Crash of a Piper PA-31-350 Navajo Chieftain in Araracuara: 10 killed

Date & Time: Sep 6, 2014 at 1505 LT
Operator:
Registration:
HK-4755
Flight Phase:
Survivors:
No
Schedule:
Araracuara – Florencia
MSN:
31-7952044
YOM:
1979
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
792
Captain / Total hours on type:
523.00
Copilot / Total flying hours:
211
Aircraft flight hours:
14601
Circumstances:
The twin engine aircraft departed Araracuara Airport runway 09 at 1503LT on a charter flight to Florencia, carrying eight passengers and two pilots. During initial climb, the right engine failed. The crew lost control of the airplane that stalled and crashed in a wooded area. The wreckage was found 8,2 km from the airport. The airplane disintegrated on impact and all 10 occupants were killed, among them a Swiss citizen.
Probable cause:
Loss of control during initial climb following the failure of the right engine for undetermined reasons.
The following contributing factors were identified:
- The crew failed to follow the published procedures when the right engine failed,
- The aircraft was likely operated with a total weight above MTOW,
- A poor risk assessment while performing an operation outside of the aircraft's performance limits.
Final Report:

Crash of an Antonov AN-12BK in Tamanrasset: 7 killed

Date & Time: Aug 30, 2014 at 0244 LT
Type of aircraft:
Operator:
Registration:
UR-DWF
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Glasgow – Ghardaïa – Tamanrasset – Malabo
MSN:
8 3 458 02
YOM:
1968
Flight number:
UKL4061
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The four engine aircraft was performing a cargo flight from Glasgow-Prestwick to Malabo, Equatorial Guinea, with intermediate stops in Ghardaïa and Tamanrasset. On board were seven crew members and a load consisting of oil equipment. About three minutes after takeoff from Tamanrasset-Aguenar-Hadj Bey Akhamok Airport, radio contact was lost when the aircraft crashed in a mountainous terrain located some 15 km south of the airport. The wreckage was found few hours later. The aircraft was destroyed by impact forces and a post crash fire and all seven crew members (six Ukrainians and one Russian) were killed.

Crash of a Cessna 421C Golden Eagle III in Las Cruces: 4 killed

Date & Time: Aug 27, 2014 at 1903 LT
Registration:
N51RX
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Las Cruces – Phoenix
MSN:
421C-0871
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2432
Captain / Total hours on type:
52.00
Aircraft flight hours:
8181
Circumstances:
According to the line service technician who worked for the fixed-base operator (FBO), before taking off for the air ambulance flight with two medical crewmembers and one patient onboard, the pilot verbally asked him to add 40 gallons of fuel to the airplane, but the pilot did not specify the type of fuel. The line service technician drove a fuel truck to the front of the airplane and added 20 gallons of fuel to each of the multiengine airplane's wing tanks. The pilot was present during the refueling and helped the line service technician replace both fuel caps. Shortly after takeoff, a medical crewmember called the company medical dispatcher and reported that they were returning to the airport because smoke was coming from the right engine. Two witnesses reported seeing smoke from the airplane Several other witnesses reported seeing or hearing the impact and then immediately seeing smoke or flames. On-scene evidence showed the airplane was generally eastbound and upright when it impacted terrain. A postimpact fire immediately ensued and consumed most of the airplane. Investigators who arrived at the scene the day following the accident reported clearly detecting the smell of jet fuel. The airplane, which was equipped with two reciprocating engines, should have been serviced with aviation gasoline, and this was noted on labels near the fuel filler ports, which stated "AVGAS ONLY." However, a postaccident review of refueling records, statements from the line service technician, and the on-scene smell of jet fuel are consistent with the airplane having been misfueled with Jet A fuel instead of the required 100LL aviation gasoline, which can result in detonation in the engine and the subsequent loss of engine power. Postaccident examination of the engines revealed internal damage and evidence of detonation. It was the joint responsibility of the line technician and pilot to ensure that the airplane was filled with aviation fuel instead of jet fuel and their failure to do so led to the detonation in the engine and the subsequent loss of power during initial climb.In accordance with voluntary industry standards, the FBO's jet fuel truck should have been equipped with an oversized fuel nozzle; instead, it was equipped with a smaller diameter nozzle, which allowed the nozzle to be inserted into the smaller fuel filler ports on airplanes that used aviation gasoline. The FBO's use of a small nozzle allowed it to be inserted in the accident airplane's filler port and for jet fuel to be inadvertently added to the airplane.
Probable cause:
The misfueling of the airplane with jet fuel instead of the required aviation fuel, and the resultant detonation and a total loss of engine power during initial climb. Contributing to the accident were the line service technician's inadvertent misfueling of the airplane, the pilot's inadequate supervision of the fuel servicing, and the fixed-base operator's use of a small fuel nozzle on its jet fuel truck.
Final Report:

