Crash of a Beechcraft B60 Duke in Bogotá: 9 killed

Date & Time: Oct 18, 2015 at 1619 LT
Type of aircraft:
Operator:
Registration:
HK-3917G
Flight Phase:
Survivors:
No
Site:
Schedule:
Bogotá - Bogotá
MSN:
P-410
YOM:
1977
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
4916
Aircraft flight hours:
1788
Circumstances:
The twin engine aircraft departed Bogotá-El Dorado on a short flight to Bogotá-Guaymaral Airport, carrying three passengers and one pilot. Three minutes after takeoff from runway 13L, while climbing to a height of 200 feet in VFR conditions, the airplane entered a left turn then descended into the ground and crashed into several houses located in the district of Engativá, near the airport, bursting into flames. The aircraft as well as several houses and vehicles were destroyed. All four occupants as well as five people on the ground were killed. Thirteen others were injured, seven seriously.
Probable cause:
The pilot lost control of the airplane following a loss of power on the left engine during initial climb. Investigations were unable to determine the exact cause of this loss of power. The aircraft's speed dropped to 107 knots and the pilot likely did not have time to identify the problem. Operation from a high density altitude airport contributed to the accident.
Final Report:

Crash of a Cessna 207 Skywagon in Taylor: 2 killed

Date & Time: Oct 16, 2015 at 1515 LT
Registration:
C-GNVZ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Taylor – Vernon
MSN:
207-0317
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from a grassy airstrip located just outside from the town of Taylor, some 15 km southeast of Fort St John, the single engine aircraft crashed in an open field, bursting into flames. The aircraft was totally destroyed by a post crash fire and both occupants, a father and his son, were killed.

Crash of a Cessna 421B Golden Eagle II in Hammond: 2 killed

Date & Time: Oct 14, 2015 at 1548 LT
Operator:
Registration:
N33FA
Flight Phase:
Survivors:
No
Schedule:
Hammond - Atlanta
MSN:
421B-0502
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The twin-engine airplane, flown by a commercial pilot, was departing on a business flight from runway 31 when the right engine lost power. According to a pilot-rated witness, the airplane was about halfway down the 6,500 ft runway at an altitude of about 100 ft above ground level when he heard a "loud pop" and then saw the airplane's right propeller slow. The witness reported that the airplane yawed to the right and then began a right turn toward runway 18 with the right engine's propeller windmilling. The witness further reported that the airplane cleared a tree line by about 150 ft, rolled right, descended straight down to ground impact, and burst into flames. Postaccident examination of the airplane's right engine revealed that the crankshaft was fractured adjacent to the No. 2 main bearing, which had rotated. The crankcase halves adjacent to the No. 2 main bearing were fretted where the case through-studs were located. The fretting of the mating surfaces was consistent with insufficient clamping force due to insufficient torque of the through-stud nuts. Records indicated that all six cylinders on the right engine had been replaced at the airplane's most recent annual inspection 8 months before the accident. In order to replace the cylinders, the through-stud nuts had to be removed as they also served to hold down the cylinders. It is likely that when the cylinders were replaced, the through-stud nuts were not properly torqued, which, over time, allowed the case halves to move and led to the bearing spinning and the crankshaft fracturing. During the accident sequence, the pilot made a right turn in an attempt to return to the airport and did not feather the failed (right) engine's propeller, allowing it to windmill, thereby creating excessive drag. It is likely that the pilot allowed the airspeed to decay below the minimum required for the airplane to remain controllable, which combined with his failure to feather the failed engine's propeller and the turn in the direction of the failed engine resulted in a loss of airplane control.
Probable cause:
The loss of right engine power on takeoff due to maintenance personnel's failure to properly tighten the crankcase through-studs during cylinder replacement, which resulted in crankshaft fracture. Also causal were the pilot's failure to feather the propeller on the right engine and his failure to maintain control of the twin-engine airplane while maneuvering to return to the airport.
Final Report:

Crash of a Cessna 208B Grand Caravan near Bamyan: 2 killed

Date & Time: Oct 12, 2015 at 1400 LT
Type of aircraft:
Operator:
Registration:
YA22382
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
MSN:
208B-2382
YOM:
2012
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Few minutes after takeoff from Bamyan Airport, the single engine crashed on the top of a rocky mountain. Both pilots were killed while five passengers were injured. The aircraft was destroyed. The aircraft was repatriating the body of a deceased soldier when the accident occurred.

