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.

Crash of a Fokker 50 in Nairobi

Date & Time: Oct 11, 2019 at 0902 LT
Type of aircraft:
Operator:
Registration:
5Y-IZO
Flight Phase:
Survivors:
Yes
Schedule:
Nairobi - Mombasa - Lamu
MSN:
20244
YOM:
1992
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
50
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7492
Captain / Total hours on type:
262.00
Copilot / Total flying hours:
4156
Circumstances:
On October 11, 2019 at about 0902 Kenya daylight time, a Silverstone Air Services Fokker 27 Mark 050 registration 5Y-IZO experienced runway excursion on takeoff runway 14 at Wilson Airport with 55 occupants onboard (5 crew and 50 passengers). The aircraft was performing a scheduled flight from Wilson airport to Mombasa, Lamu and back to Wilson airport. The aircraft was fueled then the passengers boarded the plane before the normal pre take off procedures which were reported as uneventful as collaborated by the information from the FDR. The Right Hand engine receded the Left Hand engine in startup as depicted by the parameters from the recorders. From engine startup, taxi, lineup runway 14, power up and including the initial stages of ground roll were uneventful. At 06.02.50 GMT, while still on ground roll take off, the LH engine ITT began to fluctuate, dropped from 707.8 to 175.8. The RH ITT remained stable. The other parameters of both engines were stable. Subsequent power down ensued at 06.03.01, IAS dropped from 110.2Knots and the aircraft magnetic heading increased gradually to 144 consistent with the deviation of the aircraft to the right of the runway axis when it left the paved surface of the runway, before colliding with the airport perimeter fence, went through an embankment before coming to rest tilted to the right after the starboard wing made contact with a tree. The passengers were deplaned through the two left hand side front and rear exit doors. Immediately the event occurred, ATS Wilson airport issued a crash alert and Wilson Airport Fire Service (AFS) responded without delay, found the passengers already evacuated from the aircraft and applied foam to the sections of the aircraft with leaking fuel. Runway 14/32 was closed and all inbound and departure traffic made use of the remaining runway. Preliminary information retrieved from the Flight Data Recorder Radar regarding the engine ITT seems to correlate with the flight crew statements regarding the observed fluctuations on the LHS engine ITT.

Crash of a Cessna 207 Skywagon in Monterrey

Date & Time: Oct 7, 2019 at 1005 LT
Operator:
Registration:
XB-MHS
Flight Phase:
Survivors:
Yes
MSN:
207-0063
YOM:
1969
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from runway 11 at Monterrey-Del Norte Airport, while in initial climb, the single engine airplane lost height and crashed on a highway located past the runway end. Fortunately, the airplane did not struck any vehicles and eventually crashed in a field, about 15 meters below the motorway. The pilot, sole on board, was seriously injured and the aircraft was damaged beyond repair.

Crash of a Piper PA-60-602P in Kokomo: 1 killed

Date & Time: Oct 5, 2019 at 1637 LT
Operator:
Registration:
N326CW
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kokomo - Kokomo
MSN:
60-0869-8165008
YOM:
1981
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7500
Aircraft flight hours:
3002
Circumstances:
The airline transport pilot arrived at the departure airport in the reciprocating engine-powered airplane where it was fueled with Jet A jet fuel by an airport employee/line service technician. A witness stated that she saw a "low flying" airplane flying from north to south. The airplane made a "sharp left turn" to the east. The left wing "dipped low" and she then lost sight of the airplane, but when she approached the intersection near the accident site, she saw the airplane on the ground. The airplane impacted a field that had dry, level, and hard features conducive for an off-airport landing, and the airplane was destroyed. The wreckage path length and impact damage to the airplane were consistent with an accelerated stall. Postaccident examination of the airplane found Jet A jet fuel in the airplane fuel system and evidence of detonation in both engines from the use of Jet A and not the required 100 low lead fuel. Use of Jet A rather than 100 low lead fuel in an engine would result in detonation in the cylinders and lead to damage and a catastrophic engine failure. According to the Airplane Flying Handbook, the pilot should witness refueling to ensure that the correct fuel and quantity is dispensed into the airplane and that any caps and cowls are properly secured after refueling.
Probable cause:
The pilot's exceedance of the airplane’s critical angle of attack following a dual engine power loss caused by the line service technician fueling the airplane with the wrong fuel, which resulted in an aerodynamic stall and subsequent loss of control. Contributing was the pilot's inadequate supervision of the fuel servicing.
Final Report:

Crash of a Cessna 421A Golden Eagle I in DeLand: 3 killed

Date & Time: Sep 29, 2019 at 1600 LT
Type of aircraft:
Operator:
Registration:
N731PF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
DeLand - DeLand
MSN:
421A-0164
YOM:
1968
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
500
Captain / Total hours on type:
0.00
Aircraft flight hours:
858
Circumstances:
The owner of the airplane had purchased the airplane with the intent to resell it after repairs had been made. As part of that process, a mechanic hired by the owner had assessed the airplane’s condition, proposed the necessary repairs to the airplane’s owner, and had identified a pilot who would, once the repairs and required inspection annual inspection had been completed, fly the airplane from where it was located to where the owner resided. While the mechanic had identified a potential pilot for the relocation flight, he had not yet completed the repairs to the airplane, nor had he completed the necessary logbook entries that would have returned the airplane to service. The pilot-rated passenger onboard the airplane for the accident flight, was the pilot who had been identified by the mechanic for the relocation flight. Review of the pilot-rated passenger’s flight experience revealed that he did not possess the necessary pilot certificate rating, nor did he have the flight experience necessary to act as pilot-in-command of the complex, highperformance, pressurized, multi-engine airplane. Additionally, the owner of the airplane had not given the pilot-rated-passenger, or anyone else, permission to fly the airplane. The reason for, and the circumstances under which the pilot-rated passenger and the commercial pilot (who did hold a multi-engine rating) were flying the airplane on the accident flight could not be definitively determined, although because another passenger was onboard the airplane, it is most likely that the accident flight was personal in nature. Given the commercial pilot’s previous flight experience, it is also likely that he was acting as pilot-in-command for the flight. One witness said that he heard the airplane’s engines backfiring as it flew overhead, while another witness located about 1 mile from the accident site heard the accident airplane flying overhead. The second witness said that both engines were running, but they seemed to be running at idle and that the flaps and landing gear were retracted. The witness saw the airplane roll to the left three times before descending below the tree line. As the airplane descended toward the ground, the witness heard the engines make “two pop” sounds. The airplane impacted a wooded area about 4 miles from the departure airport, and the wreckage path through the trees was only about 75-feet long. While the witnesses described the airplane’s engines backfiring or popping before the accident, the postaccident examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Additionally, examination of both propeller blades showed evidence of low rotational energy at impact, and that neither propeller had been feathered in flight. Given the witness statement describing the airplane “rolling three times” before it descended from view toward the ground, it is most likely that the pilot lost control of the airplane and while maneuvering. It is also likely that the pilot’s lack of any documented previous training or flight experience in the accident airplane make and model contributed to his inability to maintain control of the airplane. Toxicology testing was performed on the pilot’s chest cavity blood. The results identified 6.7 ng/ml of delta-9-tetrahydracannabinol (THC, the active compound in marijuana) as well as 2.6 ng/ml of its active metabolite, 11-hydroxy-THC and 41.3 ng/ml of its inactive metabolite delta9-carboxy-THC. Because the measured THC levels were from cavity blood, it was not possible to determine when the pilot last used marijuana or whether he was impaired by it at the time of the flight. As a result, it could not be determined whether effects from the pilot’s use of marijuana contributed to the accident circumstances.
Probable cause:
The pilot’s failure to maintain control of the airplane, which resulted in a collision with terrain. Contributing was the pilot’s lack of training and experience in the accident airplane make and model.
Final Report:

Crash of a Cessna 208B Grand Caravan in Seronera: 2 killed

Date & Time: Sep 23, 2019
Type of aircraft:
Operator:
Registration:
5H-AAM
Flight Phase:
Survivors:
No
Schedule:
Seronera - Grumeti Hills
MSN:
208B-2430
YOM:
2013
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The single engine airplane departed Seronera Airstrip in the early morning on a short flight to Grumeti Hills, about 40 km northwest, according to a statement from the operator. Shortly after takeoff, the airplane went out of control, struck a concrete wall and crashed upside down. The pilot and the sole passenger were killed.

Statement from the operator:
https://www.auricair.com/About-Us/5HAAM_Accident_23Sept2019

Crash of a Cessna 208B Grand Caravan in Manaus

Date & Time: Sep 16, 2019 at 1225 LT
Type of aircraft:
Operator:
Registration:
PT-MHC
Flight Phase:
Survivors:
Yes
Schedule:
Manaus - Maués
MSN:
208B-0543
YOM:
1996
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
22800
Captain / Total hours on type:
14150.00
Copilot / Total flying hours:
947
Copilot / Total hours on type:
791
Circumstances:
The single engine airplane departed Manaus-Eduardo Gomes Airport Runway 29 in heavy rain falls as weather conditions deteriorated shortly prior to takeoff. After liftoff, while in initial climb, the airplane lost altitude and crashed in a dense wooded area located 600 metres past the runway end. The aircraft was destroyed by impact forces and all 10 occupants were injured, among them six seriously. At the time of the accident, weather conditions were poor with heavy rain falls, turbulence and windshear.
Probable cause:
The accident was the consequence of the combination of the following factors:
- Control skills – undetermined.
While facing adverse conditions, the use of controls may have been inappropriate for the situation and may have contributed to the aircraft not being able to maintain a positive climb rate.
- Attitude – undetermined.
Familiarization with the region may have led to an attitude, on the part of the PIC, of minimizing the importance of analyzing adverse weather conditions, to the detriment of compliance with the minimum limits established by the company in its manuals.
- Training – undetermined.
It is possible that, due to possible inadequate training, the SIC did not identify the critical situation that arose shortly after the take-off in time to assist the PIC in maintaining flight control.
- Tasks characteristics – undetermined.
The characteristics present in the type of operation, compliance with schedules without the possibility of delays, due to the runway closing period, may have favored the self imposed pressure on the part of the PIC, leading him to operate with reduced safety margins.
- Adverse meteorological conditions – a contributor.
The conditions at the time of the take-off contributed to the aircraft not being able to maintain the flight with a positive climb rate. The probable occurrence of Windshear determined that the trajectory of the aircraft was modified until its collision with the ground.
- Crew Resource Management – undetermined.
On the part of the SIC, no assertive attitude was perceived in the sense of alerting the PIC that those conditions were not favorable for takeoff. Thus, the crew decided to carry out the take-off despite the company's SOP.
- Organizational culture – undetermined.
The company encouraged compliance with the legs even though, within the planning of flights, there was not an adequate margin of time to absorb any delays. This culture may have influenced the PIC's decision-making, which, despite encountering adverse conditions, chose to take off, since the short time on the ground in the intermediate locations did not allow room for delays.
- Emotional state – undetermined.
The reports indicated that the PIC felt pressured to perform the take-off even in the weather conditions found on the day of this occurrence. Also, according to the interviewees, this pressure would be related to the fulfillment of the flight schedule and the need to keep to the scheduled times. In this way, it is possible that their assessment of the performance of the flight was influenced by the stress resulting from the pressure to complete the flight within the expected time, given the closing time of the runway for works.
- Flight planning – a contributor.
The flight planning was not carried out properly, considering that the planned schedules and routes would end after the closing time of the SBEG runway for works, provided for in the NOTAM. This meant that there was little time to adjust the legs, increasing the workload and stress in the cabin.
- Decision-making process – a contributor.
There was a wrong assessment of the meteorological conditions, which contributed to the decision of performing it in an adverse situation.
- ATS publication– undetermined.
The TWR-EG did not inform, before the take-off, of the changes in the significant weather conditions that were occurring at the terminal, which could have contributed to the PIC's decision-making.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Popayán: 7 killed

Date & Time: Sep 15, 2019 at 1406 LT
Operator:
Registration:
HK-5229
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Popayán - López de Micay
MSN:
31-7405212
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
3291
Captain / Total hours on type:
991.00
Copilot / Total flying hours:
300
Copilot / Total hours on type:
55
Aircraft flight hours:
12304
Circumstances:
The twin engine airplane departed Popayán-Guillermo León Valencia Airport runway 26 at 14:06:06. The aircraft encountered difficulties to gain sufficient height. About 20 seconds after liftoff, at a speed of 82 knots, the aircraft rolled to the right then entered an uncontrolled descent and crashed onto two houses located 530 metres past the runway end. Two passengers were seriously injured and seven other occupants were killed.
Probable cause:
A loss of in-flight control of the aircraft due to possible excess weight. The aircraft probably managed to take off due to "ground effect", but, once in the air and out of ground effect, it was not able to obtain the speed that would allow it to safely accomplish the climb.
Contributing Factors:
- Absence of Dispatch procedures of the operator to perform a correct Weight and Balance of the aircraft, and the effective control of the boarded cargo.
- Incorrect calculation of the weight and balance of the aircraft by the crew, by not considering all the cargo that was loaded, causing the aircraft to take off with a possible excess weight.
- Weak operational safety management processes of the operator by not considering the operating characteristics of airfields such as Popayán (high altitude, high ambient temperature) that significantly limit the operation.
Final Report:

Crash of a Cessna 510 Citation Mustang in El Monte

Date & Time: Aug 31, 2019 at 1105 LT
Operator:
Registration:
N551WH
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
El Monte - Thermal
MSN:
510-0055
YOM:
2008
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2217
Captain / Total hours on type:
477.00
Circumstances:
The pilot reported that, while holding short of the runway, he set the parking brake while waiting for his takeoff clearance. Upon receiving takeoff clearance, he reached down to the parking brake handle and, "quickly pushed the parking brakes back in"; however, he did not visually verify that he disengaged the parking brake. During the takeoff roll, he noticed that the airplane was not accelerating beyond about 70 knots and decided to abort the takeoff. The airplane subsequently veered to the left, exited the departure end of the runway, and impacted an airport perimeter fence. The pilot reported that he must have not fully disengaged the parking brake before takeoff and that there were no mechanical issues with the airplane that would have precluded normal operation. Postaccident examination of the airplane revealed that the parking brake handle was partially extended, which likely resulted in the airplane’s decreased acceleration during the takeoff roll.
Probable cause:
The pilot's failure to disengage the parking brake before takeoff, which resulted in decreased acceleration and a subsequent runway overrun following an aborted takeoff.
Final Report:

Crash of a Cessna 560XL Citation Excel in Oroville

Date & Time: Aug 21, 2019 at 1132 LT
Operator:
Registration:
N91GY
Flight Phase:
Survivors:
Yes
Schedule:
Oroville - Portland
MSN:
560-5314
YOM:
2003
Flight number:
DPJ91
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6482
Captain / Total hours on type:
192.00
Copilot / Total flying hours:
4748
Copilot / Total hours on type:
858
Aircraft flight hours:
9876
Circumstances:
The crew was conducting an on-demand charter flight with eight passengers onboard. As the flight crew taxied the airplane to the departure runway, the copilot called air traffic control using his mobile phone to obtain the departure clearance and release. According to the pilot, while continuing to taxi, he stopped the airplane short of the runway where he performed a rudder bias check (the last item in the taxi checklist) and applied the parking brake without verbalizing the parking brake or rudder bias actions because the copilot was on the phone. After the pilot lined up on the runway and shortly before takeoff, the flight crew discussed and corrected a NO TAKEOFF annunciation for an unsafe trim setting. After the copilot confirmed takeoff power was set, he stated that the airplane was barely moving then said that something was not right, to which the pilot replied the airplane was rolling and to call the airspeeds. About 16 seconds later, the pilot indicated that the airplane was using more runway than he expected then made callouts for takeoff-decision speed and rotation speed. The pilot stated that he pulled the yoke back twice, but the airplane did not lift off. Shortly after, the pilot applied full thrust reversers and maximum braking, then the airplane exited the departure end of the runway, impacted a ditch, and came to rest 1,990 ft beyond the departure end of the runway. The airplane was destroyed by a postcrash fire, and the crew and passengers were not injured.
Probable cause:
The pilot’s failure to release the parking brake before attempting to initiate the takeoff, which produced an unexpected retarding force and airplane nose down pitching moment. Also causal was the flight crew’s delayed decision to abort the takeoff, which resulted in a runway excursion. Contributing to the accident was the lack of a NO TAKEOFF annunciation warning that the parking brake was engaged, and lack of a checklist item to ensure the parking brake was fully released immediately before takeoff.
Final Report: