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:

Crash of a De Havilland DHC-3T Turbo Otter in Iliamna: 3 killed

Date & Time: Sep 15, 2015 at 0606 LT
Type of aircraft:
Operator:
Registration:
N928RK
Flight Phase:
Survivors:
Yes
Schedule:
Iliamna - Swishak River
MSN:
61
YOM:
1954
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
11300
Captain / Total hours on type:
450.00
Aircraft flight hours:
15436
Circumstances:
On September 15, 2015, about 0606 Alaska daylight time, a single-engine, turbine-powered, float-equipped de Havilland DHC-3T (Otter) airplane, N928RK, impacted tundra-covered terrain just after takeoff from East Wind Lake, about 1 mile east of the Iliamna Airport, Iliamna, Alaska. Of the 10 people on board, three passengers died at the scene, the airline transport pilot and four passengers sustained serious injuries, and two passengers sustained minor injuries. The airplane sustained substantial damage. The airplane was registered to and operated by Rainbow King Lodge, Inc., Lemoore, California, as a visual flight rules other work use flight under the provisions of 14 Code of Federal Regulations (CFR) Part 91. Dark night, visual meteorological conditions existed at the departure point at the time of the accident, and no flight plan was filed for the flight. At the time of the accident, the airplane was en route to a remote fishing site on the Swishak River, about 75 miles northwest of Kodiak, Alaska.
Probable cause:
The pilot's decision to depart in dark night, visual meteorological conditions over water, which resulted in his subsequent spatial disorientation and loss of airplane control. Contributing to the accident was the pilot's failure to determine the airplane's actual preflight weight and balance and center of gravity (CG), which led to the airplane being loaded and operated outside of the weight and CG limits and to a subsequent aerodynamic stall.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage off Cannes

Date & Time: Aug 31, 2015 at 0855 LT
Operator:
Registration:
D-ESPE
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cannes – Triengen
MSN:
46-22063
YOM:
1989
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18213
Captain / Total hours on type:
900.00
Circumstances:
The single engine aircraft departed Cannes-Mandelieu Airport on a private flight to Triengen, Switzerland, with one passenger and one pilot on board. Shortly after takeoff from runway 17, while in initial climb, the pilot noticed engine troubles and the speed dropped. He was able to maintain a straight-in path and eventually ditched the airplane few hundred metres offshore. Both occupants were slightly injured and the aircraft sank and was lost.
Probable cause:
The engine failure was the result of an incorrect refueling, due to an intake initial order probably incorrect that the incomplete application of procedures by the operator in charge of refueling and the lack of attention of the pilot did not allow recovery. The quantity of 100LL present in the feeders and the pipes allowed the taxiing and the take-off run, without the pilot noticing any anomaly. Once this quantity of 100LL consumed, the JET A1 present in the lower part of the tanks fed the engine and caused the power decrease.
Contributed to the accident:
- Coordination between the aerodrome operator and its subcontractors during the fuel order taken by the ramp agent, who does not encourage the operator in charge of refueling to confirm the type of fuel in a service carried out under strong time constraints,
- A usual practice for refueling certain types of helicopters, whose reservoir ports are not compatible with the dimensions of the standard refueling nozzles, which trivialize the change of nozzle for the refueling of JET A1, occasionally leading to the filling of order confirmation vouchers, thus reducing the effectiveness of the manifest safety for the operator through the presence of keying devices specific to each fuel,
- The ineffectiveness of the fuel type check item of the pre-flight procedure.
Final Report:

Crash of a Technoavia SMG-92 Turbo Finist in Casale Monferrato

Date & Time: Aug 29, 2015 at 1430 LT
Operator:
Registration:
HA-YDJ
Flight Phase:
Survivors:
Yes
Schedule:
Casale Monferrato - Casale Monferrato
MSN:
02-001
YOM:
1993
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
600
Captain / Total hours on type:
35.00
Aircraft flight hours:
800
Circumstances:
The single engine aircraft departed Casale Monferrato-Francesco Cappa Airfield on a local skydiving mission, the 13th sortie of the day, carrying seven skydivers, three tourists and one pilot). Shortly after rotation from a grassy runway, the pilot encountered engine problems. The aircraft continued in a flat attitude, collided with a hedge and few trees before coming to rest in a wooded area located 300 metres past the runway end. All 11 occupants were injured, some of them seriously. The aircraft was damaged beyond repair.
Probable cause:
The accident is the consequence of an engine failure caused by the loss of connection in the power module between the quill shaft and the PT shaft.
The following contributing factors were identified:
- A control system of the aircraft as part of 'aircraft operator CAMO not sufficiently thorough,
- The inaccurate, non-timely and incorrect reporting by the user of the aircraft of critical parameters for monitoring engine life,
- A national regulation, in force at the time of the accident, relating to the flight activity for launching paratroopers, which did not provide, in fact, adequate surveillance technique by the aeronautical authority on the aircraft used in this activity,
- The absence of adequate retention and safety devices for paratroopers on board the aircraft.
Final Report:

Crash of a Dornier DO228-212 in Kaduna: 7 killed

Date & Time: Aug 29, 2015 at 0647 LT
Type of aircraft:
Operator:
Registration:
NAF030
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Kaduna – Abuja
MSN:
8219
YOM:
1993
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
Shortly after takeoff from the Kaduna Military Airfield, while climbing, the aircraft went out of control and crashed into a house located in the Ribadu Cantonment, bursting into flames. All seven occupants (two pilots, two engineers and three passengers) were killed.

Crash of a Piper PA-46-500TP Malibu Meridian in Saranac Lake: 4 killed

Date & Time: Aug 7, 2015 at 1750 LT
Operator:
Registration:
N819TB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Saranac Lake – Rochester
MSN:
46-97117
YOM:
2001
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
4620
Captain / Total hours on type:
230.00
Circumstances:
The private pilot, who was experienced flying the accident airplane, was conducting a personal flight with three passengers on board the single-engine turboprop airplane. Earlier that day, the pilot flew uneventfully from his home airport to an airport about 1 hour away. During takeoff for the return flight, the airplane impacted wooded terrain about 0.5 mile northwest of the departure end of the runway. There were no witnesses to the accident, but the pilot's radio communications with flight service and on the common traffic advisory frequency were routine, and no distress calls were received. A postcrash fire consumed a majority of the wreckage, but no preimpact mechanical malfunctions were observed in the remaining wreckage. Examination of the propeller revealed that the propeller reversing lever guide pin had been installed backward. Without the guide pin installed correctly, the reversing lever and carbon block could dislodge from the beta ring and result in the propeller blades traveling to an uncommanded feathered position. However, examination of the propeller components indicated that the carbon block was in place and that the propeller was in the normal operating range at the time of impact. Additionally, the airplane had been operated for about 9 months and 100 flight hours since the most recent annual inspection had been completed, which was the last time the propeller was removed from and reinstalled on the engine. Therefore, the improper installation of the propeller reversing lever guide pin likely did not cause the accident. Review of the pilot's autopsy report revealed that he had severe coronary artery disease with 70 to 80 percent stenosis of the right coronary artery, 80 percent stenosis of the left anterior descending artery, and mitral annular calcification. The severe coronary artery disease combined with the mitral annular calcification placed the pilot at high risk for an acute cardiac event such as angina, a heart attack, or an arrhythmia. Such an event would have caused sudden symptoms such as chest pain, shortness of breath, palpitations, or fainting/loss of consciousness and would not have left any specific evidence to be found during the autopsy. It is likely that the pilot was acutely impaired or incapacitated at the time of the accident due to an acute cardiac event, which resulted in his loss of airplane control.
Probable cause:
The pilot's loss of airplane control during takeoff, which resulted from his impairment or incapacitation due to an acute cardiac event.
Final Report:

Crash of a PZL-Mielec AN-2R in Stăncuța: 1 killed

Date & Time: Aug 1, 2015 at 0805 LT
Type of aircraft:
Operator:
Registration:
YR-PEG
Flight Phase:
Survivors:
Yes
MSN:
1G197-44
YOM:
1982
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
6577
Circumstances:
The history of occurrence was established based on the witnesses’ statements. On 31.07.2015, the aircraft AN-2 registered YR-PEG was positioned on a flight field in the vicinity of the farm in Stӑncuţa commune, Brăila County, being prepared in order to perform several aviochemical flights in Giurgeni area on the following day. In the morning of 01.08.2015, the pilot and the aeronautical technical staff from his team were informed by the beneficiary of aviochemical works that, because it was raining in Giurgeni area, they will perform some aviochemical flights in Stӑncuţa area, in the vicinity of the flight field. Consequently, the aircraft was prepared for the flight in the area as follows: 200 l of gasoline were defueled from the aircraft tanks, the engine was started and the operating parameters were checked according to the specific diagram. The aircraft was supplied with chemical substances for the aerial work and after only a few minutes, the engine was started again, in order to take-off. Onboard there were the pilot and an aeronautical technician (hereinafter referred to as passenger) who occupied the pilot's seat on the right. The take-off on the S-N direction was normal in the first part. The take-off run was short – approximately 100 m, in the witnesses’ opinion – under the conditions of a gusty wind from the E direction, whose speed was gradually increasing. During the initial climb, at a height of about 15-20 m, the aircraft began to lean to the left and descend slightly. During this turn in descent, bank angle continued to increase, the aircraft flying with the left wing at very low height above the aircrafts parked towards the northern end of the flight field. Considering the aircraft evolution and observing that the pilot was not acting for correction, the passenger onboard on the right-hand pilot seat, tried instinctively to turn the aircraft control yoke to the right. According to his statement, he failed to operate the control yoke, considering that this was in a blocking state of which nature he could not specify. With the engine still running in take-off mode, the aircraft continued to descend, and after passing the parked aircrafts, it hit the ground with the propeller and the left wing tip. The impact of the wing tip determined the aircraft to pivot to the left and make a hard contact with the ground. The engine stopped because of the shock. An early fire was extinguished by witnesses arrived at the accident site. Amid the destruction of the cockpit and fuselage, the pilot was thrown out of the aircraft suffering serious injuries. The passenger, who occupied the right-hand seat, managed (after recovering from the shock) to exit the aircraft wreckage. The pilot and passenger were transported to the hospital. Later on, the pilot died due to multiple traumatic injuries, and the passenger required a long hospitalization period due to the injuries suffered. The aircraft was totally destroyed. There was no other damage in the area.
Probable cause:
The probable causes of this accident are the following:
- Temporary incapacitation of the pilot,
- Use of flaps upon take-off in the conditions of deterioration/modification of weather conditions during take-off (wind direction and speed),
- Aircraft operation with incomplete crew.
Final Report:

Crash of an Embraer C-95BM Bandeirante in Lagoa Santa

Date & Time: Jul 27, 2015
Type of aircraft:
Operator:
Registration:
2326
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lagoa Santa - Lagoa Santa
MSN:
110443
YOM:
1984
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was conducting a training mission at Lagoa Santa AFB, consisting of touch-and-go maneuvers. During the takeoff roll, the pilot-in-command pulled on the control column to initiate the rotation but the aircraft did not respond. It went out of control, veered off runway to the right, struck an embankment, lost its undercarriage and slid for few dozen metres before coming to rest in a grassy area. All three occupants escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
It is believed that the accident was a consequence of a wrong takeoff configuration as the crew did not set the flaps properly.

Crash of a Piper PA-46-350P Malibu Mirage in Chofu: 3 killed

Date & Time: Jul 26, 2015 at 1058 LT
Operator:
Registration:
JA4060
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Chōfu - Amami
MSN:
46-22011
YOM:
1989
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1300
Captain / Total hours on type:
120.00
Aircraft flight hours:
2284
Circumstances:
On Sunday, July 26, 2015 at around 10:58 Japan Standard Time (JST: UTC + 9 hrs: unless otherwise stated, all times are indicated in JST using the 24-hour clock), a privately owned Piper PA-64-350P, registered JA4060, crashed into a private house at Fujimi Town in Chōfu City, right after its takeoff from Runway 17 of Chōfu Airport There were five people on board, consisting of the captain and four passengers. The captain and one passenger died and three passengers were seriously injured. In addition, one resident died and two residents had minor injuries. The aircraft was destroyed and a fire broke out. Furthermore, the house where the Aircraft crashed into were consumed in a fire, and neighboring houses sustained damage due to the fire and other factors.
Probable cause:
It is highly probable that this accident occurred as the speed of the Aircraft decreased during takeoff and climb, which led the Aircraft to stall and crashed into a residential area near Chōfu Airport. It is highly probable that decreased speed was caused by the weight of the Aircraft exceeding the maximum takeoff weight, takeoff at low speed, and continued excessive nose-up attitude. As for the fact that the Captain made the flight with the weight of the Aircraft exceeding the maximum takeoff weight, it is not possible to determine whether or not the Captain was aware of the weight of the Aircraft exceeded the maximum takeoff weight prior to the flight of the accident because the Captain is dead. However, it is somewhat likely that the Captain had insufficient understanding of the risks of making flights under such situation and safety awareness of observing relevant laws and regulations. It is somewhat likely that taking off at low speed occurred because the Captain decided to take a procedure to take off at such a speed; or because the Captain reacted and took off due to the approach of the Aircraft to the runway threshold. It is somewhat likely that excessive nose-up attitude was continued in the state that nose-up tended to occur because the position of the C.G. of the Aircraft was close to the aft limit, or the Captain maintained the nose-up attitude as he prioritized climbing over speed. Adding to these factors, exceeding maximum takeoff weight, takeoff at low speed and continued excessive nose-up attitude, as the result of analysis using mathematical models, it is somewhat likely that the decreased speed was caused by the decreased engine power of the Aircraft; however, as there was no evidence of showing the engine malfunction, it was not possible to determine this.
Final Report:

Crash of a Cessna 208B Grand Caravan in Dubai

Date & Time: Jul 7, 2015 at 0800 LT
Type of aircraft:
Operator:
Registration:
DU-SD1
Flight Phase:
Survivors:
Yes
Schedule:
Dubai - Dubai
MSN:
208B-1141
YOM:
2005
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After takeoff from Dubai-Skydive Campus Airfield, while climbing to a height of 2,500 feet, the pilot encountered engine problems. He elected to return to the airport but eventually attempted an emergency landing in a desert area close to the airport. The aircraft crash landed and came to rest, bursting into flames. All 15 occupants escaped uninjured and the aircraft was destroyed by a post crash fire.