Crash of a Cessna 207 Stationair 7 in Cayenne

Date & Time: Jan 25, 2019 at 1435 LT
Operator:
Registration:
F-OSIA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cayenne – Maripasoula
MSN:
207-0042
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3620
Circumstances:
The single engine airplane departed Cayenne-Rochambeau-Félix Eboué Airport on a cargo flight to Maripasoula, carrying a load of foods on behalf of a restaurant. The pilot was sole on board. Shortly after takeoff, while in initial climb, the engine lost power. The pilot reduced his altitude and attempted an emergency landing on a known open area located near the airport. But on short final, the aircraft struck a embankment and came to rest upside down. The pilot was seriously injured and the aircraft was destroyed.
Probable cause:
The flight was undertaken with an airplane whose center of gravity was beyond the rear center of gravity limits and a mass greater than the maximum take-off mass. The load was not secured. As a result, the performance of the aircraft was degraded and piloting made more difficult. The BEA investigation did not reveal any major failure that could explain a loss of power. Engine performance may have been lower than the manufacturer's standards, due in particular to improper adjustment of the mechanical fuel pump, probably resulting from unsuitable maintenance. This defect was most likely already present on previous flights. It is likely that the power required for the initial climb was greater than what the engine could deliver. This brought the aircraft into a situation where the speed gradually decreased. When the pilot turned, the stall warning sounded and the pilot sensed the engine was losing power.
Final Report:

Crash of an AMI DC-3-65TP in Kidron: 2 killed

Date & Time: Jan 21, 2019 at 0912 LT
Type of aircraft:
Operator:
Registration:
N467KS
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Kidron - Akron
MSN:
20175
YOM:
1944
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
15457
Captain / Total hours on type:
5612.00
Copilot / Total flying hours:
9969
Copilot / Total hours on type:
12
Aircraft flight hours:
37504
Circumstances:
The two pilots departed in a turbine powered DC-3C at maximum gross weight for a repositioning flight. The airplane was part of a test program for new, higher horsepower engine installation. Soon after liftoff and about 3 seconds after decision speed (V1), the left engine lost total power. The propeller began to auto-feather but stopped feathering about 3 seconds after the power loss. The airplane yawed and banked to the left, descended, and impacted terrain. Recorded engine data indicated the power loss was due to an engine flameout; however, examination of the engine did not determine a reason for the flameout or the auto-feather system interruption. While it is plausible that an air pocket developed in the fuel system during the refueling just before the flight, this scenario was not able to be tested or confirmed. It is possible that the auto-feather system interruption would have occurred if the left power lever was manually retarded during the auto-feather sequence. The power loss and auto-feather system interruption occurred during a critical, time-sensitive phase of flight since the airplane was at low altitude and below minimum controllable airspeed (Vmc). The acutely transitional phase of flight would have challenged the pilots' ability to manually feather the propeller quickly and accurately. The time available for the crew to respond to the unexpected event was likely less than needed to recognize the problem and take this necessary action – even as an immediate action checklist/memory item.
Probable cause:
The loss of airplane control after an engine flameout and auto-feather system interruption during the takeoff climb, which resulted in an impact with terrain.
Final Report:

Crash of a Cessna 560 Citation V in Atlanta: 4 killed

Date & Time: Dec 20, 2018 at 1210 LT
Type of aircraft:
Operator:
Registration:
N188CW
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Atlanta - Millington
MSN:
560-0148
YOM:
1991
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2300
Captain / Total hours on type:
110.00
Aircraft flight hours:
6854
Circumstances:
The pilot departed on an instrument flight rules flight into instrument meteorological conditions (IMC). Radar data indicated that the airplane entered a left turn after takeoff, consistent with the pilot's instrument clearance. As the airplane climbed to an altitude about 2,410 ft above ground level, its rate of climb increased from about 3,500 ft per minute to 9,600 ft per minute, the stick shaker activated, and the airplane decelerated to about 75 knots. The airplane then entered a descending right turn and rolled inverted before impacting terrain about 1 mile from the airport. All major components of the airplane were located at the accident site, and examination of the wreckage revealed no anomalies with the airplane that would have precluded normal operation. The weather conditions about the time of the accident included an overcast cloud ceiling about 600 ft above ground level. It is likely that the pilot became spatially disoriented after entering the cloud layer, which resulted in the airplane's high rate of climb, rapid loss of airspeed, and a likely aerodynamic stall. The steep descending right turn, the airplane's roll to an inverted attitude, and the high-energy impact are also consistent with a loss of control due to spatial disorientation.
Probable cause:
The pilot's loss of airplane control due to spatial disorientation during initial climb in instrument meteorological conditions.
Final Report:

Crash of a Cessna 525 CitationJet Cj2+ in Memphis: 3 killed

Date & Time: Nov 30, 2018 at 1028 LT
Type of aircraft:
Operator:
Registration:
N525EG
Flight Phase:
Survivors:
No
Schedule:
Jeffersonville – Chicago
MSN:
525-0449
YOM:
2009
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
3500
Aircraft flight hours:
3306
Circumstances:
On November 30, 2018, about 1028 central standard time, a Cessna 525A (Citation) airplane, N525EG, was destroyed when it was involved in an accident near Memphis, Indiana. The pilot and two passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. The cross-country flight originated from Clark Regional Airport (JVY), Jeffersonville, Indiana, and was en route to Chicago Midway International Airport (MDW), Chicago, Illinois. The airplane was equipped with automatic dependent surveillance–broadcast (ADS-B), which recorded latitude and longitude from GPS, pressure and geometric altitude, and selected altitude and heading. The airplane was also equipped with a cockpit voice recorder (CVR), which recorded the accident flight and annunciations from the enhanced ground proximity warning system (EGPWS). It was not equipped with a flight data recorder (FDR) nor was it required to be. Review of the CVR transcript showed that the pilot operated as a single pilot but verbalized his actions as he configured the airplane before departure. He referenced items from the Before Taxi checklist and included in his crew briefing that in the event of a problem after takeoff decision speed, he would handle it as an in-flight emergency and “fly the airplane, address the problem, get the autopilot on, talk on the radios, divert over to Stanford.” The air traffic controller provided initial clearance for the pilot to fly direct to the STREP intersection and to climb and maintain 3,000 ft mean sea level. Before the departure from JVY, the pilot announced on the common traffic advisory frequency that he was departing runway 36 and verbalized in the cockpit “this is three six” before he advanced the throttles. The flight departed JVY about 1024:36 into instrument meteorological conditions. The CVR recorded the pilot state that he set power to maximum cruise thrust, switched the engine sync on, and turned on the yaw dampers. The pilot also verbalized his interaction with the autopilot, including navigation mode, direct STREP, and vertical speed climb up to 3,000 ft. According to the National Transportation Safety Board’s (NTSB) airplane performance study, the airplane climbed to about 1,400 ft msl before it turned left onto a course of 330° and continued to climb. The CVR recorded the pilot state he was turning on the autopilot at 1025:22. At 1025:39, the pilot was cleared up to 10,000 ft and asked to “ident,” and the airplane was subsequently identified on radar. The pilot verbalized setting the autopilot for 10,000 ft and read items on the After Takeoff/Climb checklist. The performance study indicated that the airplane passed 3,000 ft about 1026, with an airspeed between 230 and 240 kts, and continued to climb steadily. At 1026:29, while the pilot was conducting the checklist, the controller instructed him to contact the Indianapolis Air Route Traffic Control Center; the pilot acknowledged. At 1026:38, the pilot resumed the checklist and stated, “uhhh lets seeee. Pressurization pressurizing anti ice de-ice systems are not required at this time.” The performance study indicated that, at 1026:45, the airplane began to bank to the left at a rate of about 5° per second and that after the onset of the roll, the airplane maintained airspeed while it continued to climb for 12 seconds, consistent with engine power not being reduced in response to the roll onset. At 1026:48, the CVR recorded the airplane’s autopilot disconnect annunciation, “autopilot.” The performance study indicated that about this time, the airplane was in about a 30° left bank. About 1 second later, the pilot stated, “whooooaaaaah.” Over the next 8 seconds, the airplane’s EGPWS annunciated six “bank angle” alerts. At 1026:57, the airplane reached its maximum altitude of about 6,100 ft msl and then began to descend rapidly, in excess of 11,000 ft per minute. At 1026:58, the bank angle was about 70° left wing down, and by 1027:05, the airplane was near 90° left wing down. At 1027:04, the CVR recorded a sound similar to an overspeed warning alert, which continued to the end of the flight. The performance study indicated that about the time of the overspeed warning, the airplane passed about 250 kts calibrated airspeed at an altitude of about 5,600 ft. After the overspeed warning, the pilot shouted three expletives, and the bank angle alert sounded two more times. According to the performance study, at 1027:18, the final ADS-B data point, the airplane was about 1,000 ft msl, with the airspeed about 380 kts and in a 53° left bank. At 1027:11, the CVR recorded the pilot shouting a radio transmission, “mayday mayday mayday citation five two five echo golf is in an emergency descent unable to gain control of the aircraft.” At 1027:16, the CVR recorded the EGPWS annunciating “terrain terrain.” The sound of impact was recorded about 1027:20. The total time from the beginning of the left roll until ground impact was about 35 seconds. The accident site was located about 8.5 miles northwest of JVY.
Probable cause:
The asymmetric deployment of the left wing load alleviation system for undetermined reasons, which resulted in an in-flight upset from which the pilot was not able to recover.
Final Report:

Crash of a Cessna 441 Conquest II in Harmon: 3 killed

Date & Time: Nov 18, 2018 at 2240 LT
Type of aircraft:
Operator:
Registration:
N441CX
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bismarck - Williston
MSN:
441-0305
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4685
Captain / Total hours on type:
70.00
Circumstances:
The pilot and two medical crewmembers were repositioning the airplane to pick up a patient for aeromedical transport. Dark night instrument meteorological conditions prevailed for the flight. Radar data showed the airplane climb to 14,000 ft mean sea level after departure and proceed direct toward the destination airport before beginning a right descending turn. The airplane subsequently broke up inflight and impacted terrain. No distress calls were received from the pilot before the accident. Although weather conditions were conducive for inflight icing, no evidence of structural icing was identified at the scene. The debris field was 2,500 ft long and the disbursement of the wreckage confirmed that both wings, the horizontal stabilizer, both elevators, and both engines separated from the airplane before impacting the ground. Examination of the wreckage revealed that the initiating failure was the failure of the wing where it passed through the center of the airplane. The three wing spars exhibited S-bending deformation, indicative of positive overload producing compressive buckling and fracture. Further, impact signatures as black paint transfers and gouged aluminum, were consistent with the left outboard wing separating when it was struck by the right engine after the wing spars failed. There was no evidence of any pre-exiting conditions that would have degraded the strength of the airplane structure at the fracture locations. Flight control continuity was confirmed. An examination of the engines, propellers, and available systems showed no mechanical malfunctions or failure that could have contributed to the accident. The descending right turn was inconsistent with the intended flight track and ATC-provided clearance. However, there was insufficient information to determine how it was initiated and when the pilot became aware of the airplane's state in the dark night IMC conditions. Yet, the
absence of a distress call or communication with ATC about the airplane's deviation suggests that the pilot was not initially aware of the change in state. The structural failure signatures on the airplane were indicative of the wings failing in positive overload, which was consistent with the pilot initiating a pullup maneuver that exceeded the airplane spars' structural integrity during an attempted recovery from the spiral dive.
Probable cause:
The pilot's failure to maintain control of the airplane in dark night conditions that resulted in an in-flight positive overload failure of the wings and the subsequent in-flight breakup of the airplane.
Final Report:

Crash of a Boeing 737 MAX 8 off Jakarta: 189 killed

Date & Time: Oct 29, 2018 at 0631 LT
Type of aircraft:
Operator:
Registration:
PK-LQP
Flight Phase:
Survivors:
No
Schedule:
Jakarta - Pangkal Pinang
MSN:
43000
YOM:
2018
Flight number:
JT610
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
181
Pax fatalities:
Other fatalities:
Total fatalities:
189
Captain / Total flying hours:
6028
Captain / Total hours on type:
5176.00
Copilot / Total flying hours:
5174
Copilot / Total hours on type:
4286
Aircraft flight hours:
895
Aircraft flight cycles:
443
Circumstances:
The aircraft departed runway 25L at Jakarta-Soekarno-Hatta Airport at 0621LT bound for Pangkal Pinang, carrying 181 passengers and 8 crew members. The crew was cleared to climb but apparently encountered technical problems and was unable to reach a higher altitude than 5,375 feet. At this time, the flight shows erratic speed and altitude values. The pilot declared an emergency and elected to return to Jakarta when control was lost while at an altitude of 3,650 feet and at a speed of 345 knots. The airplane entered a dive and crashed 12 minutes after takeoff into the Kerawang Sea, about 63 km northeast from its departure point. The airplane disintegrated on impact and few debris were already recovered but unfortunately no survivors. It has been reported that the aircraft suffered various technical issues during the previous flight on Sunday night but was released for service on Monday morning. Brand new, the airplane was delivered to Lion Air last August 18. At the time of the accident, weather conditions were considered as good. The Cockpit Voice Recorder (CVR) was found on 14 January 2019. In the initial stages of the investigation, it was found that there is a potential for repeated automatic nose down trim commands of the horizontal stabilizer when the flight control system on a Boeing 737 MAX aircraft receives an erroneously high single AOA sensor input. Such a specific condition could among others potentially result in the stick shaker activating on the affected side and IAS, ALT and/or AOA DISAGREE alerts. The logic behind the automatic nose down trim lies in the aircraft's MCAS (Maneuvering Characteristics Augmentation System) that was introduced by Boeing on the MAX series aircraft. This feature was added to prevent the aircraft from entering a stall under specific conditions. On November 6, 2018, Boeing issued an Operations Manual Bulletin (OMB) directing operators to existing flight crew procedures to address circumstances where there is erroneous input from an AOA sensor. On November 7, the FAA issued an emergency Airworthiness Directive requiring "revising certificate limitations and operating procedures of the airplane flight manual (AFM) to provide the flight crew with runaway horizontal stabilizer trim procedures to follow under certain conditions.
Probable cause:
Contributing factors defines as actions, omissions, events, conditions, or a combination thereof, which, if eliminated, avoided or absent, would have reduced the probability of the accident or incident occurring, or mitigated the severity of the
consequences of the accident or incident. The presentation is based on chronological order and not to show the degree of contribution.
1. During the design and certification of the Boeing 737-8 (MAX), assumptions were made about flight crew response to malfunctions which, even though consistent with current industry guidelines, turned out to be incorrect.
2. Based on the incorrect assumptions about flight crew response and an incomplete review of associated multiple flight deck effects, MCAS’s reliance on a single sensor was deemed appropriate and met all certification requirements.
3. MCAS was designed to rely on a single AOA sensor, making it vulnerable to erroneous input from that sensor.
4. The absence of guidance on MCAS or more detailed use of trim in the flight manuals and in flight crew training, made it more difficult for flight crews to properly respond to uncommanded MCAS.
5. The AOA DISAGREE alert was not correctly enabled during Boeing 737-8 (MAX) development. As a result, it did not appear during flight with the mis-calibrated AOA sensor, could not be documented by the flight crew and was therefore not available to help maintenance identify the mis-calibrated AOA sensor.
6. The replacement AOA sensor that was installed on the accident aircraft had been mis-calibrated during an earlier repair. This mis-calibration was not detected during the repair.
7. The investigation could not determine that the installation test of the AOA sensor was performed properly. The mis-calibration was not detected.
8. Lack of documentation in the aircraft flight and maintenance log about the continuous stick shaker and use of the Runaway Stabilizer NNC meant that information was not available to the maintenance crew in Jakarta nor was it available to the accident crew, making it more difficult for each to take the appropriate actions.
9. The multiple alerts, repetitive MCAS activations, and distractions related to numerous ATC communications were not able to be effectively managed. This was caused by the difficulty of the situation and performance in manual handling, NNC execution, and flight crew communication, leading to ineffective CRM application and workload management. These performances had previously been identified during training and reappeared during the accident flight.
Final Report:

Crash of a Cessna 340A in Santa Cruz

Date & Time: Oct 28, 2018 at 1030 LT
Type of aircraft:
Operator:
Registration:
N5224J
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Santa Cruz - Manaus
MSN:
340A-1035
YOM:
1980
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane was engaged in a humanitarian flight from Bolivia to Brazil, carrying one passenger and a pilot. Shortly after takeoff from a little private airstrip located in the suburb of Santa Cruz, the crew was supposed to land at Santa Cruz-Viru Viru International Airport before continuing to Manaus, Brazil. After takeoff, the pilot encountered engine problems (power issue) and decided to return for an emergency landing when the airplane struck trees and belly landed in a grassy area located in Barrio Lindo. Both occupants were uninjured while the aircraft was damaged beyond repair.

Crash of a Piper PA-46-350P Malibu Mirage in Hurricane

Date & Time: Oct 21, 2018 at 1500 LT
Registration:
N413LL
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Hurricane - Salt Lake City
MSN:
46-36413
YOM:
2007
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7000
Captain / Total hours on type:
1500.00
Aircraft flight hours:
1088
Circumstances:
Shortly after takeoff, the pilot smelled smoke. As he began to turn the airplane back to the airport, the engine lost total power. He conducted a forced landing in a field just short of the airport, during which the airplane struck a metal fence and pipe. All occupants egressed, and the pilot then noticed that a fire had erupted under the airplane's engine cowling. Postaccident examination revealed that the airplane sustained fire damage to the roof and forward end of the baggage compartment along with the engine accessory area between the firewall and aft air baffles. Further examination revealed that one of the engine exhaust crossover pipe assemblies was misaligned at the slip joint. An engine manufacturer service bulletin (SB) called for inspections of the exhaust system slip and flange joints to identify misaligned exhaust components. The last maintenance event occurred about 7 1/2 flight hours before the accident, during which the SB was performed and resulted in the replacement of crossover pipes. The mechanic who had performed the most recent maintenance did not follow the correct procedures for reinstallation of the crossover pipe, and the inspector who reviewed his work did not examine the installation as it progressed but instead inspected the pipes after they were installed and essentially hidden from view by their protective heat shield. As a result of the misaligned engine exhaust crossover pipe, hot exhaust gases escaped into the engine compartment and started a fire, which compromised critical engine fuel and oil lines, and resulted in the loss of engine power.
Probable cause:
The mechanic's failure to properly align the engine exhaust crossover pipe during replacement, and his supervisor's failure to properly inspect the installation, which resulted in an in-flight fire and the loss of engine power.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Igiugig

Date & Time: Sep 20, 2018 at 1530 LT
Type of aircraft:
Operator:
Registration:
N121AK
Flight Phase:
Survivors:
Yes
MSN:
121
YOM:
1951
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12496
Captain / Total hours on type:
5000.00
Circumstances:
The pilot of the float-equipped airplane reported that, during the initial climb after a water takeoff, about 200 feet, he turned right, and the engine lost power. He immediately switched fuel tanks and attempted to restart the engine to no avail. The airplane descended and struck trees, and the right wing impacted terrain. The airplane sustained substantial damage to the right wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The pilot reported to the Federal Aviation Administration inspector that, during the initial climb and after the engine lost power, he noticed that the center tank, which was selected for takeoff, was empty. He added that passengers stated that the engine did regain power after switching tanks, but the airplane had already struck trees. The pilot reported as a recommendation to more closely follow checklists.
Probable cause:
The pilot's selection of an empty fuel tank for takeoff, which resulted in fuel starvation and the subsequent total loss of engine power.
Final Report:

Crash of a Grumman G-64 in the Atlantic Ocean

Date & Time: Aug 25, 2018
Type of aircraft:
Operator:
Registration:
N1955G
Flight Phase:
Survivors:
Yes
Schedule:
Elizabeth City - Elizabeth City
MSN:
G-406
YOM:
1954
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew departed Elizabeth City CGAS in North Carolina to deploy weather buoys in the Atlantic Ocean. Several landings were completed successfully. While taking off, the seaplane struck an unkknown object floating on water and came to rest some 680 km east off Cape Hatteras, North Carolina. All five crew members evacuated the cabin and were later recovered by the crew of a container vessel. The aircraft sank and was lost.
Probable cause:
Collision with an unknown floating object while taking off.