Crash of a Cessna S550 Citation S/II in Warroad

Date & Time: Nov 11, 2011 at 2130 LT
Type of aircraft:
Registration:
N600KM
Survivors:
Yes
MSN:
S550-0008
YOM:
1984
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After a night landing on runway 13 at Warroad Airport, the aircraft collided with a White-tailed deer. The crew was able to stop the aircraft that suffered structural damages to the left wing. There were no injuries but the aircraft was damaged beyond repair.
Probable cause:
No investigation was conducted by NTSB.

Crash of a Fokker 50 in Guriceel

Date & Time: Nov 10, 2011
Type of aircraft:
Operator:
Registration:
5Y-VVK
Flight Type:
Survivors:
Yes
Schedule:
Nairobi – Guriceel
MSN:
20213
YOM:
1991
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Nairobi-Wilson Airport on a cargo flight to Guriceel, Somalia, carrying three crew members and a load of khat. After landing, the airplane encountered difficulties to decelerate properly and was unable to stop within the remaining distance. It overran, contacted rough terrain, lost its nose and left main gear before coming to rest. There was no fire. All three occupants escaped uninjured and the aircraft was damaged beyond repair.

Crash of a Socata TBM-700 in Lyon: 1 killed

Date & Time: Nov 9, 2011 at 0912 LT
Type of aircraft:
Operator:
Registration:
N228CX
Flight Type:
Survivors:
No
Schedule:
Toussus-le-Noble - Lyon
MSN:
84
YOM:
1993
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2000
Circumstances:
The pilot departed Toussus-le-Noble Airport at 0810LT on an IFR flight to Lyon. After contacting ATC, the pilot was vectored for a LOC DME approach to runway 16 at Lyon-Bron Airport. He reported being established on localizer at 0907LT, then was transferred to the tower and was cleared to land. At 0910LT, he reported he was initiating a go-around procedure and was instructed to climb to 3,000 feet maintaining a straight-in path. ATC requested twice the pilot to confirm the approach interruption but he failed to respond. A few moments later, the pilot reported 'Now, I'm not good at all'. The airplane crashed in a retention basin located 1,500 meters short of runway 16 threshold, bursting into flames. The aircraft was destroyed and the pilot, sole on board, was killed.
Probable cause:
Loss of control while approaching at a speed close to stall speed in clouds without any external visual references, in a phase of flight where the pilot encountered difficulties. Investigations were unable to determine the exact cause of the loss of control and the reason why the pilot was unable to regain control.
Final Report:

Crash of a Boeing 767-35DER in Warsaw

Date & Time: Nov 1, 2011 at 1439 LT
Type of aircraft:
Operator:
Registration:
SP-LPC
Survivors:
Yes
Schedule:
Newark - Warsaw
MSN:
28656/659
YOM:
1997
Flight number:
LOT016
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
221
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15980
Captain / Total hours on type:
13307.00
Copilot / Total flying hours:
9431
Copilot / Total hours on type:
1981
Aircraft flight hours:
85429
Aircraft flight cycles:
8002
Circumstances:
On November 1, 2011 a passenger LO 16 flight of B767-300ER airplane, registration marks SP-LPC, was scheduled from KEWR to EPWA. The Pre-Departure Check of the airplane was carried out by a ground engineer from a contracted service organization in accordance with Operator’s requirements. The ground engineer was responsible for conducting PRE-DEPARTURE CHECK and ETOPS CHECK. The above procedures did not include cockpit check. The ground engineer did not find any failures or irregularities and did not notice anything unusual. The flight crew arrived at Newark Liberty Airport at a time specified by Operator and in accordance with its operating procedures. When commencing the flight duty period the crew members were rested, refreshed, in a good psychophysical condition. They did not report overload by air operations. Upon arrival at the aircraft stand each flight crew member performed his duties as provided for in the operating procedures of the airline. CPT conducted Exterior Walk Around while FO conducted cockpit check. FO checked on-board equipment and the cockpit preparation for the flight. According to the flight crew statement no failures or irregularities were found. The crew deemed the airplane fully operational for the flight to Warsaw. The ground engineer from the contracted maintenance organization was not present in the cockpit during the flight crew preparation. During the flight CPT was PF and FO was PM. At 03:58:11 hrs the crew started the engines. The take-off took place at 04:19:08 hrs. After the take-off, during the retraction of landing gear and flaps the hydraulic fluid from the center hydraulic system (C system) flew out, which consequently led to pressure drop in this system. The pressure drop in the C system was signaled on the hydraulic panel – SYS PRESS and on EICAS - C HYD SYS PRESS and recorded by on-board flight data recorders. After completion HYDRAULIC SYSTEM PRESSURE (C only) procedure contained in QRH and consultation with the Operator's MCC, the flight crew decided to continue the flight to Warsaw. The flight proceeded without significant distortions. Landing in Warsaw was to be carried out with the alternate landing gear extension system. This situation was well known to pilots due to numerous exercises carried out in a flight simulator. Taking advantage of the available time, the CPT and FO developed a plan for landing in accordance with the procedure contained in QRH and discussed an anticipated sequence of events. At 12:17 hrs, during approach to landing on EPWA aerodrome the flight crew performed the procedure of the lading gear extension using the alternate landing gear extension system. However, after the anticipated time the landing gear was not extended. The crew checked the correctness of execution of the procedure against QRH and again attempted to extend the landing gear. After failure of the second attempt to extend the landing gear with the alternate system the approach to landing was abandoned. At 12:22 hrs the crew reported to ATC inability to extend the landing gear and requested the Operator’s MCC assistance. Around 12:25 hrs the flight crew declared EMERGENCY. The airplane was directed to a holding zone. The Operator’s Operations Centre enabled the crew to communicate with experts. FO executed expert recommendations and checked the alternate landing gear extension switch and circuit breakers on P-11 and P6-1 panels. After that FO reported to Operations Centre and to CPT that the circuit breakers had been checked. FO also cycled (pulled and reset) the ALT EXT MOTOR circuit breaker as indicated by an expert. However, the landing gear was not extended. In the meantime pilots of two F-16s of the Polish Air Force inspected SP-LPC from the air and informed the crew that the landing gear was still in the retracted position but the tail skid was extended. After that information the crew attempted to extend the landing gear in a gravitational way, but it also ended in failure. After a series of unsuccessful attempts to extend the landing gear and due to low fuel quantity, the crew decided to carry out an emergency gear up landing. CC1 was instructed by Captain to prepare the cabin and passengers for emergency landing. During the preparation the passengers were calm, they carried out the crew instructions, there was no panic. Prior to the landing firefighters distributed foam over RWY 33 at a distance of about 3000 m. External services arrived at the airport (PSP and emergency ambulances). The plane touched down on RWY 33 of EPWA aerodrome (Figure 7) at 13:39 hrs. At the time of touchdown about 1600 kg of fuel (1939 liters at a density of 0.825 kg/l) was in its tanks, the engines were running and their recorded speeds were N1ACTL = 57%, N1ACTR = 38%. The plane was moving on RWY 33 along its centre line and stopped 42 m after the intersection with RWY 29. When the aircraft was moving, sparks were coming out of the right engine, and they were suppressed by the applied foam; then the engine caught fire. When the airplane came to rest, the crew evacuated the passengers and LSP extinguished the fire. During the evacuation none of the passengers or crew suffered any injuries. During the landing the aircraft sustained substantial damage, which caused its withdrawal from service.
Probable cause:
Causes of the accident:
1. Failure of the hydraulic hose connecting the hydraulic system on the right leg of the main landing gear with the center hydraulic system, which initiated the occurrence.
2. Open C829 BAT BUS DISTR circuit breaker in the power supply circuit of the alternate landing gear extension system in the situation when the center hydraulic system was inoperative.
3. The crew’s failure to detect the open C829 circuit breaker during approach to landing, after detecting that the landing gear could not be extended with the alternate system.
Factors contributing to the occurrence were as follow:
1. Lack of guards protecting the circuit breakers on P6-1 panel against inadvertent mechanical opening; from 863 production line the guards have been mounted in the manufacturing process (SP-LPC was 659 production line).
2. C829 location on panel P6-1 (extremely low position), impeding observation of its setting and favoring its inadvertent mechanical opening.
3. Lack of effective procedures at the Operator’s Operations Centre, which impeded specialist support for the crew.
4. Operator’s failure to incorporate Service Bulletin 767-32-0162.
Final Report:

Crash of a Gulfstream G150 in Key West

Date & Time: Oct 31, 2011 at 1942 LT
Type of aircraft:
Operator:
Registration:
N480JJ
Flight Type:
Survivors:
Yes
Schedule:
Stuart - Key West
MSN:
241
YOM:
2007
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11000
Captain / Total hours on type:
290.00
Copilot / Total flying hours:
13800
Copilot / Total hours on type:
75
Aircraft flight hours:
1190
Circumstances:
The airplane was approaching the destination airport in night visual meteorological conditions. After losing sight of the runway once and going around, they continued the approach, even though the pilot in command (PIC) stated that he thought they were going to land long. The PIC stated that the main landing gear touched down near the 1,000-foot marker of the 4,801-foot-long runway, about the landing reference speed (Vref) of 120 knots. The PIC stated that he then applied the brakes but thought they were not working; he had not yet activated the thrust reversers. He alerted the second in command (SIC), who also depressed the brake pedals with no apparent results. The PIC suggested a go-around, but the SIC responded that it was too late. The airplane subsequently traveled off the end of the runway, struck a gravel berm, and came to rest about 816 feet beyond the end of the runway. During the impact, one of the passenger seats dislodged from its seat track and was found on the cabin floor, with the passenger still in it. Review of cockpit voice recorder, video, and performance data revealed that the main landing gear touched down at Vref and about 1,650 feet beyond the approach end of the runway. The nosegear then touched down 2.4 seconds later and about 2,120 feet beyond the approach end of the runway, with about 2,680 feet of runway remaining. Digital electronic engine control data revealed that about 8 seconds after weight-on-wheels, the power levers were advanced from the idle position to the takeoff position. The power levers were then returned to the idle position 6 seconds later. The power levers were moved to the reverse thrust position 8 seconds after that and remained in that position for the duration of the accident sequence; both thrust reversers deployed when commanded. Examination and testing of the airplane systems did not reveal any evidence of preimpact mechanical malfunctions with the wheels brakes or any other systems. Although armed, the airbrakes did not deploy upon touchdown; the data available was inconclusive to determine what position the throttles were in at touchdown and why the airbrakes did not deploy. It is likely that the pilots did not detect the wheel braking because its effect was less than expected with the airplane at full power and with the airbrakes stowed. Landing distance data revealed that the airplane required about 2,551 feet to stop at its given weight in the given weather conditions. With a runway distance of 2,680 feet remaining, the airplane could have stopped or gone around uneventfully with appropriate use of all deceleration devices. The landing procedure stated to activate the thrust reversers after nosewheel touchdown and then apply the brakes, as necessary; however, the PIC only applied the brakes. Further, no callouts were made to verify ground spoiler or reverse thrust deployment. The PIC then stated that he was going to go around, but the SIC said it was too late, so the thrust levers were brought back to idle and the reversers were deployed. The PIC's delayed decision to stop or go around resulted in about a 22-second delay in thrust reverser activation, which resulted in the runway overrun. Additionally, the procedure for a (perceived) failed brake system would have been to activate the emergency brake, which neither pilot did. Examination of the seats revealed that a forward-facing seat was installed in the aft-facing position and an aft-facing seat was installed in the forward-facing position. Additionally, the ejected seat's shear plungers were found in the raised position. Had the seat been installed correctly, the plungers would have been in the lowered position, in the seat track. The improper installation most likely resulted in the passenger’s seat separating from the seat track and exacerbating his injuries.
Probable cause:
The pilot in command's failure to follow the normal landing procedures (placing engines into reverse thrust first and then brake), his delayed decision to continue the landing or go-around, and the flight crew's failure to follow emergency procedures once a perceived loss of brakes occurred. Contributing to the seriousness of the passenger's injury was the improper securing of the passenger seat by maintenance personnel.
Final Report:

Crash of a PZL-Mielec AN-28 in Shabunda

Date & Time: Oct 31, 2011
Type of aircraft:
Operator:
Registration:
9Q-CSX
Survivors:
Yes
MSN:
1AJ003-12
YOM:
1987
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Shabunda Airport, the crew reported engine problems and elected to return. After touchdown, the twin engine airplane was unable to stop within the remaining distance, overran and came to rest against an embankment. All 16 passengers escaped unhurt while both pilots were injured. The aircraft was damaged beyond repair. The exact date of the mishap remains unknown, somewhere during October 2011.

Crash of a Piper PA-31T Cheyenne II in Toulouse: 4 killed

Date & Time: Oct 28, 2011 at 2135 LT
Type of aircraft:
Registration:
OE-FKG
Flight Type:
Survivors:
No
Schedule:
Kassel-Calden - Toulouse
MSN:
31-8020036
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1145
Captain / Total hours on type:
217.00
Aircraft flight hours:
7300
Aircraft flight cycles:
5434
Circumstances:
The pilot, accompanied by three passengers who were family members, took off at 1835LT from Kassel-Calden Airport (Germany) for a private flight under IFR to Toulouse-Blagnac. After about three hours of flight, he was cleared for approach and received radar vectoring for the runway 14R ILS. During the last exchange with the controller, as the aeroplane was on final at 900 feet, the pilot stated that he had a problem without specifying what type, as the message was interrupted. Shortly afterwards, radar and radio contact was lost. The wreckage was found close to the threshold of runway 14R. Two passengers were rescued while the pilot and another passenger were killed. The occupants were four members of the same family : the parents and two children, a boy aged nine and a girl aged 13. While the parents were killed upon impact, the daughter died from her injuries a day later and the boy died three days later.
Probable cause:
Causes of the Accident:
It is likely that during the final approach, a right engine anomaly, detected by the pilot, led to power asymmetry. As a result of a high workload, during the phase of deceleration and gear and flap extension, the pilot likely did not monitor the indicated airspeed, or noted a decrease in it. He may then have encountered difficulties in managing the power asymmetry before losing control of the aeroplane.
The following factors may have contributed to the accident:
- continuation of a fast arrival in a cloud layer, at night to a height of about 1,000 feet before configuring the aeroplane to land, which resulted in a significant increase in the pilot’s workload during processing of the anomaly;
- probable fascination with the objective given the proximity of the runway and the attraction induced by the approach lights;
- degraded type rating training to adapt to the pilot’s constraints during its renewal;
- absence of specific exercises relating to the conduct of a single engine approach at a speed close to VMCA, in the type rating training for single pilot multi-engine high performance aeroplanes.
Final Report:

Crash of a Beechcraft A100 King Air in Vancouver: 2 killed

Date & Time: Oct 27, 2011 at 1612 LT
Type of aircraft:
Operator:
Registration:
C-GXRX
Survivors:
Yes
Schedule:
Vancouver - Kelowna
MSN:
B-36
YOM:
1970
Flight number:
NTA204
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
13876
Captain / Total hours on type:
978.00
Copilot / Total flying hours:
1316
Copilot / Total hours on type:
85
Aircraft flight hours:
26993
Circumstances:
The Northern Thunderbird Air Incorporated Beechcraft King Air 100 (serial number B-36, registration C‑GXRX) departed Vancouver International Airport for Kelowna, British Columbia, with 7 passengers and 2 pilots on board. About 15 minutes after take-off, the flight diverted back to Vancouver because of an oil leak. No emergency was declared. At 1611 Pacific Daylight Time, when the aircraft was about 300 feet above ground level and about 0.5 statute miles from the runway, it suddenly banked left and pitched nose-down. The aircraft collided with the ground and caught fire before coming to rest on a roadway just outside of the airport fence. Passersby helped to evacuate 6 passengers; fire and rescue personnel rescued the remaining passenger and the pilots. The aircraft was destroyed, and all of the passengers were seriously injured. Both pilots succumbed to their injuries in hospital. The aircraft’s emergency locator transmitter had been removed.
Probable cause:
Findings as to causes and contributing factors:
During routine aircraft maintenance, it is likely that the left-engine oil-reservoir cap was left unsecured.
There was no complete preflight inspection of the aircraft, resulting in the unsecured engine oil-reservoir cap not being detected, and the left engine venting significant oil during operation.
A non-mandatory modification, designed to limit oil loss when the engine oil cap is left unsecure, had not been made to the engines.
Oil that leaked from the left engine while the aircraft was repositioned was pointed out to the crew, who did not determine its source before the flight departure.
On final approach, the aircraft slowed to below VREF speed. When power was applied, likely only to the right engine, the aircraft speed was below that required to maintain directional control, and it yawed and rolled left, and pitched down.
A partially effective recovery was likely initiated by reducing the right engine’s power; however, there was insufficient altitude to complete the recovery, and the aircraft collided with the ground.
Impact damage compromised the fuel system. Ignition sources resulting from metal friction, and possibly from the aircraft’s electrical system, started fires.
The damaged electrical system remained powered by the battery, resulting in arcing that may have ignited fires, including in the cockpit area.
Impact-related injuries sustained by the pilots and most of the passengers limited their ability to extricate themselves from the aircraft.
Findings as to risk:
Multi-engine−aircraft flight manuals and training programs do not include cautions and minimum control speeds for use of asymmetrical thrust in situations when an engine is at low power or the propeller is not feathered. There is a risk that pilots will not anticipate aircraft behavior when using asymmetrical thrust near or below unpublished critical speeds, and will lose control of the aircraft.
The company’s standard operating procedures lacked clear directions for how the aircraft was to be configured for the last 500 feet, or what to do if an approach is still unstable when 500 feet is reached, specifically in an abnormal situation. There is a demonstrated risk of accidents occurring as a result of unstabilized approaches below 500 feet above ground level.
Without isolation of the aircraft batteries following aircraft damage, there is a risk that an energized battery may ignite fires by electrical arcing.
Erroneous data used for weight-and-balance calculations can cause crews to inadvertently fly aircraft outside of the allowable center-of-gravity envelope.
Final Report:

Crash of an Antonov AN-26 at Al Anad AFB: 4 killed

Date & Time: Oct 25, 2011
Type of aircraft:
Operator:
Flight Type:
Survivors:
Yes
Schedule:
Sanaa – Al Anad
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The aircraft departed Sanaa Airport on a flight to Al Anad AFB (Kadamat Al Awdhali), carrying 11 passengers and four crew members, among them 8 Syrian engineers and 7 Yemen citizens. The aircraft crashed upon landing under unknown circumstances. Three Syrian and one Yemen citizen were killed.

Crash of a Cessna 401A near Nairobi: 2 killed

Date & Time: Oct 21, 2011 at 1523 LT
Type of aircraft:
Registration:
5Y-CAE
Survivors:
Yes
Schedule:
Nairobi - Marsabit - Lodwar - Nairobi
MSN:
401-0011
YOM:
1967
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The twin engine aircraft departed Nairobi-Wilson Airport in the morning for a flight to Marsabit and Lodwar, carrying exam documents. While returning to Wilson Airport in the afternoon, the airplane went out of control and crashed in an open field located about 15 km west of Wilson Airport. The pilot and a passenger were killed while the second passenger was seriously injured. The aircraft was destroyed.