Crash of a Piper PA-31-325 Navajo C/R in Bogotá: 2 killed

Date & Time: Oct 3, 2015 at 1212 LT
Type of aircraft:
Registration:
HK-3909G
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Bogotá – Medellín
MSN:
31-7612070
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
10377
Captain / Total hours on type:
121.00
Aircraft flight hours:
5209
Circumstances:
Shortly after takeoff from Bogotá-Guaymaral Airport, while climbing, the pilot declared an emergency after the failure of the right engine. He attempted an emergency landing in an open field when the aircraft crashed in a prairie located near the Los Andes hippodrome, some 5 km northeast of Guaymaral Airport, bursting into flames. A passenger was seriously injured while both other occupants were killed.
Probable cause:
Failure of the right engine during initial climb due to the failure of internal components. The high density altitude was considered as a contributing factor as its affected the aircraft performances.
Final Report:

Crash of a Beechcraft B200 Super King Air in Chigwell: 2 killed

Date & Time: Oct 3, 2015 at 1020 LT
Operator:
Registration:
G-BYCP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Stapleford - Brize Norton
MSN:
BB-966
YOM:
1982
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1941
Captain / Total hours on type:
162.00
Aircraft flight hours:
14493
Aircraft flight cycles:
12222
Circumstances:
G-BYCP was planned to operate a non-commercial flight from Stapleford Aerodrome to RAF Brize Norton with two company employees on board (including the pilot) to pick up two passengers for onward travel. The pilot (the aircraft commander) held a Commercial Pilot’s Licence (CPL) and occupied the left seat and another pilot, who held an Airline Transport Pilot’s Licence (ATPL), occupied the right. The second occupant worked for the operator of G-BYCP but his licence was valid on Bombardier Challenger 300 and Embraer ERJ 135/145 aircraft and not on the King Air. The pilot reported for work at approximately 0715 hrs for a planned departure at 0815 hrs but he delayed the flight because of poor meteorological visibility. The general weather conditions were fog and low cloud with a calm wind. At approximately 0850 hrs the visibility was judged to be approximately 600 m, based on the known distance from the operations room to a feature on the aerodrome. At approximately 0915 hrs, trees were visible just beyond the end of Runway 22L, indicating that visibility was at least 1,000 m and the pilot decided that conditions were suitable for departure. At 0908 hrs, the pilot called the en-route Air Navigation Service Provider (ANSP) on his mobile phone to ask for a departure clearance. He was instructed to remain clear of controlled airspace when airborne and call London Tactical Control Northeast (TCNE) on 118.825 MHz. The planned departure was to turn right after takeoff and intercept the 128° radial from Brookman’s Park VOR (BPK) heading towards the beacon, and climb to a maximum altitude of 2,400 ft amsl to remain below the London TMA which has a lower limit of 2,500 ft amsl. The aircraft took off at 0921 hrs and was observed climbing in a wings level attitude until it faded from view shortly after takeoff. After takeoff, the aircraft climbed on a track of approximately 205°M and, when passing approximately 750 ft amsl (565 ft aal), began to turn right. The aircraft continued to climb in the turn until it reached 875 ft amsl (690 ft aal) when it began to descend. The descent continued until the aircraft struck some trees at the edge of a field approximately 1.8 nm southwest of the aerodrome. The pilot and passenger were both fatally injured in the accident, which was not survivable. A secondary radar return, thought to be G-BYCP, was observed briefly near Stapleford Aerodrome by London ATC but no radio transmission was received from the aircraft. A witness was walking approximately 30 m north-east of where the aircraft struck the trees. She suddenly heard the aircraft, turned towards the sound and saw the aircraft in a nose‑down attitude fly into the trees. Although she saw the aircraft only briefly, she saw clearly that the right wing was slightly low, and that the aircraft appeared to be intact and was not on fire. She also stated that the aircraft was “not falling” but flew “full pelt” into the ground.
Probable cause:
Examination of the powerplants showed that they were probably producing medium to high power at impact. There was contradictory evidence as to whether or not the left inboard flap was fully extended at impact but it was concluded that the aircraft would have been controllable even if there had been a flap asymmetry. The possibility of a preaccident control restriction could not be discounted, although the late change of aircraft attitude showed that, had there been a restriction, it cleared itself. The evidence available suggested a loss of aircraft control while in IMC followed by an unsuccessful attempt to recover the aircraft to safe flight. It is possible that the pilot lost control through a lack of skill but this seemed highly unlikely given that he was properly licensed and had just completed an extensive period of supervised training. Incapacitation of the pilot, followed by an attempted recovery by the additional crew member, was a possibility consistent with the evidence and supported by the post-mortem report. Without direct evidence from within the cockpit, it could not be stated unequivocally that the pilot became incapacitated. Likewise, loss of control due to a lack of skill, control restriction or distraction due to flap asymmetry could not be excluded entirely. On the balance of probabilities, however, it was likely that the pilot lost control of the aircraft due to medical incapacitation and the additional crew member was unable to recover the aircraft in the height available.
Final Report:

Crash of a Lockheed C-130J-30 in Jalalabad: 14 killed

Date & Time: Oct 2, 2015 at 0016 LT
Type of aircraft:
Operator:
Registration:
08-3174
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Jalalabad - Bagram
MSN:
5648
YOM:
2011
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
14
Captain / Total flying hours:
943
Copilot / Total flying hours:
338
Aircraft flight hours:
2551
Circumstances:
On 2 October 2015, at approximately 0016LT, the airplane crashed after takeoff from runway 31 at Jalalabad Airfield, on the second scheduled leg of a contingency airlift mission. The mishap aircraft was assigned to the 455th Air Expeditionary Wing at Bagram Airfield, Afghanistan. The mishap crew (MC) was from the 774th Expeditionary Airlift Squadron. The MC consisted of the mishap pilot (MP), the mishap copilot (MCP), and two mishap loadmasters. Also on board were two fly-away security team (FAST) members and five contractors travelling as passengers. Upon impact, all eleven individuals onboard the aircraft died instantly. The aircraft struck a guard tower manned by three Afghan Special Reaction Force (ASRF) members, whom also died. The MA and cargo load were destroyed, and a perimeter wall and guard tower were damaged.
Probable cause:
The Accident Investigation Board (AIB) president found by a preponderance of the evidence that the causes of the mishap were the MP’s placement of the hard-shell NVG case in front of the yoke blocking forward movement of the flight controls, the distractions experienced by the MP and MCP during the course of the ERO, and the misidentification of the malfunction once airborne. The AIB president also found by a preponderance of the evidence that environmental conditions, inaccurate expectations, and fixation substantially contributed to the mishap.
Final Report:

Crash of a De Havilland DHC-8-Q402 in Saarbrücken

Date & Time: Sep 30, 2015 at 1016 LT
Operator:
Registration:
LX-LGH
Flight Phase:
Survivors:
Yes
Schedule:
Hamburg - Saarbrücken - Luxembourg
MSN:
4420
YOM:
2012
Flight number:
LG9562
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11927
Captain / Total hours on type:
3649.00
Copilot / Total flying hours:
3295
Copilot / Total hours on type:
1483
Aircraft flight hours:
7131
Circumstances:
On the day of the accident, the crew of four was deployed for flights from Luxembourg (LUX) via Saarbrucken (SCN) to Hamburg (HAM) and back again via Saarbrucken to Luxembourg with a Bombardier DHC-8-402. The crew stated that they had met at about 0530 hrs for pre-flight preparations. The flights up until the take-off in Saarbrucken had occurred without incident. All in all the working atmosphere had been good and relaxed and they had been ahead of schedule. Saarbrucken was the destination airport for 14 passengers. The remaining 16 passengers’ destination airport was Luxembourg. According to the Cockpit Voice Recorder (CVR), the Flight Data Recorder (FDR), and the radio communication recordings, the engine start-up clearance was issued at 1009:47 hrs approximately 25 minutes ahead of schedule. At 1015:03 hrs while taxiing on taxiway C take-off clearance was issued. The Into Position Check was conducted at 1015:33 hrs on runway 09. The Pilot in Command (PIC) was Pilot Flying (PF) and the co-pilot Pilot Non Flying (PNF). The plan was to conduct take-off with reduced engine thrust (81%). During take-off the following callouts were made:
1016:24 PF take off, my controls
1016:25 PNF your controls
1016:27 PNF spoiler is closed
1016:30 PNF autofeather armed
1016:33 PF looks like spring
1016:35 PNF yeah, power is checked
1016:36 PNF 80 knots
1016:37 PF checked
1016:40 PNF V1, rotate
1016:42 Background click sound, probably gear lever UP
1016:43 PNF upps, sorry
During the rotation phase with approximately 127 KIAS and a nose-up attitude of approximately 5°, the landing gear retracted. At 1016:44 hrs the airplane’s tail had the first ground contact (tail strike). The tail strike warning light illuminated. Approximately 875 m after the initial ground contact the airplane came to a stop after it had bounced three times and skidded on the fuselage. The cabin crew stated that due to smoke and fume development in the cabin the airplane was evacuated right away. All passengers and the crew were uninjured and left the severely damaged airplane without help.
Probable cause:
The air accident was the result of an early retraction of the retractable landing gear during take-off, which was not prevented by the landing gear selector lever and the retracting control logic.
Contributory factors:
- Reduced concentration level,
- A break in the callout process / task sequence on the part of the PNF,
- Actuation of the landing gear lever to the UP Position too early,
- Control logic design allows retraction of the landing gear with one wheel airborne.
Final Report:

Crash of a Cessna 550 Citation Bravo in Lismore

Date & Time: Sep 25, 2015 at 1300 LT
Type of aircraft:
Operator:
Registration:
VH-FGK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lismore - Baryulgil
MSN:
550-0852
YOM:
1998
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5937
Copilot / Total flying hours:
377
Aircraft flight hours:
2768
Circumstances:
On the morning of 25 September 2015, the captain and copilot of a Cessna 550 aircraft (Citation Bravo), registered VH-FGK, prepared to conduct a private flight from Lismore Airport to Baryulgil, about 40 NM south-west of Lismore, New South Wales. The aircraft had been parked at the northern end of the airport overnight, with engine covers and control locks on. After arriving at the airport, the flight crew conducted a pre-flight inspection, with no abnormalities identified. They then commenced the normal pre-start checks, which included the disengagement of the flight control locks. The crew elected to use runway 15 for take-off, and used the Cessna simplified take-off performance criteria (see Take-off performance simplified criteria) to determine the thrust settings and take-off reference speeds. The resultant reference speeds were 105 kt for the decision speed (V1) and 108 kt for the rotation speed (VR). At about 1300 Eastern Standard Time, the flight crew started the engines and performed the associated checks, with all indications normal. The crew reported that they completed the after start checks, and the captain then taxied the aircraft to the holding point for runway 15, less than 200 m from where the aircraft was parked. While stopped at the holding point, the crew completed the taxi and pre-take-off checks, the copilot broadcast the standard calls on the common traffic advisory frequency, and the captain communicated with air traffic control (ATC). The captain taxied the aircraft onto the runway, and turned left onto the runway centreline to commence the take-off run from the intersection. While rolling along the runway, the captain advanced the thrust levers to the approximate take-off setting. The captain then called ‘set thrust’, and the copilot set the thrust levers to the more precise position needed to achieve the planned engine thrust for the take-off. As the aircraft accelerated, the copilot called ‘80 knots’ and crosschecked the two airspeed indicators were in agreement and reading 80 kt. The copilot called ‘V1’ and the captain moved their hands from the thrust levers to the control column in accordance with the operator’s normal procedure. A few seconds later, the copilot called ‘rotate’ and the captain initiated a normal rotate action on the control column. The crew reported that the aircraft did not rotate and that they did not feel any indication that the aircraft would lift off. The copilot looked outside and did not detect any change in the aircraft’s attitude as would normally occur at that stage. The captain stated to the copilot that the aircraft would not rotate, and pulled back harder on the control column. The copilot looked across and saw the captain had pulled the control column firmly into their stomach. Although the aircraft’s speed was then about 112 kt, and above VR, the crew did not detect any movement of the attitude director indicator or the nose wheel lifting off the ground, so the captain rejected the take-off; applied full brakes, and set the thrust levers to idle and then into reverse thrust. The aircraft continued to the end of the sealed runway and onto the grass in the runway end safety area (RESA), coming to rest slightly left of the extended centreline, about 100 m beyond the end of the runway. The aircraft sustained substantial damage and the flight crew, who were the only occupants of the aircraft, were uninjured. The nose landing gear separated from the aircraft during the overrun, and there was significant structural damage to the fuselage and wings. The right wheel tyre had deflated due to an apparent wheel lockup and flat spot, which had progressed to a point that a large hole had been worn in the tyre.
Probable cause:
Contributing factors:
- There was probably residual braking pressure in the wheel brakes during the take-off run.
- The aircraft’s parking brake was probably applied while at the holding point and not disengaged before taxing onto the runway for take-off.
- The Citation aircraft did not have an annunciator light to show that the parking brake is engaged, and the manufacturer’s before take-off checklist did not include a check to ensure the parking brake is disengaged.
- The aircraft experienced a retarded acceleration during the take-off run, and did not rotate as normal when the appropriate rotate speed was reached, resulting in a critical rejected take-off
and a runway overrun.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Thompson

Date & Time: Sep 15, 2015 at 1821 LT
Operator:
Registration:
C-FXLO
Flight Phase:
Survivors:
Yes
Schedule:
Thompson – Winnipeg
MSN:
31-8052022
YOM:
1980
Flight number:
KEE208
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2000
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
446
Copilot / Total hours on type:
120
Circumstances:
At 1817 Central Daylight Time, the Keystone Air Service Ltd. Piper PA-31-350 (registration C-FXLO, serial number 31-8052022) departed Runway 06 at Thompson Airport, Manitoba, on an instrument flight rules flight to Winnipeg/James Armstrong Richardson International Airport, Manitoba, with 2 pilots and 6 passengers on board. Shortly after rotation, both engines began to lose power. The crew attempted to return to the airport, but the aircraft was unable to maintain altitude. The landing gear was extended in preparation for a forced landing on a highway southwest of the airport. Due to oncoming traffic, the forced landing was conducted in a forested area adjacent to the highway, approximately 700 metres south of the threshold of Runway 06. The occupants sustained varying serious injuries but were able to assist each other and exit the aircraft. The emergency locator transmitter activated, and there was no fire. Emergency services were activated by a 911 call and by the Thompson flight service station. Initial assistance was provided by sheriffs of the Manitoba Department of Justice after a crew member flagged down their vehicle on the highway.
Probable cause:
Findings as to causes and contributing factors:
1. Delivery of the incorrect type of aircraft fuel caused loss of power from both engines, necessitating a forced landing.
2. The fueling operation was not adequately supervised by the flight crew.
3. A reduced-diameter spout was installed that enabled the delivery of Jet-A1 fuel into the AVGAS fuel filler openings.
4. The fuel slip indicating that Jet-A1 fuel had been delivered was not available for scrutiny by the crew.

Findings as to risk:
1. If administrative and physical defences against errors in aviation fuel operations are circumvented or disabled, there is a risk that the incorrect type of fuel will be delivered.
2. If a reduced-diameter spout is available to accommodate non-standard fuel filler openings, there is an increased risk that Jet-A1 fuel can be dispensed into an aircraft that requires AVGAS.

Other findings:
1. Aircraft that were manufactured prior to the current airworthiness standards, or that have been modified by the installation of turbine engines, may have fuel filler openings that do not meet the dimension requirements.
2. The airworthiness standards for rotorcraft do not specify the size of fuel filler openings.
3. The use of all of the available restraint systems in the aircraft contributed to the survival of the occupants.
4. There was no post-crash fire, likely due to the separation of the battery from the aircraft and to the rain-saturated crash site.
5. The absence of a post-impact fire contributed to the survival of all of the aircraft's occupants.
Final Report: