Crash of a Piper PA-31-310 Navajo in Bogotá: 4 killed

Date & Time: Feb 12, 2020 at 1544 LT
Type of aircraft:
Operator:
Registration:
HK-4686
Flight Phase:
Survivors:
No
Schedule:
Bogotá – Villagarzón
MSN:
31-344
YOM:
1968
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1890
Captain / Total hours on type:
250.00
Copilot / Total flying hours:
646
Aircraft flight hours:
10251
Circumstances:
Shortly after takeoff from Bogotá-Guaymaral Airport, while in initial climb, the crew informed ATC about the failure of the right engine. He was cleared to return for an emergency and completed a circuit to land on ruwnay 11. On final, the airplane lost height and crashed in a wooded area located about 800 metres short of runway, bursting into flames. The aircraft was destroyed by a post crash fire and all four occupants were killed.
Probable cause:
The investigation determined that the accident was caused by the following probable cause(s):
- Loss of in-flight control as a result of slowing below Minimum Control Speed and drag, generated by the failure of the right engine (No. 2).
- Failure of engine No. 2, due to lack of lubrication, possibly caused by oil leakage through an 11.5 mm fracture, found in one of the sides of cylinder No. 2 at the height of the intake valves.
- Inappropriate application by the crew of the emergency procedure for landing with an inoperative engine, by not declaring the emergency, not feathering the propeller of the inoperative engine and configuring the aircraft early for landing (with landing gear and flaps) without having a safe runway, making it difficult to control the aircraft and placing it in a condition of loss of lift and control.

Contributing Factors:
- Failure of the operator to emphasize in the crew training program the techniques and procedures to be followed in the event of engine failure, among others, the declaration of emergency to ATC, the flagging of the propeller of the inoperative engine, the care in the application of power to the good engine so as not to increase yaw and not to configure the aircraft until landing has been assured.
- Lack of emergency calls by the crew, which denotes deficiencies in the Operator's Safety Management System, and which prevented the early warning of the aerodrome support services and deprived the crew of possible assistance from other aircraft or from the same operator.
Final Report:

Crash of a Stinson V-77 Reliant in Auburn: 2 killed

Date & Time: Jan 24, 2020 at 0956 LT
Type of aircraft:
Registration:
N50249
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Auburn - Auburn
MSN:
77-458
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
650
Circumstances:
The pilot departed on a local flight with two passengers. Several witnesses reported that they heard the airplane’s engine backfiring and sputtering and subsequently heard the engine quit. The surviving passenger, who was seated in the front right seat, stated that the engine lost power and there was nowhere to land. The airplane subsequently impacted heavily wooded terrain about 1 mile from the departure airport. Postaccident examination of the engine revealed that the No. 7 cylinder intake valve was stuck open. The No. 2 cylinder front spark plug was defective, and the Nos. 2- and 4-cylinders’ ignition wires were frayed, worn, and displayed arcing, which likely led to erratic operation or a lack of ignition in these two cylinders. The culmination of these issues most likely led to the engine running rough, backfiring, and subsequently losing total power. An annual inspection was accomplished on the airframe and engine about 2 months before the
accident. General maintenance practices and the inspection should have identified the anomalies that were found during the postaccident engine examination.
Probable cause:
A total loss of engine power due to a combination of mechanical engine anomalies. Contributing to the accident was inadequate maintenance that failed to identify the engine anomalies.
Final Report:

Crash of a Beechcraft B200 King Air off Dutch Harbor

Date & Time: Jan 16, 2020 at 0806 LT
Operator:
Registration:
N547LM
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Dutch Harbor - Adak
MSN:
BB-1642
YOM:
1998
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6470
Captain / Total hours on type:
756.00
Aircraft flight hours:
7058
Circumstances:
According to the pilot, when the airplane’s airspeed reached about 90 knots during the takeoff roll, he applied back pressure to the control yoke to initiate the takeoff and noted a brief positive rate of climb followed by a sinking sensation. The airspeed rapidly decayed, and the stall warning horn sounded. To correct for the decaying airspeed, he lowered the nose then pulled back on the airplane’s control yoke and leveled the wings just before impacting the ocean. The pilot stated there were no pre accident mechanical malfunctions or anomalies that would have precluded normal operation. Wind about the time of the accident was recorded as 110º downwind of the airplane at 15 knots gusting to 28 knots. The passengers recalled that the pilot’s preflight briefing mentioned the downwind takeoff but included no discussion of the potential effect of the wind conditions on the takeoff. The airplane’s estimated gross weight at the time of the accident was about 769.6 pounds over its approved maximum gross weight, and the airplane’s estimated center of gravity was about 8.24 inches beyond the approved aft limit at its maximum gross weight. It is likely that the pilot’s decision to takeoff downwind and operate the airplane over the maximum gross weight with an aft center of gravity led to the aerodynamic stall during takeoff and loss of control. Downwind takeoffs result in higher groundspeeds and increase takeoff distance. While excessive aircraft weight increases the takeoff distance and stability, and an aft center of gravity decreases controllability. Several instances of the operator’s noncompliance with its operational procedures and risk mitigations were discovered during the investigation, including two overweight flights, inaccurate and missing information on aircraft flight logs, and the accident pilot’s failure to complete a flight risk assessment for the accident flight. The operator had a safety management system (SMS) in place at the time of the accident that required active monitoring of its systems and processes to ensure compliance with internal and external requirements. However, the discrepancies noted with several flights, including the accident flight, indicate that the operator’s SMS program was inadequate to actively monitor, identify, and mitigate hazards and deficiencies.
Probable cause:
The pilot’s improper decision to takeoff downwind and to load the airplane beyond its allowable gross weight and center of gravity limits, which resulted in an aerodynamic stall and loss of control. Contributing to the accident was the inadequacy of the operator’s safety management system to actively monitor, identify, and mitigate hazards and deficiencies.
Final Report:

Crash of a Boeing 737-8KV in Sabashahr: 176 killed

Date & Time: Jan 8, 2020 at 0618 LT
Type of aircraft:
Operator:
Registration:
UR-PSR
Flight Phase:
Survivors:
No
Schedule:
Tehran - Kiev
MSN:
38124
YOM:
2016
Flight number:
PS752
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
167
Pax fatalities:
Other fatalities:
Total fatalities:
176
Captain / Total flying hours:
11590
Captain / Total hours on type:
8428.00
Copilot / Total flying hours:
7633
Copilot / Total hours on type:
3642
Circumstances:
On Wednesday, January 08, 2020, at 00:53, the inbound flight No. 751 of Ukraine International, Boeing 737-800, UR-PSR, en route to Tehran Imam Khomeini INTL. Airport from Kyiv Boryspyl INTL. Airport was cleared for landing, and after four minutes landed on the IKA runway. After disembarking 58 passengers and refueling, the flight crew went on to check into the hotel located at IKA. From 01:16 to 01:38, the aircraft was refueled with 9510 kg (11800 liters) of fuel. Once the total weight of the cargo received from passengers (310 packages weighing 6794 kg) was determined, in order to comply with the maximum takeoff weight allowed for aircraft, 82 packages in 2094 kg in weight, were separated by Airport Service Company, that is, they were not loaded. Initially, 78 packages of the passenger's luggage were not loaded first, then due to the large volume of passengers' hand luggage, the flight attendants passed some of them on to the Airport Service Company personnel to be placed in the aircraft cargo. After that, 4 packages belonging to the passengers were removed from the aft cargo door, where the hand luggage was placed. At 04:35, the flight crew embarked on the aircraft. After checking the aircraft and cabin, boarding was announced at 04:45, and passengers started to board the plane. Based on the available documents, 167 passengers proceeded to the Airport Services Co. counter at the airport terminal, all of whom went on board. Only one of the passengers who received the boarding pass online the night before the flight, due to the delay in arriving in Tehran from another city did not go to the airport in person, and therefore had been removed from the list of passengers provided by the UIA. At 05:13, the pilot made his first radio contact with the IKA's control tower ground unit and requested the initial clearance for flying, which was issued by the controller subsequently. At 05:48, all the aircraft documents required to start the flight operations were filled out, and all the doors were then closed at 05:49. The flight was initially scheduled for 05:15, and based on the flight coordinator's report form, the reason given for its delay was the aircraft being overweight and the decision not to load the passengers' lugga for reducing the aircraft weight. At 05:51 the pilot notified his position at the airport parking, declared his readiness to exit the parking and start up the aircraft. The IKA tower asked him to wait for receiving the clearance since they wanted to make the coordination required with other relevant units. At 05:52, the IKA tower made the necessary coordination with the Mehrabad approach unit, who contacted Tehran ACC asking for clearance. Accordingly, the controller in ACC made coordination on Ukrainian flight clearance with the CMOCC. The clearance was issued by the CMOCC. At 05:54, the Mehrabad approach unit, received the FL260 clearance for the flight AUI752 from ACC, and forwarded it to IKA via the telecommunication system. Flight no. 752 was detached from the A1 Jet Bridge and at about 05:55 started to leave its parking position, NO 116 on the right, by a pushback truck. Following that, at 05:55 the ground controller cleared the AUI752 flight for startup and exiting the parking, which was read back by the pilot. At 06:12, the aircraft took off from the Runway 29 Right of IKA and was delivered to the Mehrabad approach unit. The pilot contacted the approach unit, and announced the IKA 1A radar procedure as SID procedure. Next, the Mehrabad approach identified and cleared the flight to climb to FL260. The controller instructed the pilot to turn to the right after 6,000 feet, and continue straight to PAROT. After it was read back by the pilot, the controller again instructed the pilot to continue to PAROT point once passing the 6000-foot altitude, which was read back by the pilot. From 06:17 onwards, upon the disappearance of the PS752 information from the radarscope, the controller called the captain repeatedly, but received no response. According to the data extracted from the surveillance systems and FDR, the aircraft climbed to an altitude of 8,100 feet; thereafter, the label including the call sign and altitude of aircraft disappeared from the radarscope, yet no radio contact indicating unusual conditions was received from the pilot. FDR recording terminated at 06:14:56. This time corresponds to the termination of Secondary Surveillance Radar (SSR) and ADS-B information. After the mentioned time, the aircraft was still being detected by the Primary Surveillance Radar (PSR), according to which the aircraft veered right and after approximately three minutes of flying, it disappeared from the PSR at 06:18 too. The aircraft was conducting the flight under the Instrument Flight Rules (IFR) and the accident occurred around half an hour before the sunset.
Probable cause:
Cause of the Accident:
- The air defense's launching two surface-to-air missiles at the flight PS752, UR-PSR aircraft the detonation of the first missile warhead in proximity of the aircraft caused damage to the aircraft systems and the intensification of damage led the aircraft to crash into the ground and explode instantly.

Other Contributing Factors:
- The mitigating measures and defense layers in risk management proved to be ineffective due to the occurrence of an unanticipated error in threat identifications, and ultimately failed to protect the flight safety against the threats caused by the alertness of defense forces.
Final Report:

Crash of an Antonov AN-12A in Geneina: 18 killed

Date & Time: Jan 2, 2020
Type of aircraft:
Operator:
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Geneina - Khartoum
MSN:
2340606
YOM:
1962
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
18
Circumstances:
Shortly after takeoff from Geneina Airport, the four engine aircraft went out of control and crashed in flames about 5 km from the airport. The aircraft was destroyed by impact forces and a post crash fire and all 18 occupants were killed, among them three children. The aircraft was returning to Khartoum after delivering medical aid.

Crash of a Piper PA-31T Cheyenne II in Lafayette: 5 killed

Date & Time: Dec 28, 2019 at 0921 LT
Type of aircraft:
Registration:
N42CV
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Lafayette - Atlanta
MSN:
31T-8020067
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
1531
Captain / Total hours on type:
730.00
Aircraft flight hours:
5954
Circumstances:
The personal flight departed from Lafayette Regional Airport/Paul Fournet Field (LFT), Lafayette, Louisiana, and entered the clouds when the airplane was at an altitude of about 200 ft above ground level. Before takeoff, the controller issued an instrument flight rules clearance to the pilot, instructing him to turn right onto a heading of 240° and climb to and maintain an altitude of 2,000 ft mean sea level (msl) after takeoff. Automatic dependent surveillance-broadcast (ADS-B) data for the accident flight started at 0920:05, and aircraft performance calculations showed that the airplane was climbing through an altitude of 150 ft msl at that time. The calculations also showed that the airplane then turned slightly to the right toward the assigned heading of 240° and climbed at a rate that varied between 1,000 and 2,400 ft per minute and an airspeed that increased from about 151 to 165 knots. At 0920:13, the airplane started rolling back toward wings level and, 7 seconds later, rolled through wings level and toward the left. At that time, the airplane was tracking 232° at an altitude of 474 ft and an airspeed of 165 knots. The airplane’s airspeed remained at 165 knots for about 10 seconds before it started increasing again, and the airplane continued to roll steadily to the left at an average roll rate of about 2° per second. The aircraft performance calculations further showed that, at 0920:40, the airplane reached a peak altitude of 925 ft msl. At that time, the airplane was tracking 200°, its bank angle was about 35° to the left, and its airspeed was about 169 knots. The airplane then started to descend while the left roll continued. At 0920:55, the airplane reached a peak airspeed of about 197 knots, which then started decreasing. At 0920:57, the airplane descended through 320 ft at a rate of descent of about 2,500 ft per minute and reached a bank angle of 75° to the left. At 0920:58, the controller issued a low altitude alert, stating that the pilot should “check [the airplane’s] altitude immediately” because the airplane appeared to be at an altitude of 300 ft msl. The pilot did not respond, and no mayday or emergency transmission was received from the airplane. The last ADS-B data point was recorded at 0920:59; aircraft performance calculations showed that, at that time, the airplane was descending through an altitude of 230 ft msl at a flightpath angle of about -7°, an airspeed of 176 knots, and a rate of descent of about 2,300 ft per minute. (The flightpath angle is in the vertical plane—that is, relative to the ground. The ground track, as discussed previously, is in the horizontal plane—that is, relative to north.) The airplane struck trees and power lines before striking the ground, traveled across a parking lot, and struck a car. The car rolled several times and came to rest inverted at the edge of the parking lot, and a postcrash fire ensued. The airplane continued to travel, shedding parts before coming to rest at the far end of an adjacent field. At the accident site, the surviving passenger told a local police officer that “the plane went straight up and then straight down.”
Probable cause:
The pilot’s loss of airplane control due to spatial disorientation during the initial climb in instrument meteorological conditions.
Final Report:

Crash of a Fokker 100 in Almaty: 12 killed

Date & Time: Dec 27, 2019 at 0721 LT
Type of aircraft:
Operator:
Registration:
UP-F1007
Flight Phase:
Survivors:
Yes
Schedule:
Almaty – Nursultan
MSN:
11496
YOM:
1996
Flight number:
Z92100
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
93
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
20141
Captain / Total hours on type:
3956.00
Copilot / Total flying hours:
11544
Copilot / Total hours on type:
4144
Aircraft flight hours:
44632
Aircraft flight cycles:
52771
Circumstances:
The Fokker 100 departed Almaty Airport on a regular schedule service (flight Z92100) to Astana-Nursultan Nazarbayev Airport, carrying 93 passengers and a crew of five. During the takeoff roll on runway 05R with flaps at zero, after a course of 36 seconds and at a speed of 148 knots, the crew started the rotation. Immediately after liftoff, the airplane rolled to the right at an angle of 5° then to the left at an angle of 19° without an increase of the indicated airspeed. After reaching the height of 20 feet in a pitch angle of 14°, the airplane started to descend then hit the runway surface with the base of the tail. It landed on its main landing gear and rolled for about 15 seconds with the nose gear still in the air. The airplane took off again at a speed of 138 knots then the crew retracted the landing gear. In a pitch angle of 19°, the airplane lost speed (130 knots), veered to the right, belly landed and slid for about 850 metres, went through a fence and eventually crashed into a house located near the perimeter fence, some 80 metres to the right of the extended center line. 47 occupants were injured, 39 escaped unhurt and 12 others were killed, among them the captain. The aircraft was destroyed. There was not fire.
Probable cause:
The accident was the consequence of an asymmetrical loss of wing lift properties at the stage of takeoff, which resulted in the aircraft crashing down immediately after leaving the runway and rolling to the right on the snowy ground, breaching the airport perimeter fence and colliding with a two-story private building located 9-10 m from the fence. As a result of collision, 11 passengers and one crew member died and 47 passengers received different injuries because of overloading, striking, destruction and crushing of the aircraft structure. The cause of the loss of wing lift properties was most likely the effect of ground icing.
Contributing factors:
- The crew, after analyzing the actual meteorological situation at Almaty airport, may not have drawn sufficient conclusions to better inspect the entire aircraft and especially (tactile method) the leading edge of the wing;
- The Flight Safety Management System (FMS) of Beck Air JSC contains mainly only general provisions and specific actions that were not adapted for implementation, which did not allow timely identification and elimination of existing risks affecting flight safety.
- Collision of the aircraft with a two-storey private structure, which affected the severity of the consequences.
Final Report:

Crash of an Angel Aircraft Corporation Model 44 Angel in Mareeba: 2 killed

Date & Time: Dec 14, 2019 at 1115 LT
Registration:
VH-IAZ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mareeba - Mareeba
MSN:
004
YOM:
2008
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
20000
Captain / Total hours on type:
300.00
Copilot / Total flying hours:
5029
Copilot / Total hours on type:
0
Aircraft flight hours:
1803
Circumstances:
On 14 December 2019, at 1046 Eastern Standard Time, an Angel Aircraft Corporation Model 44 aircraft, registered VH-IAZ, commenced taxiing at Mareeba Airport, Queensland. On board the aircraft were two pilots. The pilot in the left seat (‘the pilot’) owned the aircraft and was undertaking a flight review, which was being conducted by the Grade 1 flight instructor in the right seat (‘the instructor’). The planned flight was to operate in the local area, as a private flight and under visual flight rules. As the aircraft taxied towards the runway intersection, the pilot broadcast on the common traffic advisory frequency (CTAF) that VH-IAZ was taxiing for runway 28. The pilot made another broadcast when entering and backtracking the runway, then at 1058, broadcast that the aircraft had commenced the take-off roll. Witnesses who heard the aircraft during the take-off reported that it sounded like one of the engines was hesitating and misfiring. An aircraft maintainer who observed the aircraft take off, reported seeing black sooty smoke trailing from the right engine. The maintainer then watched the aircraft climb slowly and turn right towards the north. Another witness who heard the aircraft in flight soon afterwards, reported that it sounded normal for that aircraft, which had a distinctive sound because the engines’ exhaust gases pass through the propellers. Once airborne, the pilot broadcast that they were ‘making a low-level right-hand turn and then climbing up to not above 4,500 [feet] for the south-west training area.’ About 2 minutes later, the instructor broadcast that they were just to the west of the airfield in the training area at 2,500 ft and on climb to 4,000 ft, and communicated with a helicopter pilot operating in the area. After 8 minutes in the training area, the pilot broadcast that they were inbound to the aerodrome. At 1112, the aircraft’s final transmission was broadcast by the pilot, advising that they were joining the crosswind circuit leg for runway 28. Witnesses then saw the aircraft touch down on the runway and continue to take off again, consistent with a ‘touch-and-go’ manoeuvre, and heard one engine ‘splutter’ as the aircraft climbed to an estimated 100–150 ft above ground level. At about 1115, the aircraft was observed overhead a banana plantation beyond the end of the runway, banked to the right in a descending turn, before it suddenly rolled right. Witnesses observed the right wing drop to near vertical and the aircraft impacted terrain in a cornfield. Both pilots were fatally injured and the aircraft was destroyed.
Probable cause:
Contributing factors:
• The flight instructor very likely conducted a simulated engine failure after take-off in environmental conditions and a configuration in which the aircraft was unable to maintain altitude with one engine inoperative.
• Having not acted quickly to restore power to the simulated inoperative engine, the pilots did not reduce power and land ahead (in accordance with the Airplane Flight Manual procedure) before the combination of low airspeed and bank angle resulted in a loss of directional control at a height too low to recover.
• The instructor had very limited experience with the aircraft type, and with limited preparation for the flight, was likely unaware of the landing gear and flap retraction time and the extent of their influence on performance with one engine inoperative.

Other factors that increased risk:
• The pilot had not flown for 3 years prior to the accident flight, which likely resulted in a decay in skills at managing tasks such as an engine failure after take-off and in decision-making ability. The absence of flying practice before the flight review probably affected the pilot’s ability to manage the asymmetric low-level flight.
• The aircraft had not been flown for more than 2 years and had not been stored in accordance with the airframe and engine manufacturers’ recommendations. This very likely resulted in some of the right engine cylinders running with excessive fuel to air ratio for complete combustion and may also have reduced the expected service life of both engines’ components.
• The right-side altimeter was probably set to an incorrect barometric pressure, resulting in it over-reading the aircraft’s altitude by about 90 ft.
Final Report:

Crash of a Pilatus PC-12/47E in Chamberlain: 9 killed

Date & Time: Nov 30, 2019 at 1233 LT
Type of aircraft:
Operator:
Registration:
N56KJ
Flight Phase:
Survivors:
Yes
Schedule:
Chamberlain – Idaho Falls
MSN:
1431
YOM:
2013
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
2314
Captain / Total hours on type:
1274.00
Aircraft flight hours:
1725
Circumstances:
The pilot and passengers flew in the day before the accident and the airplane remained parked outside on the airport ramp overnight. Light to moderate snow and freezing drizzle persisted during the 12 to 24-hour period preceding the accident. In addition, low instrument meteorological conditions existed at the time of the accident takeoff. Before the flight, the pilot removed snow and ice from the airplane wings. However, the horizontal stabilizer was not accessible to the pilot and was not cleared of accumulated snow. In addition, the airplane was loaded over the maximum certificated gross weight and beyond the aft center-of-gravity limit. A total of 12 occupants were on board the airplane, though only 10 seats were available. None of the occupants qualified as lap children under regulations. The takeoff rotation was initiated about 88 kts which was about 4 kts slower than specified with the airplane configured for icing conditions. After takeoff, the airplane entered a left turn. Airspeed varied between 89 and 97 kts during the initial climb; however, it decayed to about 80 kts as the airplane altitude and bank angle peaked. The airplane ultimately reached a left bank angle of 64° at the peak altitude of about 380 ft above ground level. The airplane then entered a descent that continued until impact. The stall warning and stick shaker activated about 1 second after liftoff. The stick pusher became active about 15 seconds after liftoff. All three continued intermittently for the duration of the flight. A witness located about 1/2-mile northwest of the airport reported hearing the airplane takeoff. It was cloudy and snowing at the time. He was not able to see the airplane but noted that it entered a left turn based on the sound. He heard the airplane for about 4 or 5 seconds and the engine seemed to be “running good” until the sound stopped. The airplane impacted a dormant corn field about 3/4-mile west of the airport. A postaccident airframe examination did not reveal any anomalies consistent with a preimpact failure or malfunction. On board recorder data indicated that the engine was operating normally at the time of the accident. An airplane performance analysis indicated that the accumulated snow and ice on the empennage did not significantly degrade the airplane performance after takeoff. However, the effect of the snow and ice on the airplane center-of-gravity and the pitch (elevator) control forces could not be determined. Simulations indicated that the pitch oscillations recorded on the flight could be duplicated with control inputs, and that the flight control authority available to the pilot would have been sufficient to maintain control until the airplane entered an aerodynamic stall about 22 seconds after lifting off (the maximum bank angle of 64° occurred after the critical angle-of-attack was exceeded). In addition, similar but less extreme pitch oscillations recorded on the previous flight (during which the airplane was not contaminated with snow but was loaded to a similar center-of-gravity position) suggest that the pitch oscillations on both flights were the result of the improper loading and not the effects of accumulated snow and ice. Flight recorder data revealed that the accident pilot tended to rotate more rapidly and to a higher pitch angle during takeoff than a second pilot who flew the airplane regularly. Piloted simulations suggested that the accident pilot’s rotation technique, which involved a relatively abrupt and heavy pull on the control column, when combined with the extreme aft CG, heavy weight, and early rotation on the accident takeoff, contributed to the airplane’s high angle-of attack immediately after rotation, the triggering of the stick shaker and stick pusher, and the pilot’s pitch control difficulties after liftoff. The resulting pitch oscillations eventually resulted in a deep penetration into the aerodynamic stall region and subsequent loss of control. Although conditions were conducive to the development of spatial disorientation, the circumstances of this accident are more consistent with the pilot’s efforts to respond to the activation of the airplane stall protection system upon takeoff. These efforts were hindered by the heightened airplane pitch sensitivity resulting from the aft-CG condition. As a result, spatial disorientation is not considered to be a factor in this accident.
Probable cause:
The pilot’s loss of control shortly after takeoff, which resulted in an inadvertent, low-altitude aerodynamic stall. Contributing to the accident was the pilot’s improper loading of the airplane, which resulted in reduced static longitudinal stability and his decision to depart into low instrument meteorological conditions.
Final Report:

Crash of a Dornier DO228-200 in Goma: 29 killed

Date & Time: Nov 24, 2019 at 0910 LT
Type of aircraft:
Operator:
Registration:
9S-GNH
Flight Phase:
Survivors:
No
Site:
Schedule:
Goma - Butembo
MSN:
8030
YOM:
1984
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
29
Circumstances:
The twin engine airplane departed runway 17 at Goma International Airport on a schedule service to Butembo (first service of the day). After takeoff, while in initial climb, the airplane lost height and crashed onto several houses located in the district of Birere, south of the airport, and burst into flames. All 19 occupants were killed as well as 10 people on the ground.