Crash of a HESA IrAn-140-100 in Tehran: 40 killed

Date & Time: Aug 10, 2014 at 0921 LT
Type of aircraft:
Operator:
Registration:
EP-GPA
Flight Phase:
Survivors:
No
Schedule:
Tehran – Tabas
MSN:
90-05
YOM:
2008
Flight number:
SPN5915
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
42
Pax fatalities:
Other fatalities:
Total fatalities:
40
Captain / Total flying hours:
9478
Captain / Total hours on type:
2000.00
Copilot / Total flying hours:
572
Copilot / Total hours on type:
400
Aircraft flight hours:
1405
Aircraft flight cycles:
1058
Circumstances:
On August 10,2014, at 04:52 UTC daylight time, an AN-140-100 aircraft , Iranian registration EP-GPA ( MSN 90-05), operated by Sepahan Airlines flight # 5915, experienced engine number 2 shutdown just about 2 seconds before lift-off and crashed shortly after take-off nearby Mehrabad International Airport (THR), TEHRAN; IR. Of IRAN; the aircraft was on lift off from runway 29L. The airplane was completely destroyed by impact forces and post-crash fire. Fatality incorporates 34 of the 40 passengers; 4 of the 4 flight attendants, and 2 of the 2 flight crewmembers. The 11 passengers received serious injuries, which finally as a result of that accident there are 40 fatalities and 8 passengers recovered from injury. Sepahan Airline was operating under the provisions of CAO.IRI operational requirement for commercial air transport. Before the accident flight the airplane dispatch from Isfahan and arrived at Tehran about 03:30. The dispatcher and PIC perform the load calculation using the aircraft FM performance charts. Because of load limitation for 15° flap position, load sheet change and re-write with 10° flap position and re-calculated MTOM. The aircraft was enrouted to Airport Tabbas Visual meteorological conditions (VMC) prevailed, and an instrument flight rules (IFR) flight plan was filed. Figure 1 below is a map showing the location of the accident and the aircraft flight path. Figure 2 shows THR runway 29L SID and figure 3 show timeline of event in the flight path. According to overview of flight crew performance, it is indicated that the crewmembers were provided with the flight release paperwork, which included weather information, notices to airmen (NOTAM), and the flight plan.
Probable cause:
The accident investigation team determined that the main cause of this accident was combination of:
1. Electronic engine control (SAY-2000) failure simultaneously with engine No: 2 shutdown, just about 2 seconds before aircraft lift-off.
2. AFM Confusing performance chart resulted the pilots relying on performance calculation that, significantly over-estimate the aircraft MTOM.
Contributing Factors to the accident were:
1. Aircraft flight manual unclear procedure, including the procedure for calculating maximum allowable take-off weight, VR and V2 and ambiguity in the climb segment definition and applications.
2. Crew performance, including:
- PIC rotated the aircraft at the speed of about 219 km/h (whereas 224 km/h is the speed recommended by the AFM table 4.2.3),
- The crew failed to perform the manual propeller feathering procedure for the failed engine,
- The PIC's decision to fly with the aircraft, notwithstanding, had about 190 kgf overweight,
- Aircraft fuel was about 500 kg more than required fuel for the accident flight.
3. The appearance of negative thrust from the unfeathered propeller blades at takeoff were not considered during the aircraft certification tests, as it was considered improbable. However, in
the accident flight the negative thrust did appear and affected the flight performance.
Final Report:

Crash of a PZL-Mielec AN-2R in Prototskiye

Date & Time: Aug 6, 2014 at 0715 LT
Type of aircraft:
Operator:
Registration:
RA-17890
Flight Phase:
Survivors:
Yes
Schedule:
Prototskiye - Prototskiye
MSN:
1G205-31
YOM:
1983
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
7503
Aircraft flight cycles:
38974
Circumstances:
The crew was engaged in a crop spraying mission on rice paddy field located in Prototskiye (Krasnoarmeisk district of the Krasnodar region). Two minutes after takeoff, while flying at a height of about 50 metres, the engine lost power. The captain attempted an emergency landing when the aircraft nosed over and came to rest upside down, some 2 km east of Prototskiye. Those parts of the fuselage which were above the water were consumed by the erupting fire and both pilots escaped uninjured.
Probable cause:
The accident with An-2 RA-17890 aircraft was caused by its nosing-over during the emergency landing at the submerged rice bay. The emergency landing was due to the engine power loss in flight caused by the destruction of the can type combustor of the exhaust collector and burnout of the carburetor intake valve with the following high-temperature gases ingestion in the intake areas of the engine carburetor. The fatigue destruction of the can type combustor of the exhaust collector was caused along the main crack near the intake flex socket, it started from the surface of the damaged inlet port under the tube attachment pin towards the exhaust collector. By the moment of the main crack formation both inlet ports in left can type combustor under the tube attachment pin towards the exhaust collector had intolerable damage and size. During the last overhaul of the engine exhaust system of An-2 RA-17890 aircraft the left can type combustor had intolerable damage in its attaching lug to the exhaust collector which wasn't eliminated. The destruction of the inlet port valve was caused by the fusion of the boundaries of it material grains in conditions of acute temperature exposure induced by the destruction of the left can type combustor wall towards the main crack. Inadequate material (aluminum alloy D-16) of the valve specified by the drawing of aluminum allow AL-9T contributed to the valve destruction.

Crash of an Embraer EMB-110P1 Bandeirante in Foz do Iguaçu

Date & Time: Jul 28, 2014 at 1500 LT
Operator:
Registration:
PT-TAW
Flight Phase:
Survivors:
Yes
Schedule:
Foz do Iguaçu - Curitiba
MSN:
110-258
YOM:
1980
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Foz do Iguaçu-Cataratas Airport, while climbing, the crew reported technical problems and elected to return. The crew realized he could not make it so he attempted an emergency landing in a corn field. Upon landing, the aircraft lost its undercarriage and slid for few dozen metres before coming to rest. Among the four occupants, one passenger was slightly injured and the aircraft was damaged beyond repair.

Crash of a Piper PA-46-310P Malibu in Clayton: 1 killed

Date & Time: Jul 26, 2014 at 0850 LT
Operator:
Registration:
N248SP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Clayton - Aurora
MSN:
46-8608024
YOM:
1986
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4200
Aircraft flight hours:
3593
Circumstances:
The pilot was departing the private, fly-in community airport on a personal flight. He was familiar with the airport/fly-in community and was instrumental in its development. Fog was present at the time, and, according to witnesses, it was "rolling up the valley," which was a frequent event at the airport. The witnesses observed the airplane lift off the runway, drift to the left, and disappear into the fog with the landing gear extended. They heard the engine running normally, with no change in sound, until the crash. They heard two distinct "booms" about 4 to 6 seconds apart. They ran down to the departure end of the runway to look for a crash site and could not see the wreckage or any smoke or fire due to the fog. The wreckage was located on elevated terrain in a heavily wooded area, about 1,500 feet north of the departure end of the runway. The elevation at the crash site was about 250 feet higher than the elevation at the departure end of runway. A swath through the treetops leading to the main wreckage was indicative of a near-level flight path at impact. An examination of the airframe and engine did not reveal any evidence of a preexisting mechanical malfunction or failure. A review of the weather by a NTSB meteorologist revealed that the departure airport was at the edge of an area of low-topped clouds. Airport remarks included "Mountainous terrain all quadrants."
Probable cause:
The pilot's decision to begin a flight with fog and low clouds present at the airport, which resulted in an encounter with instrument meteorological conditions immediately after takeoff and a controlled flight into terrain.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Saint John Harbour

Date & Time: Jul 11, 2014 at 1550 LT
Type of aircraft:
Registration:
C-FFRL
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
St John Harbour - Sandspit
MSN:
482
YOM:
1953
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after take off from Saint John Harbour, the single engine aircraft went out of control and crashed on the shore of the Athlone Island, bursting into flames. The aircraft was destroyed by impact forces and a post crash fire and all four occupants were injured.

Crash of a Piper PA-31P Pressurized Navajo in Częstochowa: 11 killed

Date & Time: Jul 5, 2014 at 1611 LT
Type of aircraft:
Registration:
N11WB
Flight Phase:
Survivors:
Yes
Schedule:
Częstochowa - Częstochowa
MSN:
31P-7630005
YOM:
1976
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
11
Captain / Total flying hours:
996
Captain / Total hours on type:
40.00
Circumstances:
The twin engine aircraft was engaged in a series of skydiving flights at Częstochowa-Rudniki Airport, Silesia. It took off from runway 26C with 11 skydivers and one pilot on board. During initial climb, at an altitude of 100 metres, the pilot encountered technical problems with the engines and elected to make an emergency landing. He informed the passengers about the emergency situation and reduced his altitude when the aircraft rolled to the left to an angle of 70° then stalled and crashed in a wooded area, bursting into flames. The wreckage was found 4,200 metres past the runway end. Three skydivers were seriously injured while 9 other occupants were killed. Few minutes later, two of the survivors died from their injuries.
Probable cause:
The following findings were identified:
- The aircraft was operated without a valid CofA,
- Failure of the left engine during initial climb after the crankshaft failed, causing the malfunction of the propeller that could not be feathered, resulting in an asymmetry that caused the aircraft to enter a stall condition. Damages to the pin clutch connecting the crankshaft to the drive shaft of the right engine transmission could be due to the following causes: an earlier impact of a propeller's blade with an obstacle, in circumstances and time which could not be determined and/or a long-term fatigue process caused by uneven engine operation (one of the cylinders was replaced on the right engine),
- Improper maintenance of the aircraft,
- The left engine was producing low power due to improper operation,
- The fuel in the tanks did not meet the engine manufacturer's requirements,
- The aircraft was modified in violation of its Type Certificate,
- A high ambiant temperature.
Final Report:

Crash of a Fokker 50 in Nairobi: 4 killed

Date & Time: Jul 2, 2014 at 0417 LT
Type of aircraft:
Operator:
Registration:
5Y-CET
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Nairobi - Mogadishu
MSN:
20262
YOM:
26
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
14531
Captain / Total hours on type:
6821.00
Copilot / Total flying hours:
823
Copilot / Total hours on type:
513
Aircraft flight hours:
27342
Aircraft flight cycles:
26358
Circumstances:
On 2 July 2014, about 01.14 UTC, 5Y-CET, a Fokker F50, an international cargo flight, operated by Skyward International, crashed shortly after takeoff from Jomo Kenyatta International Airport (JKIA), Nairobi, Kenya (JKIA). Instrument Meteorological Conditions prevailed at the time and the airplane was on an instrument flight plan. The four crewmembers were fatally injured. The airplane was destroyed and consumed by post-crash fire. The destination of the flight was Aden Adee International Airport, Mogadishu, Somalia. The airplane was repositioned from its home base at Wilson Airport in Nairobi, the day before. The accident captain (CAPT) and another first officer conducted the repositioning flight. (see Aircraft Information). At JKIA, the airplane was loaded with cargo in preparation for the accident flight. The accident crew consisted of the Capt and FO in addition to a maintenance engineer and loadmaster. According to air traffic control (ATC), the flight plan was filed for duration of 2.5 hours at an altitude of 19,000 feet along with 5 hours of fuel aboard. Based on flight recorder data, the Capt was the pilot-flying and the FO was the pilot-monitoring. The accident flight was reconstructed using data from air traffic control and flight recorder information. According to FDR data, engine start occurred at at 01.50.20. At about 01.10.59 the flight made initial contact with JKIA air traffic control tower and after routine communication, including the confirmation of the number of person and fuel endurance, the flight was cleared for takeoff at 0112.30. At 01.11.58, both engines accelerated to a high power setting with engine no. 1 stabilizing at 78% torque, 100% propeller speed and engine 2 stabilizing at 80% torque, 99% propeller speed. About six seconds later, the Capt indicates “power is set”. About 2 seconds afterwards the Capt indicated “the auto-feather is off, left” and then 5 seconds later, the FO calls out “seven eighty” (?). About 16 seconds after initial engine acceleration was applied, the first of a series of three chimes audio alerts occurred, and continued at 1 second interval throughout the CVR recording. Immediately after the initial chimes, the Capt said “you see” and “how much is that?”. The FO responded “okay niner”. The Capt then asked “it has gotten to?” The FO replied “thirty four thirty ninety two” and shortly afterward “the left one is thirty”. About 24 seconds after initial engine acceleration, engine 1 torque climbs over a period of 2 seconds to a recorded value of 119.9%, the maximum value the recorder is capable of recording. Simultaneously Engine 1 propeller speed falls from 100% to 57%. Other engine shaft speeds remain at approximately their original high power values. Airspeed at the point this change occurs was less than 30 knots. During this period, the FO called out “one twenty two now [pause] torque”. The Capt responded “it is rising eh? The FO then noted “torque one twenty six now”. About 31 seconds after initial engine acceleration, the FO called out “okay speed alive sixty”. About a second later the Capt asked “do we reduce or”? The FO responded “we can just cut”. The Capt inquired “do we abort or continue?” The FO responded, “okay one one twelve and nine four point three” and then “okay one sixteen [pause] ninety four.” The Capt acknowledged “yeah okay” About 47 seconds after initial engine acceleration, the Capt said twice “did I reduce it?”and the FO responded sequentially “yeah” and “okay”] About 52 seconds after initial engine acceleration, the Capt asked “how is it now?” and the FO replied “yeah one oh two [pause] ninety four”. About 7 seconds later the FO called out “okay, one sixteen ninety four”. About 1 minute after initial engine acceleration, the Capt inquired “Is it really going?” The FO replied “one oh one, ninety five”. The Capt acknowledged and shortly afterward he queried “is it going really, is the aircraft really moving”. The FO responded “okay, one oh one, ninety five”. About 4 seconds later, the Capt indicated “it is not giving power” About 1 minute 9 seconds after the initial engine acceleration the FO called out “okay speed has now reached about hundred”. The Capt responded “oh yeah” and immediately afterward the FO called out “okay one eleven, ninety five”. About 1 minute 18 seconds after the initial engine acceleration, the FO indicated “hundred now”. The Capt acknowledged. About 1 minute 26 seconds after the initial engine acceleration, the FO called out “V one V R rotate” About 1 minute 33 seconds after the initial engine acceleration a transition of the airplane from ground to air mode is recorded and the pressure altitude begins to climb along with the Capt immediately afterward expressing two exclamations. Following the transition to air mode there were 51 seconds of flight recorder data before the recording ended. During this time and over a period of about 3 seconds, the FO calls out “positive rate of climb” and the Capt responded “gear up”. About 3 second later, the Capt expressed “it doesn’t have power [pause] it’s on one side.” About 6 seconds afterward, the FO said “we can also turn back”. About 3 seconds later the first of seven “don’t sink” (GPWS aural warning alerts) begins over a period of 23 seconds. After the second GPWS alert the Capt queried “ok, we’re ok?” After the third GPWS alert, the FO said “we can turn back” and the Capt immediately responded “let’s just go”. The FO replied “okay”. After the fifth GPWS alert, the Capt indicated “and this one is showing one fourteen” and then queried? “we can turn back?”. About 2 seconds later, the FO called out “okay speed is one hundred” and the Capt responded “but this one has nothing” About 1 second later and about the time of the sixth GPW alert, JKIA control tower radioed “five yankee charlie echo tango contact radar one two three decimal three. Good morning.” After the seventh GPWS alert the recording ended about 13 seconds later. During this time, the controller called the aircraft again. The Capt expressed “tell him [pause] tell him we have no power”. The last CVR data indicates the FO radioed, “ah tower charlie echo” and the transmission abruptly ended along with simultaneous sounds of distress. According to FDR data, about 15 seconds after the airplane transitioned from ground to air mode the recorded altitude peaked about 5060 feet and accompanied by a maximum airspeed of 100 knots. Along with a variation of airspeed between 90 knots and 100 knots for the remainder of the recording, during the following 20 seconds the altitude decreased to about 5000 feet and then increased to 5050 feet over the next 10 seconds where it remained until the recording ended at 1.14.27. Witness Accounts (Air Traffic Controller Civilians). The aircraft crashed during the hours of darkness at geographical coordinates of 01° 17’16”S, 36° 57’5”E.
Probable cause:
The probable cause of the accident was the decision by the crew to conduct the flight with a known mechanical problem and their failure to abort or reject the takeoff after receiving twenty seven cautions.
The following findings were identified:
- A three chime alert occurred during the positioning flight from HKNW to HKJK,
- Crew continued with the flight with a known fault,
- No evidence that remedial maintenance action was taken after landing from that flight prior to the event flight,
- No evidence of the anomaly being captured in the aircraft technical log,
- At least one of the occupants during the event flight, possibly the PIC, had been present during the positioning flight and thus was aware of the three chime alert that had occurred then,
- Twenty seven sound of three chime alert event occurred during the take off roll on the accident flight,
- The aforementioned alert occurred well before V1,
- The left engine exhibited high torque values (in excess of 120%) while the left propeller speed was reduced to the range between 45% to 55% rpm for most of the flight,
- Crew continued with take of roll and subsequent rotation despite the twenty seven chime alert,
- When airborne, crew contemplated turning back but eventually elected to continue with the flight,
- Cargo weight exceeded what was indicated in the load sheet 36,
- There was no evidence of any maintenance having been conducted on the aircraft since its Certificate of Airworthiness issue two months previously (9th May 2014).
Final Report: