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:

Crash of a Cessna 750 Citation X at La Carlota AFB

Date & Time: Aug 21, 2019 at 1100 LT
Type of aircraft:
Operator:
Registration:
1060
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
La Carlota - La Carlota
MSN:
750-0134
YOM:
2000
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was engaged in a local test flight at La Carlota-General Francisco de Miranda AFB in Caracas. During the takeoff roll, a tire burst on the right main gear that collapsed and was torn off. The airplane veered off runway to the left then the left main gear collapsed as well and the airplane came to rest on its belly with the nose gear still extended. There were no injuries among the crew.

Crash of a Cessna T303 Crusader in Lagrangeville: 2 killed

Date & Time: Aug 17, 2019 at 1613 LT
Type of aircraft:
Registration:
N303TL
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Sky Acres - Farmingdale
MSN:
303-00286
YOM:
1984
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1586
Captain / Total hours on type:
358.00
Aircraft flight hours:
2932
Circumstances:
After flying one flight leg earlier in the day, the pilot flew to an intermediate stop on the way to his home base to purchase fuel. A surveillance video recording from the fueling airport showed the airplane land and taxi to the self-serve fuel pump where the engines were shut down for about 10 minutes while the airplane was fueled. The pilot then had difficulty starting both engines over several minutes. After the engines were running, the airplane taxied to the runway and did not appear to stop for an engine run-up. The pilot performed a rolling takeoff, and the airplane lifted off after a roll of about 2,100 ft, slightly more than half the available runway length. A passenger reported that after liftoff, at an altitude of about 50 to 100 ft above ground level (agl), both engines lost partial power and began “stuttering,” which continued for the remainder of the flight. He further reported that the engines did not stop, but they were “not producing full RPM.” The airplane drifted left of centerline, which a witness described as a left yawing motion. The pilot corrected the drift and flew the runway heading over the grass on the left side of the runway; however, the airplane would not climb. After crossing the end of the runway, the pilot pitched the airplane up to avoid obstacles. Automatic dependent surveillance-broadcast data indicated that the airplane climbed from about 20 to 120 ft agl in a gradual left turn. During this time the groundspeed decreased from about 80 knots to about 69 knots. The altitude then decreased to about 50 ft agl, the groundspeed decreased to about 66 knots, and the left turn decreased in radius until the recorded data ended about 100 ft west of the accident site. The airplane descended and
impacted a house. Witness descriptions of the airplane yawing to the left while over the runway and again during its final left turn suggest that the loss of engine power may not have been symmetric (that is, one engine may have suffered more of a loss than the other).
Probable cause:
A partial loss of engine power in both engines during initial climb for reasons that could not be determined based on the available information.
Final Report:

Crash of an Airbus A321-211 in Moscow

Date & Time: Aug 15, 2019 at 0615 LT
Type of aircraft:
Operator:
Registration:
VQ-BOZ
Flight Phase:
Survivors:
Yes
Schedule:
Moscow - Simferopol
MSN:
2117
YOM:
2003
Flight number:
U6178
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
226
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Moscow-Zukhovski Airport runway 12, while climbing to an altitude of 750 feet in excellent weather conditions, the airplane collided with a flock of birds (sea gulls). Some of them were ingested by both engines that lost power. It was later reported by the crew that the left engine stopped almost immediately while the right engine lost power and run irregularly. Unable to maintain a positive rate of climb, the captain decided to attempt an emergency landing in a cornfield. The airplane belly landed approximately 3,5 km past the runway end and slid for dozen meters before coming to rest with its both engines partially torn off. All 233 occupants were able to evacuate the cabin and it is reported that 23 people were slightly injured.

Crash of a Cessna 208B Grand Caravan in Kilindoni

Date & Time: Aug 6, 2019
Type of aircraft:
Operator:
Registration:
5H-NOW
Flight Phase:
Survivors:
Yes
Schedule:
Kilindoni - Dar es Salaam
MSN:
208B-2209
YOM:
2010
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Kilindoni Airport, the single engine airplane crashed in flames. All nine occupants were able to evacuate the cabin and six of them were injured and transported to local hospital. The aircraft was completely destroyed by fire.

Crash of a De Havilland DHC-2 Beaver off Seldovia: 1 killed

Date & Time: Jul 19, 2019 at 1010 LT
Type of aircraft:
Operator:
Registration:
N68083
Flight Phase:
Survivors:
Yes
Schedule:
Seldovia – Anchorage
MSN:
1254
YOM:
1958
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2689
Captain / Total hours on type:
150.00
Aircraft flight hours:
29448
Circumstances:
The pilot stated that, during takeoff in the float-equipped airplane, he saw the left float begin to move into his peripheral vision from the left cockpit window and the airplane began to yaw to the left. The left wing subsequently impacted the water and the airplane nosed over, separating the right wing from the fuselage. The passengers consistently reported choppy water conditions at the time of the accident; one passenger reported that white caps were visible on the ocean waves in the distance. The passengers said that, during the takeoff, the airplane impacted a swell or wave and nosed over abruptly, and the cabin rapidly filled with water. Examination of the float assembly revealed fractures in the left front flying wire attachment fitting and the right rear flying wire attachment strap and hole elongation in the left rear flying wire attachment fitting. Additionally, the bolts attaching the two left flying wire attachment fittings to the left float were bent, and the two flying wires that had been attached to the fractured attachment fitting and attachment strap were buckled. While some areas of corrosion were observed on the fractured left forward fitting, the total area of corrosion was a small percentage of the total cross-section, and the remainder of the fracture and associated deformation of the lug was consistent with ductile overstress fracture. Similar areas of corrosion were also observed on each of the intact flying wire attachment fittings. Post-accident testing completed by the float manufacturer revealed that buckling of flying wires similar to that observed on the accident airplane was only reproduced at strap and fitting failure loads above 9,000 pounds force; the design specification load was 3,453 pounds of force. This indicates that the small amount of corrosion present on the fractured flying wire attachment fitting did not reduce its loadcarrying capability below the design specification load of 3,453 pounds of force, and that both the flying wire attachment fitting and flying wire attachment strap fractured due to overload. Therefore, it is likely that the accident airplane floats were subject to forces that exceeded their design limitations, resulting in overload of the flying wires attached to the left float. It is also likely that, given the lack of damage on either float, the force was due to impact with an ocean wave or swell and not by striking an object.
Probable cause:
The airplane's floats impact with an ocean wave or swell, which exceeded the design load specifications of the flying wire assemblies and resulted in a partial separation of the float assemblies.
Final Report:

Crash of a Cessna 404 Titan II in Moroni

Date & Time: Jul 18, 2019
Type of aircraft:
Operator:
Registration:
D6-FAT
Flight Phase:
Survivors:
Yes
Schedule:
Moroni - Mohéli
MSN:
404-0216
YOM:
1978
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Moroni-Prince Saïd Ibrahim-Hahaya Airport, while climbing, the pilot encountered an unexpected situation and apparently attempted an emergency landing when the twin engine airplane struck the ground past the runway end and came to rest inverted. All 11 occupants were evacuated, a passenger and the pilot were injured. The aircraft was partially destroyed by a post crash fire.

Crash of a De Havilland DHC-2 Beaver in Hawk Junction: 2 killed

Date & Time: Jul 11, 2019 at 0853 LT
Type of aircraft:
Operator:
Registration:
C-FBBG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hawk Junction - Oba Lake
MSN:
358
YOM:
1952
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1231
Captain / Total hours on type:
409.00
Aircraft flight hours:
17804
Circumstances:
On 11 July 2019, at approximately 0852 Eastern Daylight Time, the float-equipped de Havilland DHC-2 Mk. I Beaver aircraft (registration C-FBBG, serial number 358), operated by Hawk Air, departed from the Hawk Junction Water Aerodrome, on Hawk Lake, Ontario. The aircraft, with the pilot and 1 passenger on board, was on a daytime visual flight rules charter flight. The aircraft was going to drop off supplies at an outpost camp on Oba Lake, Ontario, approximately 35 nautical miles north-northeast of the Hawk Junction Water Aerodrome. The aircraft departed heading northeast. Shortly after takeoff, during the initial climb out, just past the northeast end of Hawk Lake, the aircraft crashed in a steep nose-down attitude, severing a power line immediately before impact, and coming to rest next to a hydro substation. The pilot and the passenger received fatal injuries. The aircraft was destroyed as a result of the impact, but there was no post-impact fire.
Probable cause:
Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. The aircraft likely departed with the fuel selector set to the rear tank position,which did not contain sufficient fuel for departure. As a result, the engine lost power due to fuel starvation shortly after takeoff during the initial climb.
2. After a loss of engine power at low altitude, a left turn was likely attempted in an effort to either return to the departure lake or head toward more desirable terrain for a forced landing. The aircraft stalled aerodynamically, entered an incipient spin, and subsequently crashed.

Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
1. If aircraft are not equipped with a stall warning system, pilots and passengers who travel on these aircraft will remain exposed to an elevated risk of injury or death as a result of a stall at low altitude.
2. If air-taxi training requirements do not address the various classes of aircraft and operations included in the sector, there is a risk that significant type-, class-, or operation-specific emergency procedures will not be required to be included in training programs.
3. If seasonal air operators conduct recurrent training at the end of the season rather than at the beginning, there is a risk that pilots will be less familiar with required emergency procedures.
4. If air operators do not tailor their airborne training programs to address emergency procedures that are relevant to their operation, there is a risk that pilots will be unprepared in a real emergency.
5. If pilots and passengers do not use available shoulder harnesses, there is an increased risk of injury in the event of an accident.
Final Report:

Crash of a Beechcraft 350i Super King Air in Addison: 10 killed

Date & Time: Jun 30, 2019 at 0911 LT
Operator:
Registration:
N534FF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Addison – Saint Petersburg
MSN:
FL-1091
YOM:
2017
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
16450
Captain / Total hours on type:
1100.00
Copilot / Total flying hours:
2357
Copilot / Total hours on type:
189
Aircraft flight hours:
691
Circumstances:
The pilot, co-pilot, and eight passengers departed on a cross-country flight in the twin-engine airplane. One witness located on the ramp at the airport reported that the airplane sounded underpowered immediately after takeoff “like it was at a reduced power setting.” Another witness stated that the airplane sounded like it did not have sufficient power to takeoff. A third witness described the rotation as “steep,” and other witnesses reported thinking that the airplane was performing aerobatics. Digital video from multiple cameras both on and off the airport showed the airplane roll to its left before reaching a maximum altitude of 100 ft above ground level; it then descended and impacted an airport hangar in an inverted attitude about 17 seconds after takeoff and an explosion immediately followed. After breaching a closed roll-up garage door, the airplane came to rest on its right side outside of the hangar and was immediately involved in a postimpact fire. Sound spectrum analysis of data from the airplane’s cockpit voice recorder (CVR) estimated that the propeller speeds were at takeoff power (1,714 to 1,728 rpm) at liftoff. About 7 seconds later, the propeller speeds diverged, with the left propeller speed decreasing to about 1,688 rpm and the right propeller speed decreasing to 1,707 rpm. Based on the airplane’s estimated calibrated airspeed of about 110 knots and the propeller rpm when the speeds diverged, the estimated thrust in the left engine decreased to near 0 while the right engine continued operating at slightly less than maximum takeoff power. Analysis of available data estimated that, 2 seconds after the propeller speed deviation, the airplane’s sideslip angle was nearly 20°. During the first 5 seconds after the propeller speed deviation, the airplane’s roll rate was about 5° per second to the left; its roll rate then rapidly increased to more than 60° per second before the airplane rolled inverted. Witness marks on the left engine and propeller, the reduction in propeller speed, and the airplane’s roll to the left suggest that the airplane most likely experienced a loss of thrust in the left engine shortly after takeoff. The airplane manufacturer’s engine-out procedure during takeoff instructed that the landing gear should be retracted once a positive rate of climb is established, and the propeller of the inoperative engine should be feathered. Right rudder should also be applied to balance the yawing moment imparted by a thrust reduction in the left engine. Examination of the wreckage found both main landing gear in a position consistent with being extended and the left propeller was unfeathered. The condition of the wreckage precluded determining whether the autofeather system was armed or activated during the accident flight. Thus, the pilot failed to properly configure the airplane once the left engine thrust was reduced. Calculations based on the airplane’s sideslip angle shortly after the propeller speed deviation determined that the thrust asymmetry alone was insufficient to produce the sideslip angle. Based on an evaluation of thrust estimates provided by the propeller manufacturer and performance data provided by the airplane manufacturer, it is likely that the pilot applied left rudder, the opposite input needed to maintain lateral control, before applying right rudder seconds later. However, by then, the airplane’s roll rate was increasing too rapidly, and its altitude was too low to recover. The data support that it would have been possible to maintain directional and lateral control of the airplane after the thrust reduction in the left engine if the pilot had commanded right rudder initially rather than left rudder. The pilot’s confused reaction to the airplane’s performance shortly after takeoff supports the possibility that he was startled by the stall warning that followed the propeller speed divergence, which may have prompted his initial, improper rudder input. In addition, the NTSB’s investigation estimated that rotation occurred before the airplane had attained Vr (rotation speed), which decreased the margin to the minimum controllable airspeed and likely lessened the amount of time available for the pilot to properly react to the reduction in thrust and maintain airplane control. Although the airplane was slightly over its maximum takeoff weight at departure, its rate of climb was near what would be expected at maximum weight in the weather conditions on the day of the accident (even with the extended landing gear adding drag); therefore, the weight exceedance likely was not a factor in the accident. Engine and propeller examinations and functional evaluations of the engine and propeller controls found no condition that would have prevented normal operation; evidence of operation in both engines at impact was found. Absent evidence of an engine malfunction, the investigation considered whether the left engine’s thrust reduction was caused by other means, such as uncommanded throttle movement due to an insufficient friction setting of the airplane’s power lever friction locks. Given the lack of callouts for checklists on the CVR and the pilot’s consistently reported history of not using checklists, it is possible that he did not check or adjust the setting of the power lever friction locks before the accident flight, which led to uncommanded movement of the throttle. Although the co-pilot reportedly had flown with the pilot many times previously and was familiar with the B-300, he was not type rated in the airplane and was not allowed by the pilot to operate the flight controls when passengers were on board. Therefore, the co-pilot may not have checked or adjusted the friction setting before the flight’s departure. Although the investigation considered inadequate friction setting the most likely cause of the thrust reduction in the left engine, other circumstances, such as a malfunction within the throttle control system, could also result in loss of engine thrust. However, heavy fire and impact damage to the throttle control system components, including the power quadrant and cockpit control lever friction components, precluded determining the position of the throttle levers at the time of the loss of thrust or the friction setting during the accident flight. Thus, the reason for the reduction in thrust could not be determined definitively. In addition to a lack of callouts for checklists on the CVR, the pilots did not discuss any emergency procedures. As a result, they did not have a shared understanding of how to respond to the emergency of losing thrust in an engine during takeoff. Although the co-pilot verbally identified the loss of the left engine in response to the pilot’s confused reaction to the airplane’s performance shortly after takeoff, it is likely the co-pilot did not initiate any corrective flight control inputs, possibly due to the pilot’s established practice of being the sole operator of flight controls when passengers were on board. The investigation considered whether fatigue from inadequately treated obstructive sleep apnea contributed to the pilot’s response to the emergency; however, the extent of any fatigue could not be determined from the available evidence. In addition, no evidence indicates that the pilot’s medical conditions or their treatment were factors in the accident. In summary, the available evidence indicates that the pilot improperly responded to the loss of thrust in the left engine by initially commanding a left rudder input and did not retract the landing gear or feather the left propeller, which was not consistent with the airplane manufacturer’s engine out procedure during takeoff. It would have been possible to maintain directional and lateral control of the airplane after the thrust reduction in the left engine if right rudder had been commanded initially rather than left rudder. It is possible that the pilot’s reported habit of not using checklists resulted in his not checking or adjusting the power lever friction locks as specified in the airplane manufacturer’s checklists. However, fire and impact damage precluded determining the position of the power levers or friction setting during the flight.
Probable cause:
The pilot’s failure to maintain airplane control following a reduction of thrust in the left engine during takeoff. The reason for the reduction in thrust could not be determined. Contributing to the accident was the pilot’s failure to conduct the airplane manufacturer’s emergency procedure following a loss of power in one engine and to follow the manufacturer’s checklists during all phases of operation.
Final Report: