Crash of a Beechcraft B200 Super King Air in Melbourne: 5 killed

Date & Time: Feb 21, 2017 at 0858 LT
Registration:
VH-ZCR
Flight Phase:
Survivors:
No
Site:
Schedule:
Melbourne - King Island
MSN:
BB-1544
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
7681
Captain / Total hours on type:
2400.00
Aircraft flight hours:
6997
Circumstances:
On 21 February 2017, the pilot of a Beechcraft B200 King Air aircraft, registered VH-ZCR (ZCR), and operated by Corporate & Leisure Aviation, was conducting a charter passenger flight from Essendon Airport, Victoria to King Island, Tasmania. There were four passengers on board. ZCR had been removed from a hangar and parked on the apron the previous afternoon in preparation for the flight. The pilot was first seen on the apron at about 0706 Eastern Daylight-saving Time. Closed-circuit television recorded the pilot walking around the aircraft and entering the cabin, consistent with conducting a pre-flight inspection of the aircraft. At about 0712, the pilot entered ZCR’s maintenance provider’s hangar. A member of staff working in the hangar reported that the pilot had a conversation with him that was unrelated to the accident flight. The pilot exited the hangar about 0715 and had a conversation with another member of staff who reported that their conversation was also unrelated to the accident flight. The pilot then returned to ZCR, and over the next 4 minutes he was observed walking around the aircraft. The pilot went into the cabin and re-appeared with an undistinguishable item. The pilot then walked around the aircraft one more time before re-entering the cabin and closing the air stair cabin door. At about 0729, the right engine was started and, shortly after, the left engine was started. Airservices Australia (Airservices) audio recordings indicated that, at 0736, the pilot requested a clearance from Essendon air traffic control (ATC) to reposition ZCR to the southern end of the passenger terminal. ATC provided the clearance and the pilot commenced taxiing to the terminal. At the terminal, ZCR was refueled and the pilot was observed on CCTV to walk around the aircraft, stopping at the left and right engines before entering the cabin. The pilot was then observed to leave the aircraft and wait for the passengers at the terminal. The passengers arrived at the terminal at 0841 and were escorted by the pilot directly to the aircraft. At 0849, the left engine was started and, shortly after, the right engine was started. At 0853, the pilot requested a taxi clearance for King Island, with five persons onboard, under the instrument flight rules. ATC instructed the pilot to taxi to holding point 'TANGO' for runway 17, and provided an airways clearance for the aircraft to King Island with a visual departure. The pilot read back the clearance. Airservices Automatic Dependent Surveillance Broadcast (ADS-B) data (refer to section titled Air traffic services information - Automatic Dependent Surveillance Broadcast data) indicated that, at 0854, ZCR was taxied from the terminal directly to the holding point. The aircraft did not enter the designated engine run-up bay positioned near holding point TANGO. At 0855, while holding at TANGO, the pilot requested a transponder code. The controller replied that he did not have one to issue yet. Two minutes later the pilot contacted ATC and stated that he was ready and waiting for a transponder code. The controller responded with the transponder code and a clearance to lineup on runway 17. At 0858, ATC cleared ZCR for take-off on runway 17 with departure instructions to turn right onto a heading of 200°. The pilot read back the instruction and commenced the takeoff roll. The aircraft’s take-off roll along runway 17 was longer than expected. Witnesses familiar with the aircraft type observed a noticeable yaw to the left after the aircraft became airborne. The aircraft entered a relatively shallow climb and the landing gear remained down. The shallow climb was followed by a substantial left sideslip, while maintaining a roll attitude of less than 10° to the left. Airservices ADS-B data indicated the aircraft reached a maximum height of approximately 160 ft above ground level while tracking in an arc to the left of the runway centreline. The aircraft’s track began diverging to the left of the runway centreline before rotation and the divergence increased as the flight progressed. Following the sustained left sideslip, the aircraft began to descend and at 0858:48 the pilot transmitted on the Essendon Tower frequency repeating the word ‘MAYDAY’ seven times in rapid succession. Approximately 10 seconds after the aircraft became airborne, and 2 seconds after the transmission was completed, the aircraft collided with the roof of a building in the Essendon Airport Bulla Road Precinct - Retail Outlet Centre (outlet centre), coming to rest in a loading area at the rear of the building. CCTV footage from a camera positioned at the rear of the building showed the final part of the accident sequence with post-impact fire evident; about 2 minutes later, first responders arrived onsite. At about 0905 and 0908 respectively, Victoria Police and the Metropolitan Fire Brigade arrived. The pilot and passengers were fatally injured and the aircraft was destroyed. There was significant structural, fire and water damage to the building. Additionally, two people on the ground received minor injuries and a number of parked vehicles were damaged.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain involving Beechcraft B200 King Air, registered VH-ZCR that occurred at Essendon Airport, Victoria on 21 February 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Contributing factors:
- The aircraft's rudder trim was likely in the full nose-left position at the commencement of the take-off.
- The aircraft's full nose-left rudder trim setting was not detected by the pilot prior to take-off.
- Following a longer than expected ground roll, the pilot took-off with full left rudder trim selected. This configuration adversely affected the aircraft's climb performance and controllability, resulting in a collision with terrain.

Other factors that increased risk:
- The flight check system approval process did not identify that the incorrect checklist was nominated in the operator’s procedures manual and it did not ensure the required checks, related to the use of the cockpit voice recorder, were incorporated.
- The aircraft's cockpit voice recorder did not record the accident flight, resulting in a valuable source of safety related information not being available.
- The aircraft's maximum take-off weight was likely exceeded by about 240 kilograms.
- Two of the four buildings within the Bulla Road Precinct Retail Outlet Centre exceeded the obstacle limitation surface (OLS) for Essendon Airport, however, the OLS for the departure runway was not infringed and VH-ZCR did not collide with those buildings.

Other findings:
- The presence of the building struck by the aircraft was unlikely to have increased the severity of the outcome of this accident.
- Both of the aircraft’s engines were likely to have been producing high power at impact.
Final Report:

Crash of a Casa 212 Aviocar 300M at Thebephatshwa AFB: 3 killed

Date & Time: Feb 9, 2017
Type of aircraft:
Operator:
Registration:
OC2
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Thebephatshwa - Gaborone
MSN:
394
YOM:
1993
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
Shortly after takeoff from Thebephatshwa AFB, en route to Gaborone, the twin engine aircraft went out of control and crashed 4 km from the airport. All three crew members were killed.

Crash of a Beechcraft 300 Super King Air in Tucson: 2 killed

Date & Time: Jan 23, 2017 at 1233 LT
Operator:
Registration:
N385KA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Tucson - Hermosillo
MSN:
FA-42
YOM:
1985
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
15100
Aircraft flight hours:
9962
Circumstances:
The pilot and the passenger departed on a cross-country, personal flight in the airplane that the operator had purchased the day before the accident. Shortly after takeoff from runway 11L, after reaching an altitude of about 100 to 150 ft above the runway in a nose-high pitch attitude, the airplane rolled left to an inverted position as its nose dropped, and it descended to terrain impact on airport property, consistent with an aerodynamic stall. Post-accident examination of the accident site revealed propeller strike marks separated at distances consistent with both propellers rotating at the speed required for takeoff and in a normal blade angle range of operation at impact. Both engines exhibited rotational scoring signatures that indicated the engines were producing symmetrical power and were most likely operating in the mid-to upper-power range at impact. The engines did not display any pre-impact anomalies or distress that would have precluded normal engine operation before impact. No evidence was found of any preexisting mechanical anomalies that would have precluded normal operation of the airplane. Toxicology testing revealed the pilot's use of multiple psychoactive substances including marijuana, venlafaxine, amphetamine, pseudoephedrine, clonazepam, and pheniramine. The wide variety of psychoactive effects of these medications precludes predicting the specific effects of their use in combination. However, it is likely that the pilot was impaired by the effects of the combination of psychoactive substances he was using and that those effects contributed to his loss of control. The investigation was unable to obtain medical records regarding any underlying neuropsychiatric disease(s); therefore, whether these may have contributed to the accident circumstances could not be determined.
Probable cause:
The pilot's exceedance of the airplane's critical angle of attack during takeoff, which resulted in an aerodynamic stall. Contributing to the accident was the pilot's impairment by the effects of a combination of psychoactive substances.
Final Report:

Crash of a Reims/Cessna F406 Caravan II in Sasakwa

Date & Time: Jan 2, 2017
Type of aircraft:
Operator:
Registration:
5H-WOW
Flight Phase:
Survivors:
Yes
MSN:
406-0060
YOM:
1991
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While taking off from runway 12/30 at Sasakwa Airfield, the twin engine aircraft went out of control and crashed, bursting into flames. All six occupants were injured, some seriously, and the aircraft burnt out.

Crash of a Cessna 525C CitationJet CJ4 off Cleveland: 6 killed

Date & Time: Dec 29, 2016 at 2257 LT
Type of aircraft:
Operator:
Registration:
N614SB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Cleveland – Columbus
MSN:
525C-0072
YOM:
2012
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
1205
Captain / Total hours on type:
56.00
Aircraft flight hours:
861
Circumstances:
The airplane entered a right turn shortly after takeoff and proceeded out over a large lake. Dark night visual conditions prevailed at the airport; however, the airplane entered instrument conditions shortly after takeoff. The airplane climb rate exceeded 6,000 fpm during the initial climb and it subsequently continued through the assigned altitude of 2,000 ft mean sea level. The flight director provided alerts before the airplane reached the assigned altitude and again after it had passed through it. The bank angle increased to about 62 degrees and the pitch attitude decreased to about 15 degrees nose down, as the airplane continued through the assigned heading. The bank angle ultimately decreased to about 25 degrees. During the subsequent descent, the airspeed and descent rate reached about 300 knots and 6,000 fpm, respectively. The enhanced ground proximity warning system (EGPWS) provided both "bank angle" and "sink rate" alerts to the pilot, followed by seven "pull up" warnings. A postaccident examination of the recovered wreckage did not reveal any anomalies consistent with a preimpact failure or malfunction. It is likely that the pilot attempted to engage the autopilot after takeoff as he had been trained. However, based on the flight profile, the autopilot was not engaged. This implied that the pilot failed to confirm autopilot engagement via an indication on the primary flight display (PFD). The PFD annunciation was the only indication of autopilot engagement. Inadequate flight instrument scanning during this time of elevated workload resulted in the pilot allowing the airplane to climb through the assigned altitude, to develop an overly steep bank angle, to continue through the assigned heading, and to ultimately enter a rapid descent without effective corrective action. A belief that the autopilot was engaged may have contributed to his lack of attention. It is also possible that differences between the avionics panel layout on the accident airplane and the airplane he previously flew resulted in mode confusion and contributed to his failure to engage the autopilot. The lack of proximal feedback on the flight guidance panel might have contributed to his failure to notice that the autopilot was not engaged.The pilot likely experienced some level of spatial disorientation due to the dark night lighting conditions, the lack of visual references over the lake, and the encounter with instrument meteorological conditions. It is possible that once the pilot became disoriented, the negative learning transfer due to the differences between the attitude indicator display on the accident airplane and the airplane previously flown by the pilot may have hindered his ability to properly apply corrective control inputs. Available information indicated that the pilot had been awake for nearly 17 hours at the time of the accident. As a result, the pilot was likely fatigued which hindered his ability to manage the high workload environment, maintain an effective instrument scan, provide prompt and accurate control inputs, and to respond to multiple bank angle and descent rate warnings.
Probable cause:
Controlled flight into terrain due to pilot spatial disorientation. Contributing to the accident was pilot fatigue, mode confusion related to the status of the autopilot, and negative learning transfer due to flight guidance panel and attitude indicator differences from the pilot's previous flight experience.
Final Report:

Crash of a Tupolev TU-154B-2 off Sochi: 92 killed

Date & Time: Dec 25, 2016 at 0525 LT
Type of aircraft:
Operator:
Registration:
RA-85572
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Moscow - Sochi - Hmeimim
MSN:
83A-572
YOM:
1983
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
84
Pax fatalities:
Other fatalities:
Total fatalities:
92
Aircraft flight hours:
6689
Circumstances:
The airplane departed Moscow-Chkhalovksy AFB at 0138LT on a flight to Hmeimin AFB located near Latakia, Syria, carrying 84 passengers and 8 crew members. At 0343LT, the aircraft landed at Sochi-Adler Airport to refuel. At 0525LT, the takeoff was initiated from runway 24. After a course of 34 seconds, the pilot-in-command initiated the rotation at a speed of 300 km/h. Shortly after liftoff, the undercarriage were raised and the pilot continued to climb with a nose-up angle of 15°. About 53 seconds after takeoff, at an altitude of 157 metres, the captain asked the flaps to be retracted while the aircraft was climbing to a height of 231 metres with a speed of 360 km/h. Following erroneous movements on the control column, the aircraft nosed down and its speed increased to 373 km/h when the GPWS alarm sounded in the cockpit. With a rate of descent of 30 metres per second, the aircraft reached the speed of 540 km/h, rolled to the left to an angle of 50° and eventually crashed in the sea some 1,270 metres offshore, at 05:25 and 49 seconds. The flight took 73 seconds between liftoff and impact with water. The wreckage was found 2,760 metres from the end of runway 24 and 340 metres to the left of its extended centerline, at a depth of 30 metres. The aircraft disintegrated on impact and all 92 occupants were killed, among them 64 members of the Alexandrov Choir of the Red Army, their Artistic Director, nine journalists, seven officers from the Ministry of Defence, two senior officials and one representative of a public Company who were traveling to Hmeimim Air Base to commemorate the New Year's Eve celebrations with Russian soldiers based in Syria.
Probable cause:
The accident was the consequence of a loss of control that occurred during initial climb by night over the sea after the pilot-in-command suffered a spatial disorientation due to an excessive neuropsychic stress combined with fatigue.

Crash of a Boeing 727-2J0F in Puerto Carreño: 5 killed

Date & Time: Dec 20, 2016 at 1722 LT
Type of aircraft:
Operator:
Registration:
HK-4544
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Puerto Carreño - Bogotá
MSN:
21105/1158
YOM:
1975
Flight number:
KRE157
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
8708
Captain / Total hours on type:
6822.00
Copilot / Total flying hours:
3285
Copilot / Total hours on type:
3285
Aircraft flight hours:
60199
Circumstances:
The crew started the takeoff procedure at 1718LT from Puerto Carreño-Germán Olano Airport Runway 07 which is 1,800 metres long. Following a long takeoff roll, the pilot-in-command initiated the rotation when the aircraft overran then rolled for about 95 metres. It collided with two perimeter fences, passed through a road then lifted off. During initial climb, the right main gear was torn off after it collided with a tree and the engine n°3 failed. The airplane continued to climb to an altitude of 790 feet then entered a right turn and eventually crashed in an open field located 7,5 km from the airport, bursting into flames. The flight engineer was seriously injured while five other occupants were killed.
Probable cause:
The following findings were identified:
- Inadequate flight planning by the operator of the aircraft, and by the crew, by failure to properly perform dispatch procedures, takeoff performance calculations and verification of limitations imposed by operational conditions of the aerodrome according to the configuration of the aircraft.
- Wrong crew decision making by not considering a key aspect affecting aircraft performance, such as the prevailing tailwind at takeoff.
- Erroneous selection of takeoff speeds V1/VR and V2, by the crew, corresponding to an aircraft without modification in its flap system, which led to rotate the aircraft with five more knots of speed, increasing the takeoff run.
- Erroneous rotation technique applied by the Pilot, delayed maneuver that extended the long takeoff run even more.
- Loss of components (landing gear, trailing inboard flap right) and damage to functional systems (loss of engine power n°3 and hydraulic system) necessary to control the aircraft in flight.
- Loss of control in flight generated by asymmetries of lift, power and emptying of the main hydraulic systems that exceeded the capacity of the crew and made it impossible to maintain adequate directional control and stability of the aircraft.
Contributing Factors:
- Non-compliance with the Aeronautical Regulations by the operating company of the aircraft, operating to an aerodrome unsuitable for the operation of B727-200 equipment, which, in addition, was not authorized for that type of aircraft in the company's Operating Specifications, approved by the Aeronautical Authority.
- Lack of standardization and supervision of the operating company of the aircraft, allowing the operation of the B727-200 equipment, to which a modification had been applied to the flap system, with the reference tables of speeds corresponding to the aircraft without modification.
- Execution of take-off with a weight that exceeded the maximum value established in the aircraft performance charts for the conditions prevailing at the Germán Olano airport.
- Omission of the crew by not activating the Standby hydraulic system, which might have allowed emergency hydraulic pressure, to regain control of the aircraft.
- Lack of supervision by the Aeronautical Authority, which allowed for several years the operation of equipment B727-200 of the company operating the aircraft at the Germán Olano aerodrome in Puerto Carreño, when the characteristics of the aerodrome did not allow it and without the operator being authorized to operate equipment B727-200 in that aerodrome.
Final Report:

Crash of a Beechcraft A100 King Air in Saint-Frédéric

Date & Time: Dec 12, 2016 at 0730 LT
Type of aircraft:
Operator:
Registration:
C-FONY
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Saint-Frédéric - Quebec
MSN:
B-154
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from runway 05 at Saint-Frédéric Airport, the twin engine deviated to the left. The pilot-in-command elected to correct the deviation and to maintain the airplane on the runway centerline but it veered off runway to the left and came to rest in the snow. Both pilots evacuated safely and the aircraft was damaged beyond repair.

Crash of a Quest Kodiak 100 in Moab: 1 killed

Date & Time: Dec 12, 2016 at 0537 LT
Type of aircraft:
Operator:
Registration:
N772RT
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Moab – Salt Lake City
MSN:
100-0140
YOM:
2015
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4635
Captain / Total hours on type:
243.00
Aircraft flight hours:
504
Circumstances:
The commercial pilot was departing on a routine positioning flight in dark night visual meteorological conditions. Footage from a security camera at the airport showed the airplane
take off normally and initiate a right turn, which was the established direction of traffic for the takeoff runway. The airplane continued the right turn, then entered an increasingly rapid descent and subsequently impacted terrain about 1 mile southwest from the airport. The wreckage distribution was consistent with a high-energy impact. Examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or anomalies that would have precluded normal operation. Autopsy and toxicology testing of the pilot did not reveal any evidence of impairment or incapacitation. Visual conditions prevailed in the area at the time of the accident; however, the setting Moon was obscured by cloud cover, and the airport was located in an area of remote, sparsely-populated high desert terrain. This would have resulted in few visual references to which the pilot could have oriented the airplane. Although the pilot had experience operating in this environment in night conditions and held an instrument rating, the circumstances of the accident are consistent with the known effects of spatial disorientation. The investigation could not determine the initiating event which led to the pilot's mismatch between the airplane's perceived and actual attitude; however, he likely experienced a sensory illusion as a result of spatial disorientation, which led to a loss of control.
Probable cause:
The pilot's loss of control shortly after takeoff due to spatial disorientation.
Final Report:

Crash of a Piper PA-31-310 Navajo C in Zielona Góra: 1 killed

Date & Time: Nov 24, 2016 at 1205 LT
Type of aircraft:
Operator:
Registration:
D-IFBU
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Zielona Góra - Nordhorn
MSN:
31T-8012050
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
9418
Captain / Total hours on type:
7371.00
Aircraft flight hours:
6641
Circumstances:
While taking off from a grassy runway at Zielona Góra-Przylep Airport, the airplane nosed down, impacted ground and crashed. Both engines were torn off and the aircraft was destroyed by impact forces. There was no fire. The pilot, sole on board, was killed. He was completing a ferry flight to Nordhorn, Lower Saxony.
Probable cause:
The pilot mistakenly retracted the undercarriage at liftoff. There was no immediate decision of the pilot to abandon the takeoff procedure when both propellers contacted the runway surface.
Final Report: