Takeoff (climb)

A Kodiak-100 aircraft, registered PK-SDF, on 9 April 2014 was being operated by PT. Adventist Aviation Indonesia as non-schedule flight from Doyo Baru Airstrip with intended destination of Ninia Airstrip, Papua. On board in this flight were 7 persons consist of one pilot and six passengers. This flight was the fourth flights for the pilot who has performed flights from Doyo Baru (DOB) – Puldamat (PUL) at 2138-2228 UTC; Puldamat (PUL) –Soya (SOY) at 2243-2247 UTC; Soya (SOY) – Doyo Baru (DOB) at 2256-2344 UTC. The flight time to destination was estimated of 1 hour with cruising altitude of 10,000 feet and the fuel on board were sufficient for 4 hours flight time. Doyo Baru Airstrip located at approximately 10 NM North West of Sentani Airport (WAJJ). Air traffic movement to and from Doyo Baru Airstrip was controlled by Sentani Tower controller. At 0015 UTC, the pilot contacted to Sentani Tower controller, requested for start engine and clearance to fly to Ninia. The requests were approved and to report when ready for departure. At 0021 UTC, the pilot reported to the Sentani Tower controller ready for departure from Doyo Baru Airstrip. The Sentani Tower Controller instructed the pilot to hold to wait an aircraft took off from Sentani Airport. At 0024 UTC, the pilot received clearance for takeoff with additional traffic information and to report after airborne. At 0027 UTC, Sentani Tower controller has not received reports from the PK-SDF pilot and tried to call but was not responded. After several observations toward Doyo Baru area and did not see PK-SDF aircraft, The Sentani Tower controller reported to the Chief Section of Sentani Tower Air Navigation. At 0030 UTC, The Chief Section of Sentani Tower Air Navigation clarified the condition of PK-SDF aircraft to one of Indonesian Adventist Aviation pilot in Doyo Baru and obtained information that the aircraft had experienced in accident during takeoff at Doyo Baru. An engineer after received the information went to the accident site and saw appearance of white smoke came out from the side of the river which was known as the accident aircraft located. After arrived at the accident site the engineer saw the Adventist’s staffs and local people tried to extinguish the fire on the aircraft engine by throwing some water and used two fire extinguishers while some people moved the passengers from the wreckage. Two occupants including the pilot were fatally injured and five other passengers were seriously injured. All occupants were taken to Yowari Hospital (Rumah Sakit Umum Daerah – RSUD Yowari).

On 25.03.2014, the operator received the travel programme for 27.3.2014, of Hon'ble Governor of Haryana from Chandigarh to Delhi. On 26.3.2014, the operations department took the flight clearances and filed the passenger manifest with the ATC and other concerned agencies. The flight plan was filed by a CPL holder, who is working as flight dispatcher with the Government of Haryana. The departure on 27.3.2014 was fixed at 1130 hrs. The cockpit crew reported at 1045 hrs for the flight. Pre flight medical examination including the breath analyzer test was carried out at 1100 hrs. The breath analyzer test for both the cockpit crew members was negative. Pre flight briefing among the crew members was carried out by using the documents prepared by the flight dispatcher. The aircraft was taxied under its own power from Haryana Government Hangar to bay no. D-2 in front of ATC building. No abnormality was observed or reported on the aircraft during this taxiing. The engines were shut down for passenger embarkation. As per the passenger manifest, in addition to the pilot and co-pilot there were 8 passengers. The baggage on board was approx. 50 lbs. There was 2100 lbs. of fuel on board. After boarding of the passengers, the aircraft engines were started at 1130 hrs. The aircraft was cleared for departure abeam „D‟ link. The aircraft was taxied out via taxiway „D‟. After ATC departure clearance the aircraft was lined up for take-off. On clearance from ATC the take off roll was initiated and all the parameters were found normal. As per the pilot just before getting airborne some stiffness was found in rudder control as is felt in yaw damper engagement. The aircraft then pulled slightly to the left which as per the Commander was controllable. As per the pilot, the rotation was initiated at 98 knots. As per the DATCO the aircraft had lifted up to 10-15 feet AGL. The Commander has stated that after lift-off, immediately the left rudder got locked in forward position resulting in the aircraft yawing and rolling to left. The pilots tried to control it with right bank but the aircraft could not be controlled. Within 3-4 seconds of getting airborne the aircraft impacted the ground in left bank attitude. The initial impact was on pucca (tar road) and the wing has taken the first impact loads with lower surface metallic surface rubbing and screeching on ground. After the aircraft came to final halt, the co-pilot opened the door and evacuation was carried out. There was no injury to any of the occupants. The engine conditions lever could not be brought back as these were stuck. The throttle and pitch levers were retarded. The fuel shut off valves were closed. Battery and avionics were put off. Friction lock nuts were found loose. As per the Commander, after ensuring safety of passengers he had gone to cockpit to confirm that all switches were „off‟. At that time he has loosened the friction lock nuts to bring back the condition lever and throttle lever. However even after loosening the nut it was not possible to bring back these levers. Fire fighting vehicles were activated by pressing crash bell and primary alarm. Hand held RT set was used to announce the crash. RCFF vehicles proceeded to the site via runway and reported all the 10 personnel are safe and out of the disabled aircraft. Water and complementary agents (foam and dry chemical powder) were used. After fire was extinguished, the Fire Fighting vehicles reported back at crash bay except one CFT which was held at crash site under instruction of COO. The aircraft was substantially damaged. There was no fire barring burning of small patch of grass due coming in contact with the hot surfaces and oil. There was no injury to any of the occupants. The accident occurred in day light conditions.

