Crash of a Piper PA-31T Cheyenne in Elko: 4 killed

Date & Time: Nov 18, 2016 at 1920 LT
Type of aircraft:
Operator:
Registration:
N779MF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Elko - Salt Lake City
MSN:
31-7920093
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
7050
Aircraft flight hours:
6600
Circumstances:
The airline transport pilot departed in the twin-engine, turbine-powered airplane on an air ambulance flight with two medical crew members and a patient on board in night visual meteorological conditions. According to a witness, during the initial climb, the airplane made a left turn of about 30° from the runway heading, then stopped climbing, made an abrupt left bank, and began to descend. The airplane impacted a parking lot and erupted into flames. In the 2 months before the accident, pilots had notified maintenance personnel three times that the left engine was not producing the same power as the right engine. In response, mechanics had replaced the left engine's bleed valve three times with the final replacement taking place three days before the accident. In addition, about 1 month before the accident, the left engine's fuel control unit was replaced during trouble shooting of an oil leak. Post accident examination revealed that the right engine and propeller displayed more pronounced rotational signatures than the left engine and propeller. This is consistent with the left engine not producing power or being at a low power setting at impact. Further, the abrupt left bank and descent observed by the witness are consistent with a loss of left engine power during initial climb. The extensive fire and impact damage to the airplane precluded determination of the reason for the loss of left engine power.
Probable cause:
A loss of engine power to the left engine for reasons that could not be determined due to the extensive fire and impact damage to the airplane.
Final Report:

Crash of a Beechcraft 100 King Air in Jeffersonville

Date & Time: Oct 30, 2016 at 1235 LT
Type of aircraft:
Operator:
Registration:
N411HA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Jeffersonville – Brunswick
MSN:
B-21
YOM:
1970
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13142
Captain / Total hours on type:
34.00
Copilot / Total flying hours:
1605
Copilot / Total hours on type:
3
Aircraft flight hours:
12583
Circumstances:
The airline transport pilot, who was the pilot flying, and commercial pilot, who was the pilot not flying and was acting as a safety pilot and was not expected to know the airplane's systems, limitations, or characteristics, were preparing to depart for a personal flight with eight passengers on board. When the pilot arrived at the airport, he determined that the airplane had 900 lbs of fuel onboard. He instructed the lineman to fuel the airplane with 211 gallons of fuel (1,413.7 lbs) for a fuel total of 2,313.7 lbs. The pilot reported that he was aware that the total weight of the eight passengers, their bags, and the fuel caused the airplane to be overweight but that he did not complete a weight and balance form or determine the expected takeoff performance before the flight. He informed the other pilot that the flight would be heavy, but he did not tell him how much the airplane exceeded the airplane's maximum gross takeoff weight. After the accident, the pilot determined that the airplane was 623 lbs over the maximum gross takeoff weight. The pilot reported that the airplane's flight controls and engines were operating normally during the pretakeoff check and that the elevator pitch trim was positioned in the "green" range. The pilot taxied the airplane onto the runway and applied the brakes and increased the throttles to takeoff power before releasing the brakes for the takeoff roll. However, he did not confirm the power settings that he applied when he advanced the throttles. The airplane did not accelerate as quickly as the pilot expected during the takeoff roll. When the airplane was about halfway down the runway, the airspeed was 80 kts, so the pilot continued the takeoff roll, but the airplane was still not accelerating as expected. He stated that he heard the other pilot say "redline," so he decreased the power. At this point, the airplane had reached the last third of the runway, and the pilot pulled back on the control yoke to lift the airplane off the runway, but the stall warning sounded. He lowered the nose, but the airplane was near the end of the runway. He added that he did not get "on" the brakes or put the propellers into reverse pitch and that the airplane then departed the runway. The pilot veered the airplane right to avoid the instrument landing system antenna, which was 500 ft from the end of the 5,500-ft-long runway, but the left wing struck the antenna, the left main landing gear and nose gear collapsed, and both propellers contacted the ground. The airplane then skidded left before stopping about 680 ft from the end of the runway. The pilot reported that the airplane did not have any preaccident mechanical malfunctions or failures. The evidence indicates that the pilot decided to depart knowing that the airplane was over its maximum gross takeoff weight and without determining the expected takeoff performance. During the takeoff roll, he did not check his engine instruments to determine if he had applied full takeoff power, although the acceleration may have been sluggish because of the excess weight onboard. The other pilot was not trained on the airplane and was not able to provide the pilot timely performance information during the takeoff. Neither the pilot nor the other pilot called out for an aborted takeoff, and when they recognized the need to abort the takeoff, it was too late to avoid a runway excursion.
Probable cause:
The pilot's inadequate preflight planning, his decision to take off knowing the airplane was over its gross takeoff weight, and his failure to abort the takeoff after he realized that the airplane was not accelerating as expected, which resulted in a runway excursion.
Final Report:

Crash of a Boeing 767-323ER in Chicago

Date & Time: Oct 28, 2016 at 1435 LT
Type of aircraft:
Operator:
Registration:
N345AN
Flight Phase:
Survivors:
Yes
Schedule:
Chicago – Miami
MSN:
33084
YOM:
2003
Flight number:
AA383
Crew on board:
9
Crew fatalities:
Pax on board:
161
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17400
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
22000
Copilot / Total hours on type:
1846
Aircraft flight hours:
50632
Aircraft flight cycles:
8120
Circumstances:
On October 28, 2016, about 1432 central daylight time, American Airlines flight 383, a Boeing 767-323, N345AN, had started its takeoff ground roll at Chicago O’Hare International Airport, Chicago, Illinois, when an uncontained engine failure in the right engine and subsequent fire occurred. The flight crew aborted the takeoff and stopped the airplane on the runway, and the flight attendants initiated an emergency evacuation. Of the 2 flight crewmembers, 7 flight attendants, and 161 passengers on board, 1 passenger received a serious injury and 1 flight attendant and 19 passengers received minor injuries during the evacuation. The airplane was substantially damaged from the fire. The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121. Visual meteorological conditions prevailed at the time of the accident. The uncontained engine failure resulted from a high-pressure turbine (HPT) stage 2 disk rupture. The HPT stage 2 disk initially separated into two fragments. One fragment penetrated through the inboard section of the right wing, severed the main engine fuel feed line, breached the fuel tank, traveled up and over the fuselage, and landed about 2,935 ft away. The other fragment exited outboard of the right engine, impacting the runway and fracturing into three pieces. Examination of the fracture surfaces in the forward bore region of the HPT stage 2 disk revealed the presence of dark gray subsurface material discontinuities with multiple cracks initiating along the edges of the discontinuities. The multiple cracks exhibited characteristics that were consistent with low-cycle fatigue. (In airplane engines, low-cycle fatigue cracks grow in single distinct increments during each flight.) Examination of the material also revealed a discrete region underneath the largest discontinuity that appeared white compared with the surrounding material. Interspersed within this region were stringers (microscopic-sized oxide particles) referred to collectively as a “discrete dirty white spot.” The National Transportation Safety Board’s (NTSB) investigation found that the discrete dirty white spot was most likely not detectable during production inspections and subsequent in-service inspections using the procedures in place. The NTSB’s investigation also found that the evacuation of the airplane occurred initially with one engine still operating. In accordance with company procedures and training, the flight crew performed memory items on the engine fire checklist, one of which instructed the crew to shut down the engine on the affected side (in this case, the right side). The captain did not perform the remaining steps of the engine fire checklist (which applied only to airplanes that were in flight) and instead called for the evacuation checklist. The left engine was shut down as part of that checklist. However, the flight attendants had already initiated the evacuation, in accordance with their authority to do so in a life-threatening situation, due to the severity of the fire on the right side of the airplane.
Probable cause:
The National Transportation Safety Board determines that the probable cause of this accident was the failure of the high-pressure turbine (HPT) stage 2 disk, which severed the main engine fuel feed line and breached the right main wing fuel tank, releasing fuel that resulted in a fire on the right side of the airplane during the takeoff roll. The HPT stage 2 disk failed because of low-cycle fatigue cracks that initiated from an internal subsurface manufacturing anomaly that was most likely not detectable during production inspections and subsequent in-service inspections using the procedures in place. Contributing to the serious passenger injury was (1) the delay in shutting down the left engine and (2) a flight attendant’s deviation from company procedures, which resulted in passengers evacuating from the left overwing exit while the left engine was still operating. Contributing to the delay in shutting down the left engine was (1) the lack of a separate checklist procedure for Boeing 767 airplanes that specifically addressed engine fires on the ground and (2) the lack of communication between the flight and cabin crews after the airplane came to a stop.
Final Report:

Crash of a Swearingen SA227AT Expediter in Luqa: 5 killed

Date & Time: Oct 24, 2016 at 0720 LT
Type of aircraft:
Operator:
Registration:
N577MX
Flight Phase:
Survivors:
No
Schedule:
Luqa - Luqa
MSN:
AT-577
YOM:
1983
Flight number:
LXC77
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
3511
Captain / Total hours on type:
1229.00
Copilot / Total flying hours:
21806
Copilot / Total hours on type:
2304
Aircraft flight hours:
9261
Aircraft flight cycles:
3503
Circumstances:
The aircraft was involved in a maritime patrol flight over the Mediterranean Sea, carrying a crew of two and three members of the French Ministry of Defense. Shortly after takeoff from runway 13, while in initial climb, the twin engine aircraft banked to the right, hit a perimeter fence and crashed in a huge explosion on the Triq Carmelo Caruana Street. The aircraft was destroyed by impact forces and a post crash fire. All five occupants were killed. It was previously reported that the flight was performed on behalf of the EU Frontex Program but this was later denied by the Border Agency. The presence of all three French Officers was confirmed by the French Minister of Defense Jean-Yves Le Drian. It was also confirmed by the Government of Malta that this kind of flight was performed by the French Customs since five months, an official operation of surveillance to identify human traffic and narcotics routes in the Mediterranean Sea.
Probable cause:
Investigations show that a technical malfunction was the cause of the accident. This malfunction probably originated in the specific modifications of the aircraft and in the application of an inappropriate maintenance to these modifications.
Three scenarios can be envisaged:
- Rupture of the HF antenna, which then wrapped around the elevator control surface;
- Inadvertent activation of the SAS, countered by the pilot;
- Jamming of the elevator due to a technical failure in the flight control line.
Given the condition of the wreckage and the absence of witness reports from the crew, only a flight data recorder could have enabled the BEA-É to confirm one of these hypothesis. However, in consideration of the factors detailed in the analysis, the hypothesis of damage to a component of the elevator control line remains the most plausible explanation.
Final Report:

Crash of a De Havilland DHC-8-Q402 in Dire Dawa

Date & Time: Oct 24, 2016
Operator:
Registration:
ET-ANY
Flight Phase:
Survivors:
Yes
Schedule:
Dire Dawa – Addis Ababa
MSN:
4334
YOM:
2010
Flight number:
ET212
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
74
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from runway 15/33 at Dire Dawa-Aba Tenna Dejazmach Yilma Airport, the aircraft collided with wild animals. The captaint abandoned the takeoff procedure and initiated an emergency braking manoeuvre when the aircraft veered off runway and came to rest. All 80 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
Collision with wild animals during takeoff.

Crash of a Cessna 500 Citation I in Winfield: 4 killed

Date & Time: Oct 13, 2016 at 2136 LT
Type of aircraft:
Operator:
Registration:
C-GTNG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kelowna – Calgary
MSN:
500-0169
YOM:
1974
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3912
Captain / Total hours on type:
525.00
Aircraft flight hours:
8649
Circumstances:
The pilot and 3 passengers boarded the aircraft. At 2126, the pilot obtained an IFR clearance from the CYLW ground controller for the KELOWNA SEVEN DEP standard instrument departure (SID) procedure for Runway 34. The instructions for the runway 34 KELOWNA SEVEN DEP SID were to climb to 9000 feet ASL, or to an altitude assigned by air traffic control (ATC), and to contact the Vancouver Area Control Centre (ACC) after passing through 4000 feet ASL. The aircraft was then to climb and track 330° magnetic (M) inbound to the Kelowna non-directional beacon (LW). From LW, the aircraft was to climb and track 330°M outbound for vectors to the filed or assigned route. At 2127, C-GTNG began to taxi toward Runway 34. At 2131, the CYLW tower controller cleared the aircraft to take off from the intersection of Runway 34 and Taxiway D. The pilot acknowledged the clearance and began the take-off roll on Runway 34 about 1 minute later. Radar data showed that, at 2133:41, the aircraft was 0.5 nautical miles (nm) beyond the departure end of the runway and was climbing at more than 4000 feet per minute (fpm) through 2800 feet ASL, at a climb angle of approximately 16°. In that time, it had deviated laterally by about 3° to the right of the 330°M track associated with the SID. At 2134:01, when the aircraft was 1.2 nm beyond the runway, it had climbed through 3800 feet ASL and deviated further to the right of the intended routing. The aircraft’s rate of climb decreased to about 1600 fpm, and its ground speed was 150 knots. A short time later, the aircraft’s rate of climb decreased to 600 fpm, its climb angle decreased to 2°, and its ground speed had increased to 160 knots. At 2134:22, the aircraft was 2.1 nm beyond the departure end of the runway, and it was climbing through approximately 4800 feet ASL. The aircraft had deviated about 13° to the right of the intended track, and its rate of climb reached its maximum value of approximately 000 fpm, 3 with a climb angle of about 22°. The ground speed was roughly 145 knots. At 2134:39, the aircraft was 2.7 nm beyond the departure end of the runway, passing through 5800 feet ASL, and had deviated about 20° to the right of the intended routing. The rate of climb was approximately 2000 fpm, with a climb angle of about 7°. According to the SID, the pilot was to make initial contact with the ACC after the aircraft had passed through 4000 feet ASL.Initial contact was made when the aircraft was passing through 6000 feet ASL, at 2134:42. At 2134:46, the ACC acknowledged the communication and indicated that the aircraft had been identified on radar. The aircraft was then cleared for a right turn direct to the MENBO waypoint once it was at a safe altitude, or once it was climbing through 8000 feet ASL. The aircraft was also cleared to follow the flight-planned route and climb to 10 000 feet ASL. At 2134:55, the pilot read back the clearance as the aircraft climbed through 6400 feet ASL, with a rate of climb of approximately 2400 fpm. The aircraft was tracking about 348°M at a ground speed of about 170 knots. At 2135:34, the aircraft began a turn to the right, which was consistent with the instruction from the ACC. Flying directly to the MENBO waypoint required the aircraft to be on a heading of 066°M, requiring a right turn of about 50°. At this point, the aircraft was still climbing and was passing through 8300 feet ASL. The rate of climb was about 3000 fpm. The aircraft continued the right turn and was tracking through 085°M. After reaching a peak altitude of approximately 8600 feet ASL, the aircraft entered a steep descending turn to the right, consistent with the characteristics of a spiral dive. At 2135:47, the ACC controller cleared C-GTNG to climb to FL 250. The lack of radar returns and radio communications from the aircraft prompted the controller to initiate search activities. At 2151, NAV CANADA notified first responders, who located the accident site in forested terrain at about midnight. The aircraft had been destroyed, and all of the occupants had been fatally injured.
Probable cause:
The aircraft departed controlled flight, for reasons that could not be determined, and collided with terrain.
Final Report:

Crash of a Cessna 208B Grand Caravan in San Antonio de Prado: 4 killed

Date & Time: Sep 30, 2016 at 1204 LT
Type of aircraft:
Registration:
HK-3804
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Medellín – Juradó
MSN:
208B-0315
YOM:
1992
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3534
Captain / Total hours on type:
335.00
Copilot / Total flying hours:
6378
Copilot / Total hours on type:
1245
Aircraft flight hours:
2867
Circumstances:
The single engine aircraft departed Medellín-Enrique Olaya Herrera Airport on a charter flight to Juradó, carrying nine passengers and two pilots. Shortly after takeoff, the crew encountered difficulties to gain sufficient altitude and apparently attempted an emergency landing when the aircraft impacted a hill and eventually crashed into trees. The copilot and three passengers were killed and seven others occupants were injured, some seriously. The aircraft was destroyed.
Probable cause:
The following findings were identified:
- Execution of a take-off with a weight approximately 17% higher than the maximum gross operating weight (MTOW) established for the C208B aircraft.
- Limited climb rate with signs of lift loss due to the low performance given by the overweight during the initial climb phase.
- Forced landing in mountainous terrain due to loss of lift caused by overweight during the initial climb.
- Absence in the identification of the risks associated to an overweight operation of the aircraft.
- Lack of supervision by the Aircraft Operator in relation to the dispatch of aircraft operating from the outside at the main base of operation.
Final Report:

Crash of a Cessna 550 Citation II in Charallave: 2 killed

Date & Time: Aug 16, 2016 at 1540 LT
Type of aircraft:
Operator:
Registration:
YV3051
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Charallave - Barinas
MSN:
550-0071
YOM:
1979
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Charallave-Óscar Machado Zuloaga Airport Runway 10, while in initial climb, the aircraft banked right, lost altitude and eventually crashed in a huge explosion in a dense wooded area located down below the airfield. The aircraft disintegrated on impact and both pilots were killed. They were completing a positioning flight to Barinas.

Crash of a De Havilland DHC-2 Beaver near Iliamna

Date & Time: Aug 8, 2016 at 1651 LT
Type of aircraft:
Operator:
Registration:
N95RC
Flight Phase:
Survivors:
Yes
Schedule:
Crosswind Lake - King Salmon
MSN:
970
YOM:
1956
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9780
Captain / Total hours on type:
535.00
Aircraft flight hours:
7632
Circumstances:
The airline transport pilot of the float-equipped airplane was attempting a takeoff with the load of passengers that he had flown to the lake earlier in the day. The pilot's calculated takeoff distances for the water run and over a 50-ft obstacle were 1,050 ft and 2,210 ft, respectively. The pilot did not add a safety margin to his takeoff distance calculations. The approximate shore-to-shore distance of the takeoff path was 1,800 ft. During taxi, the pilot retracted the wing flaps, where they remained for the takeoff. GPS data showed that the airplane attained a speed of about 49 knots before impacting terrain just beyond the shoreline. The airplane's stall speed with flaps retracted was about 52 knots. Postaccident examination revealed that the left wing flap was in the fully retracted position; the right wing flap assembly was damaged. The airplane flight manual takeoff checklist stated that flaps were to be selected to the "TAKE-OFF" position before takeoff. Additionally, the takeoff performance data contained in the flight manual was dependent upon the use of "TAKE-OFF" flaps and did not account for no-flaps takeoffs. Even if the pilot had used the correct flap setting for takeoff, the calculated takeoff distances were near the available takeoff distance, and it is likely that the airplane would still not have been able to avoid a collision with terrain. The pilot stated that there was no mechanical malfunction/failure with the airplane, and he should have "done the right thing," which was to conduct two flights, each with a half load of passengers.
Probable cause:
The pilot's decision to perform the takeoff despite calculations showing that the distance available was inadequate, which resulted in impact with terrain.
Final Report:

Crash of a Cessna 414A Chancellor off Destin: 1 killed

Date & Time: Aug 2, 2016 at 2030 LT
Type of aircraft:
Operator:
Registration:
N2735A
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Destin – Abbeville
MSN:
414A-0463
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
15000
Aircraft flight hours:
6202
Circumstances:
The instrument-rated commercial pilot departed from an airport adjacent to the Gulf of Mexico with an instrument flight rules clearance for a cross-country flight in dark night, visual
meteorological conditions. The flight continued in a south-southwesterly direction, climbing to about 900 ft over the gulf, where it entered a steep right turn. The airplane then descended at a steep rate and impacted the water in a nose-low attitude. Post accident examination of the recovered wreckage, including flight controls, engines, and propellers revealed no evidence of preimpact failure or malfunction. While the outlet fuel line from the left auxiliary fuel pump was found separated and there was evidence that the B-nut was loose and had been only secured by the first 2 threads, recorded data from the engine monitor for the flight revealed no loss of power from either engine. Therefore, the final separation likely occurred during the impact sequence. Although the accident pilot was instrument rated and had recently completed instrument currency training, the dark night conditions present at the time of the accident combined with a further lack of visual references due to the airplane's location over a large body of water, presented a situation conducive to the development of spatial disorientation. The pilot had been instructed by air traffic control to turn southwest after takeoff; however, the continuation of the turn past the intended course and the airplane's steep bank angle and excessive rate of descent are consistent with a loss of control due to spatial disorientation.
Probable cause:
The pilot's loss of control due to spatial disorientation shortly after takeoff, while maneuvering over water during dark night conditions.
Final Report: