Crash of a Cessna 421C Golden Eagle III in Presque Isle

Date & Time: Nov 22, 2017 at 1845 LT
Operator:
Registration:
N421RX
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Presque Isle – Bangor
MSN:
421C-0264
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4482
Captain / Total hours on type:
3620.00
Aircraft flight hours:
7473
Circumstances:
After takeoff, the commercial pilot saw flames coming from the left engine nacelle area. He retarded the throttle and turned off the fuel boost pump; however, the fire continued. He then feathered the propeller, shut down the engine, and maneuvered the airplane below the clouds to remain in the local traffic pattern. He attempted to keep the runway environment in sight while drifting in and out of clouds. He was unable to align the airplane for landing on the departure runway, so he attempted to land on another runway. When he realized that the airspeed was decreasing and that the airplane would not reach the runway, he landed it on an adjacent grass field. After touchdown, the landing gear separated, and the airplane came to a stop. The airframe sustained substantial damage to the wings and lower fuselage. Examination of the left engine revealed evidence of a fuel leak where the fuel mixture control shaft inserted into the fuel injector body, which likely resulted in fuel leaking onto the hot turbocharger in flight and the in-flight fire. A review of recent maintenance records did not reveal any entries regarding maintenance or repair of the fuel injection system. The pilot reported clouds as low as 500 ft with rain, snow, and reduced visibility at the time of the accident, which likely reduced his ability to see the runway and maneuver the airplane to land on it.
Probable cause:
The in-flight leakage of fuel from the fuel injection system's mixture shaft onto the hot turbocharger, which resulted in an in-flight fire, and the pilot's inability to see the runway due to reduced visibility conditions and conduct a successful landing.
Final Report:

Crash of a Cessna 208B Grand Caravan off Placencia

Date & Time: Nov 17, 2017 at 0846 LT
Type of aircraft:
Operator:
Registration:
V3-HGX
Flight Phase:
Survivors:
Yes
Schedule:
Placencia – Punta Gorda
MSN:
208B-1162
YOM:
2005
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19040
Captain / Total hours on type:
12092.00
Aircraft flight hours:
2106
Circumstances:
On 17 November, 2017, a Tropic Air Cessna 208B Grand Caravan with registration V3-HGX, departed from the Sir Barry Bowen Municipal Airport at approximately 7:15 a.m. local time with one aircraft captain, 11 passengers and 1 crew on board. The flight was a regular operated commercial passenger flight with scheduled stops in Dangriga, Placencia and with the final destination being Punta Gorda. The pilot reported that the portion of the flight from Belize City to Dangriga was uneventful and normal and so was the landing at Placencia. At approximately 8:40 a.m. local time the airplane taxied from the Tropic Air ramp and taxied towards the west on runway 25. The pilot did a turnaround using all the available runway at normal speed and started his takeoff run to the east on runway 07. The pilot proceeded down the runway in a normal takeoff roll with normal takeoff speed and prior to reaching the end of the runway, he rotated the aircraft and lifted the nose wheel to get airborne. At exactly 28 feet past the end of runway 07 and during the initial climb phase, a part of the aircraft landing gear made contact with the upper part of the front righthand passenger door frame of a vehicle that had breached the area in front of the runway which is normally protected by traffic barriers. The impact caused the aircraft to deviate from its initial climb profile, and the pilot reported that the engine was working for a couple seconds and it abruptly shut down shortly after. The pilot realized that he was unable to return to the airport. The pilot carried out emergency drills for engine loss after take-off over water and decided to ditch the aircraft in the sea, which was approximately 200-300 feet from the main shoreline in front of the Placencia airport. The flight crew and all passengers were safely evacuated from the fuselage with the assistance of witnesses and passing boats which provided an impromptu rescue for the passengers. All passengers received only minor injuries.
Probable cause:
The following are factors that are derived from the failures in the areas mentioned in section 3.00 (conclusions):
a. There is a lack of traffic surveillance to ensure that drivers comply with the warning signs of low flying aircraft and do not breach the barriers when they are down or inoperative. The left barrier at Placencia was reportedly inoperative and the right barrier was said to be working. As a result, this removed a significant level of protection for vehicles which operate on the portion of the road which intersects the departure path of aircraft. The purpose of the barriers is to protect vehicles from coming in close contact with low flying aircraft. The driver of the vehicle failed to adhere to traffic warning signs regarding low flying aircraft and drove his vehicle directly into the departure path of an aircraft (Probable cause).
b. ADAS data calculations showed that the pilot had a period of 13.33 seconds when he achieved take off performance, but he did not rotate the aircraft. Although the aircraft engine performance was normal, the actual take-off weight was within limits and the distance available to the pilot to abort the take-off was 872 feet; the pilot still flew the aircraft at a dangerously low altitude over the road and did not properly assess the risk at hand which was a vehicle advancing into the aircraft’s departure path which could cause a collision. (Probable cause).
c. The angle at which the aircraft made contact with the vehicle was not a direct head on angle, but the contact was made when the vehicle was off to the right-hand side of the extended centerline of runway 07. The aircraft did not follow the direct path of the extended center line of runway 07 prior to making contact, but instead it made a slight right turn shortly after the wheels left the ground. The pilot did not take collision avoidance (evasive) measures in a timely manner (probable cause).
d. The pilot did not demonstrate adequate knowledge of proper ditching procedures which led to an inadequate response to the emergency at hand. The operator did not provide the flight crew with the proper ditching training.

Probable causes:
1. The driver of the vehicle failed to adhere to traffic warning signs regarding low flying aircraft and drove his vehicle directly into the departure path of an aircraft.
2. The pilot flew the aircraft at a dangerously low altitude over the road and did not properly assess the risk at hand which was a vehicle advancing into the aircraft’s departure path which could cause a collision.
3. The pilot did not take collision avoidance (evasive) measures in a timely manner.
Final Report:

Crash of a Quest Kodiak 100 in Goiás

Date & Time: Nov 10, 2017 at 1327 LT
Type of aircraft:
Operator:
Registration:
N154KQ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lucas do Rio Verde – Anápolis
MSN:
100-0154
YOM:
2015
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3000
Captain / Total hours on type:
8.00
Circumstances:
The aircraft took off from the Bom Futuro Municipal Aerodrome (SILC), Lucas do Rio Verde - MT, to the Anápolis Aerodrome (SWNS) - GO, in order to carry out a transfer flight, with a pilot and three passengers on board. During the flight, the pilot identified conflicting information related to the amount of fuel remaining and chose to make an intermediate landing on an unapproved runway, located in the city of Goiás Velho - GO, in order to check the data visually. After the conference, the N154KQ took off from that location and, reaching approximately 300ft height, the aircraft lost power, colliding with vegetation 1.86 km from the runway used for takeoff. The aircraft was destroyed by the fire. The pilot suffered serious injuries and the three passengers suffered minor injuries.
Probable cause:
Contributing factors:
- Attitude – a contributor
The pilot's failure to monitor the fueling showed a complacent attitude regarding the verification of conditions that could affect flight safety. Therefore, the lack of knowledge about the real fuel levels implied the insertion of wrong data and an intermediate landing to check the situation, after its identification.
- Training – undetermined
It is possible that the pilot's little familiarization with the aircraft emergency procedures delayed the identification of the situation and limited his possibilities of action.
- Insufficient pilot’s experience – undetermined
The pilot's little experience on the aircraft may have slowed his ability to recognize the emergency and to perform the actions described in the checklist efficiently.
Final Report:

Crash of a Mitsubishi MU-2B-40 Solitaire in Ainsworth: 1 killed

Date & Time: Sep 23, 2017 at 1028 LT
Type of aircraft:
Registration:
N73MA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ainsworth – Bottineau
MSN:
414
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3775
Captain / Total hours on type:
2850.00
Aircraft flight hours:
5383
Circumstances:
The instrument-rated private pilot departed on a cross-country flight in instrument meteorological conditions (IMC) with an overcast cloud layer at 500 ft above ground level (agl)
and visibility restricted to 1 ¾ miles in mist, without receiving an instrument clearance or opening his filed instrument flight rules flight plan. There was an outage of the ground communications system at the airport and there was no evidence that the pilot attempted to open his flight plan via his cellular telephone. In addition, there was a low-level outage of the radar services in the vicinity of the accident site and investigators were unable to determine the airplane's route of flight before impact. The airport manager observed the accident airplane depart from runway 35 and enter the clouds. Witnesses located to the north of the accident site did not see the airplane but reported hearing an airplane depart about the time of the accident. One witness reported hearing a lowflying airplane and commented that the engines sounded as if they were operating at full power. The witness heard a thud as he was walking into his home but attributed it to a thunderstorm in the area. The airplane impacted a field about 3.5 miles to the northeast of the departure end of the runway and off the track for the intended route of flight. The airplane was massively fragmented during the impact and debris was scattered for about 300 ft. The damage to the airplane and ground scars at the accident site were consistent with the airplane impacting in a left wing low, nose low attitude with relatively high energy. A postaccident examination of the engines and propeller assemblies did not reveal any preimpact anomalies that would have precluded normal operation. Signatures were consistent with both engines producing power and both propellers developing thrust at the time of impact. While the massive fragmentation precluded functional testing of the equipment, there was no damage or failure that suggested preimpact anomalies with the airframe or flight controls.Several days before the accident flight, the pilot encountered a "transient flag" on the air data attitude heading reference system. The pilot reported the flag to both the co-owner of the airplane and an avionics shop; however, exact details of the flag are not known. The unit was destroyed by impact forces and could not be functionally tested. If the flag affecting the display of attitude information had occurred with the unit after takeoff, the instrument panel had adequate stand-by instrumentation from which the pilot could have continued the flight. It is not known if this unit failed during the takeoff and investigators were unable to determine what role, if any, this transient issue may have played in the accident. Based upon the reported weather conditions, the location of the wreckage, and the attitude of the airplane at the time of impact with the ground, it is likely that the pilot experienced spatial disorientation shortly after takeoff which resulted in a loss of control and descent into terrain.
Probable cause:
The pilot's loss of airplane control due to spatial disorientation.
Final Report:

Crash of a Cessna 402B in Nantucket

Date & Time: Sep 13, 2017 at 0723 LT
Type of aircraft:
Registration:
N836GW
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nantucket – Hyannis
MSN:
402B-1242
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1500
Captain / Total hours on type:
1100.00
Aircraft flight hours:
4928
Circumstances:
The commercial pilot stated that, shortly after taking off for a cross-country, personal flight and while accelerating, he noticed high airplane nose-down control forces and that the airplane became increasingly difficult to control. He used manual trim to attempt to trim out the control forces and verified that the autopilot was not engaged; however, the nose-down tendency continued, and the pilot had trouble maintaining altitude. During the subsequent emergency landing, the airframe sustained substantial damage. Postaccident examination of the airplane revealed that the elevator trim push rod assembly was separated from the elevator trim tab actuator, and the end of the elevator trim push rod assembly was found wedged against the elevator's main spar. The elevator trim indicator in the cockpit was found in the nose-up stop position; however, the elevator trim tab was deflected 24° trailing edge up/airplane nose down (the maximum airplane nose-down setting is 6°). A drilled bolt was recovered from inside the right elevator; however, the associated washer, castellated nut, and cotter pin were not found. Examination of the bolt revealed that the threads were damaged and that the bolt hole on one of the clevis yoke halves exhibited deformation, consistent with the bolt separating. About 2 weeks before the accident, the pilot flew the airplane to a maintenance facility for an annual inspection. At that time, Airworthiness Directive (AD) 2016-07-24, which required installation of new hardware at both ends of the pushrod for the elevator trim tab, was overdue. While the airplane was in for the annual inspection, AD 2016-07-24 was superseded by AD 2016-17-08, which also required the installation of new hardware. The ADs were issued to prevent jamming of the elevator trim tab in a position outside the normal limits of travel due to the loss of the attachment hardware connecting the elevator trim tab actuator to the elevator trim tab push-pull rod, which could result in loss of airplane control. While in for the annual inspection, the airplane was stripped and painted, which would have required removal of the right elevator. Although the repair station personnel indicated that they did not disconnect the elevator trim pushrod from the elevator trim tab actuator when they painted the airplane, photographs taken of the airplane while it was undergoing inspection and painting revealed that the pushrod likely had been disconnected. The repair station owner reported that he reinstalled the right elevator and the elevator trim pushrod after the airplane was painted; however, he did not replace the hardware at either end of the pushrod as required by the ADs. Subsequently, the airplane was approved for return to service. After the annual inspection, no work, repairs, or adjustments were made to the elevator trim system. The airplane had accrued about 58 hours since the annual inspection at the time of the accident. Although reusing the self-locking nut might have resulted in it coming off by itself, the cotter pin should have prevented this from happening. Therefore, although the castellated self-locking nut, washer, and cotter pin normally used to secure the elevator trim pushrod at the elevator trim tab actuator were not found, given the evidence it is likely that the hardware, which was not the required hardware, was not properly secured at installation, which allowed it to separate in flight. It is also likely that the pushrod assembly then moved aft and jammed in a position well past the maximum nose-down trim setting, which rendered controlled flight impossible.
Probable cause:
The separation of the pushrod from the elevator trim tab actuator, which rendered controlled flight impossible. Contributing to the separation of the pushrod was the failure of maintenance personnel to properly secure it to the elevator trim tab actuator.
Final Report:

Crash of a Piper PA-61P Aerostar (Ted Smith 601P) in Donegal Springs

Date & Time: Aug 19, 2017 at 1642 LT
Operator:
Registration:
N7108
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Donegal Springs - Donegal Springs
MSN:
61-0405-142
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
400
Captain / Total hours on type:
1.00
Aircraft flight hours:
3957
Circumstances:
The commercial pilot stated that, during the takeoff roll, the airplane swerved to the right, and he corrected to the left and aborted the takeoff; however, the airplane departed the left side of the runway and collided with an embankment. At the time of the accident, a quartering tailwind was present. The pilot had no previous experience in the accident airplane make and model or in any other multiengine airplane equipped with engines capable of producing 300 horsepower. During a postaccident conversation with a mechanic, the pilot stated that the airplane "got away from him" during the attempted takeoff. Because a postaccident examination of the airplane did not reveal any evidence of a preimpact mechanical malfunction or failure of the airplane's flight controls or nosewheel steering system that would have precluded normal operation and the pilot did not have any previous experience operating this make and model of airplane, it is likely that the pilot lost directional control during takeoff with a quartering tailwind.
Probable cause:
The pilot's failure to maintain directional control during takeoff with a quartering tailwind. Contributing to the accident was the pilot's lack of experience in the accident airplane make and model.
Final Report:

Crash of an Antonov AN-74TK-100 in São Tomé

Date & Time: Jul 29, 2017 at 0905 LT
Type of aircraft:
Operator:
Registration:
UR-CKC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
São Tomé – Accra
MSN:
470 95 905
YOM:
1992
Flight number:
CVK7087
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12847
Captain / Total hours on type:
986.00
Copilot / Total flying hours:
5389
Copilot / Total hours on type:
618
Aircraft flight hours:
5104
Circumstances:
On 29th July, 2017 at about 0905hrs, an Antonov aircraft Model AN-74TK-100, flight CVK7087, registration UR-CKC, owned by SWIFT SOLUTION FZC and operated by CAVOK Airlines LLC was departing Sao Tome International Airport to Kotoka International Airport, Accra, for positioning with six crew on board. The flight was on an Instrument Flight Rule (IFR) flight plan and Visual Meteorological Conditions prevailed. The aircraft exited runway 29 during a rejected take off. The Flight Navigator sustained an injury and the aircraft was destroyed. On 28th July, 2017 at 0225hrs the aircraft arrived Sao Tome International Airport from Stavanger (Norway), via Luxemburg and Ghardaia (Algeria) as a Cargo flight. On 29th July, 2017 at about 0800hrs, the crew of CVK 7087 comprising the Captain, the First Officer, the Flight Engineer, the Flight Navigator and 2 Maintenance Engineers arrived the airport and commenced the flight preparation; pre-flight inspection, determination of weight and balance, computation of performance and take-off speeds. The crew received flight briefing/weather information and refuelled the aircraft with an uplift of 5,700kg. At 0850hrs, the crew requested engine start-up clearance from Sao Tome Tower and it was approved. After completing the engine start procedures, engine parameter indications on both engines were normal. Appropriate checklist was completed and taxi clearance was requested by the crew. Sao Tome Tower initially cleared CVK 7087 to taxi on runway (RWY) 11 as favoured by the prevailing wind. However, the crew requested RWY 29 for departure. This request was approved by the Tower and the aircraft re-cleared to taxi to RWY 29 for departure. Sao Tome Tower did not provide the flight crew with the information about possible presence of birds at the aerodrome, in particular, on the runway. At 0905hrs, the aircraft began the take-off roll. The First Officer was the Pilot Flying (PF) while the Captain was the Pilot Monitoring (PM). The engines and systems parameters were reported to be normal. According to the Captain, "In the first half of the take-off run from the runway, from five to six eagles got off the ground of the runway and flew dangerously close to the aircraft". He then requested the Flight Engineer to check if the flood lights were ON and to monitor the engine parameters. The crew asserted that they observed a rising and narrowing runway as the aircarft accelerated to a speed of 180 km/hr. They stated further: "At a speed of 180 km/hr, ahead, a flock of eagles, which were not seen before this moment began to get off the ground from the runway." The Captain took control of the aircraft and decided, after assessing the situation within 4 seconds that the best option for the crew was to discontinue the take-off. At that moment, the crew heard a bang, which they suggested could be a bird strike. This was followed by aural and visual indications on the annunciator panel such as “Left Engine Failure”, “Dangerous Vibration”, and “Take-off is prohibited” and the Captain immediately initiated a rejected take-off and instructed the Flight Engineer to deploy thrust reversers. The rejected takeoff was initiated about 5 seconds after sighting the birds, at a speed of 220km/h. According to the Captain, his decision was necessitated by the consideration of losing multiple engines due to bird strike if the take-off continued. The Captain said he pressed the brake pedals completely immediately after initiating the rejected take-off, subsequently he assessed the braking action as not effective and he used the emergency braking at a speed of about 130 km/h. On realizing that the aircraft would not stop within the remaining available runway length (about 272.3m) coupled with the presence of a ravine at the end, the captain intentionally veered to the right in order to extend the runway stopping distance and also avoid the ravine. The aircraft exited the runway at a speed of approximately 76 km/h. As the aircraft’s speed decayed to 60 km/h and just before the aircraft exited the runway, the Captain instructed the Flight Engineer to close the fuel emergency shutoff cock. The aircraft travelled a distance of about 95m from the exit point before plunging into the ravine. In the process, the forward fuselage separated from the bulkhead located immediately after the cockpit section. The aircraft came to rest at a location with coordinates: N002° 2' 51'' and E006° 42' 07''. The accident occurred in daylight at about 0905hrs.
Probable cause:
The investigation determines that the cause of this accident as:
Due to the presence of birds on the runway, the take-off was rejected at a speed above decision speed V1, which is inconsistent with CAVOK’s Standard Operating Procedures (SOP).
Contributory factors:
The contributory factors to this accident include but are not limited to the following:
- Failure of the crew to deploy interceptors (speed brakes/spoilers).
- Inadequate flight crew training on details of rejected take-off procedure scenarios.
- The omission of the take-off briefing in CAVOK’s Normal Operations checklist.
- Poor Crew Resource Management (CRM), especially in a multi-crew flight operation.
Final Report:

Crash of a Mitsubishi MU-2B-26A Marquise near San Fernando: 3 killed

Date & Time: Jul 24, 2017 at 1430 LT
Type of aircraft:
Operator:
Registration:
LV-MCV
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
San Fernando – Las Lomitas
MSN:
361
YOM:
1977
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
682
Captain / Total hours on type:
58.00
Aircraft flight hours:
5804
Aircraft flight cycles:
4670
Circumstances:
Shortly after takeoff from San Fernando Airport in Buenos Aires, while in initial climb, the pilot was contacted by ATC about an apparent transponder issue. The crew did not respond when, few seconds later, the twin engine airplane entered an uncontrolled descent and crashed in a marshy area located in the delta of Paraná de la Palmas. The wreckage was found on August 19 about 17 km north of San Fernando Airport. The aircraft disintegrated on impact and all three occupants were killed.
Crew:
Matías Ronzano,
Passengers:
Emanuel Vega,
Matías Aristi.
Probable cause:
Loss of control during climb due to the combination of the following factors:
- The particular characteristics of the aircraft;
- The attention required by the transponder as it is not displayed by air traffic control;
- The detour of the planned flight at the request of the inspection department of air traffic;
- Aircraft trajectory management with autopilot switched off;
- The pilot's limited experience in instrument flight conditions. In addition, the absence of additional instruction in the aircraft type (due to the lack of specific regulations) can be considered a contributing factor, according to the probable scenario described above. In addition, the research identified the following elements with potential impact in operational safety:
- Absence of the TAWS system on the aircraft in non-conformity with the established RAAC 91;
- Lack of effective means to enable the flight plan office to quickly determine whether an aircraft has operating restrictions;
- Shortcomings in the training of staff in the units ATS and SAR in search and rescue.
Final Report:

Crash of a Piper PA-31T1 Cheyenne in Tyler: 2 killed

Date & Time: Jul 13, 2017 at 0810 LT
Type of aircraft:
Operator:
Registration:
N47GW
Flight Phase:
Survivors:
No
Schedule:
Tyler - Midland
MSN:
31T-8104030
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
17590
Aircraft flight hours:
5685
Circumstances:
The airline transport rated pilot and passenger departed on a cross-country business flight in a twin-engine, turbo-propeller-equipped airplane in day, visual meteorological conditions. Shortly after takeoff, the airplane banked left, descended, and impacted terrain about 1/2 mile from the end of the runway. There was not a post-crash fire and fuel was present on site. A postaccident airframe examination did not reveal any anomalies that would have precluded normal operation. Examination of the left engine found signatures consistent with the engine producing power at impact. Examination of the right engine revealed rotational scoring on the compressor turbine disc/blades, and rotational scoring on the upstream side of the power vane and baffle, which indicated that the compressor section was rotating at impact; however, the lack of rotational scoring on the power turbine disc assembly, indicated the engine was not producing power at impact. Testing of the right engine's fuel control unit, fuel pump, propeller governor, and overspeed governor did not reveal any abnormities that would have accounted for the loss of power. The reason for the loss of right engine power could not be determined based on the available information.
Probable cause:
The loss of engine power and the subsequent pilot's loss of control for reasons that could not be determined because post-accident engine examination revealed no anomalies.
Final Report:

Crash of a Beechcraft E90 King Air in Ruidoso: 2 killed

Date & Time: Jun 13, 2017 at 2210 LT
Type of aircraft:
Operator:
Registration:
N48TA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ruidoso – Abilene
MSN:
LW-283
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1073
Captain / Total hours on type:
25.00
Aircraft flight hours:
12621
Circumstances:
The commercial pilot had filed an instrument flight rules flight plan and was departing in dark night visual meteorological conditions on a cross-country personal flight. A witness at the departure airport stated that during takeoff, the airplane sounded and looked normal. The witness said that the airplane lifted off about halfway down runway 24, and there was "plenty" of runway remaining for the airplane to land. The witness lost sight of the airplane and did not see the accident because the airport hangars blocked her view. The wreckage was located about 2,400 ft southeast of the departure end of runway 24. Examination of the accident site indicated that the airplane impacted in a nose-down attitude with a left bank of about 20°. A left turn during departure was consistent with the airport's published instrument departure procedures for obstacle avoidance, which required an immediate climbing left turn while proceeding to a navigational beacon located about 7 miles east-northeast of the airport. Examination of the wreckage did not reveal any evidence of preimpact mechanical malfunctions that would have precluded normal operation. The pilot had reportedly been awake for about 15 hours and was conducting the departure about the time he normally went to sleep and, therefore, may have been fatigued about the time of the event; however, given the available evidence, it was impossible to determine the role of fatigue in this event. Although the circumstances of the accident are consistent with spatial disorientation, there was insufficient evidence to determine whether it may have played a role in the sequence of events.
Probable cause:
The pilot's failure to maintain clearance from terrain after takeoff during dark night conditions.
Final Report: