot’s weather briefing, the destination airport was reporting marginal visual flight rules (MVFR) conditions with the terminal area forecast (TAF) in agreement, with MVFR conditions expected to prevail through the period of the accident flight. LIFR conditions were reported about 40 minutes before the airplane’s departure and continued to the time of the accident. Light freezing precipitation was reported intermittently before and after the accident, which was not included in the TAF. The destination airport’s automated surface observing system (ASOS) reported LIFR conditions with overcast ceilings at 300 ft above ground level (agl) and light freezing drizzle at the time of the accident. Low-level turbulence and wind shear were detected, which indicated a high probability of a moderate or greater turbulence layer between 3,600 and 5,500 ft mean sea level (msl) in the clouds. During the approach, the airplane was in instrument meteorological conditions with a high probability of encountering moderate and greater turbulence, with above freezing temperatures. The National Weather Service (NWS) had issued conflicting weather information during the accident time period. The pilot’s weather briefing indicated predominately MVFR conditions reported and forecasted by the TAFs along the route of flight, while both the NWS Aviation Weather Center (AWC) AIRMET (G-AIRMET) and the Graphic Forecast for Aviation (GFA) were depicting IFR conditions over the destination airport at the time of the briefing. The TAFs, GAIRMET, and Current Icing Product (CIP)/Forecast Icing Products (FIP) were not indicating any forecast for icing conditions or freezing precipitation surrounding the accident time. The pilot reviewed the TAF in his briefing, expecting MVFR conditions to prevail at his expected time of arrival. The TAF was amended twice between the period of his briefing and the time of the accident to indicate IFR to LIFR conditions with no mention of any potential freezing precipitation or low-level wind shear (LLWS) during the period. Given the pilot’s low actual instrument experience, minimal amount of flight experience in the accident airplane, and the instrument conditions encountered during the approach with a high probability of moderate or greater turbulence, it is likely that the pilot experienced spatial disorientation and lost control of the airplane.
Probable cause:
The pilot’s flight into low instrument flight rules conditions and turbulence, which resulted in spatial disorientation, loss of control, and an impact with terrain. Contributing to the accident was the pilot’s lack of total instrument experience.
Final Report:

Crash of a Beechcraft E90 King Air in Slidell

Date & Time: Nov 6, 2022 at 2145 LT
Type of aircraft:
Operator:
Registration:
N809DM
Flight Type:
Survivors:
Yes
Schedule:
Nashville – Slidell
MSN:
LW-334
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4800
Captain / Total hours on type:
325.00
Aircraft flight hours:
7111
Circumstances:
The pilot flew a visual approach to his home airport but did a go-around due to ground fog. After receiving an instrument flight rules clearance, he flew an RNAV/GPS approach that he also discontinued due to ground fog. After executing a missed approach, the pilot flew another RNAV/GPS approach. The pilot reported that during this last approach he lost visual references and initiated a go-around, during which the airplane impacted trees about 800 ft to the right of the runway. The main wreckage came to rest upright and was consumed by a post-impact fire. The postaccident examination revealed no preimpact anomalies that would have precluded normal operation. The pilot reported that he observed the right engine was slower to accelerate than the left engine during the attempted go-around, and that he was distracted looking at the engine indications. He reported that he did not notice if the airplane yaw to the right and, before he could correct for the altitude loss, the airplane descended into and struck the trees.
Probable cause:
The pilot’s failure to maintain airplane control during an attempted go-around in low visibility conditions.
Final Report:

Crash of an ATR42-500 off Bukoba: 19 killed

Date & Time: Nov 6, 2022 at 0853 LT
Type of aircraft:
Operator:
Registration:
5H-PWF
Survivors:
Yes
Schedule:
Dar es-Salaam – Bukoba
MSN:
819
YOM:
2010
Flight number:
PW494
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
39
Pax fatalities:
Other fatalities:
Total fatalities:
19
Circumstances:
On final approach to Bukoba Airport, the crew encountered poor visibility due to heavy rain falls. In circumstances that need to be clarified, the airplane descended too low, impacted the water surface and crashed into Lake Victoria, about 100 metres short of runway 31. Fishermen with several boats were quickly on the scene and were able to evacuate 24 people. Unfortunately, 19 others including both pilots were killed. The aircraft sank by a depth about 3-4 metres.