Before pushback from the gate, the first officer, who was the pilot monitoring, initialized the flight management computer (FMC) and mistakenly entered the incorrect departure runway (27R instead of the assigned 27L). As the captain taxied onto runway 27L for departure, he noticed that the wrong runway was entered in the FMC. The captain asked the first officer to correct the runway entry in the FMC, which she completed about 27 seconds before the beginning of the takeoff roll; however, she did not enter the FLEX temperature (a reduced takeoff thrust setting) for the newly entered runway or upload the related V-speeds. As a result, the FMC's ability to execute a FLEX power takeoff was invalidated, and V-speeds did not appear on the primary flight display (PFD) or the multipurpose control display unit during the takeoff roll. According to the captain, once the airplane was cleared for takeoff on runway 27L, he set FLEX thrust with the thrust levers, and he felt that the performance and acceleration of the airplane on the takeoff roll was normal. About 2 seconds later, as the airplane reached about 56 knots indicated airspeed (KIAS), cockpit voice recorder (CVR) data indicate that the flight crew received a single level two caution chime and an electronic centralized aircraft monitoring (ECAM) message indicating that the thrust was not set correctly. The first officer called "engine thrust levers not set." According to the operator's pilot handbook, in response to an "engine thrust levers not set" ECAM message, the thrust levers should be moved to the takeoff/go-around (TO/GA) detent. However, the captain responded by saying "they're set" and moving the thrust levers from the FLEX position to the CL (climb) detent then back to the FLEX position. As the airplane continued to accelerate, the first officer did not make a callout at 80 KIAS, as required by the operator's standard operating procedures (SOPs). As the airplane reached 86 KIAS, the automated RETARD aural alert sounded and continued until the end of the CVR recording. According to Airbus, the RETARD alert is designed to occur at 20 ft radio altitude on landing and advise the pilot to reduce the thrust levers to idle. The captain later reported that he had never heard an aural RETARD alert on takeoff, only knew of it on landing, and did not know what it was telling him. He further said that when the RETARD aural alert sounded, he did not plan to reject the takeoff because they were in a high-speed regime, they had no red warning lights, and there was nothing to suggest that the takeoff should be rejected. The first officer later reported that there were no V-speeds depicted on the PFD and, thus, she could not call V1 or VR during the takeoff. She was not aware of any guidance or procedure that recommended rejecting or continuing a takeoff when there were no V-speeds displayed. She further said she "assumed [the captain] wouldn't continue to takeoff if he did not know the V-speeds." The captain stated that he had recalled the V-speeds as previously briefed from the Taxi checklist, which happened to be the same V-speeds for runway 27L. The captain continued the takeoff roll despite the lack of displayed V-speeds, no callouts from the first officer, and the continued and repeated RETARD aural alert. FDR data show that the airplane rotated at 164 KIAS. However, in a postaccident interview, the captain stated that he "had the perception the aircraft was unsafe to fly" and that he decided "the safest action was not to continue," so he commenced a rejected takeoff. FDR data indicate that the captain reduced the engines to idle and made an airplane-nose-down input as the airplane reached 167 KIAS (well above the V1 speed of 157 KIAS) and achieved a 6.7 degree nose-high attitude. The airplane's pitch decreased until the nose gear contacted the runway. However, the airplane then bounced back into the air and achieved a radio altitude of about 15 ft. Video from airport security cameras show the airplane fully above the runway surface after the bounce. The tail of the airplane then struck the runway surface, followed by the main landing gear then the nose landing gear, resulting in its fracture. The airplane slid to its final resting position on the left side of runway 27L. The operator's SOPs address the conditions under which a rejected takeoff should be performed within both low-speed (below 80 KIAS) and high-speed (between 80 KIAS and V1) regimes but provide no guidance for rejecting a takeoff after V1 and rotation. Simulator testing performed after the accident demonstrated that increasing the thrust levers to the TO/GA detent, as required by SOPs upon the activation of the "thrust not set" ECAM message, would have silenced the RETARD aural alert. At the time of the accident, neither the operator's training program nor manuals provided to flight crews specifically addressed what to do in the event the RETARD alert occurred during takeoff; although, 9 months before the accident, US Airways published a safety article regarding the conditions under which the alert would activate during takeoff. The operator's postaccident actions include a policy change (published via bulletin) to its pilot handbook specifying that moving the thrust levers to the TO/GA detent will cancel the RETARD aural alert. Although simulator testing indicated that the airplane was capable of sustaining flight after liftoff, it is likely that the cascading alerts (the ECAM message and the RETARD alert) and the lack of V-speed callouts eventually led the captain to have a heightened concern for the airplane's state as rotation occurred. FDR data indicate that the captain made erratic pitch inputs after the initial rotation, leading to the nose impacting the runway and the airplane bouncing into the air after the throttle levers had been returned to idle. Airbus simulation of the accident airplane's acceleration, rotation, and pitch response to the cyclic longitudinal inputs demonstrated that the airplane was responding as expected to the control inputs. Collectively, the events before rotation (the incorrect runway programmed in the FMC, the "thrust not set" ECAM message during the takeoff roll, the RETARD alert, and the lack of required V-speeds callouts) should have prompted the flight crew not to proceed with the takeoff roll. The flight crewmembers exhibited a self-induced pressure to continue the takeoff rather than taking the time to ensure the airplane was properly configured. Further, the captain initiated a rejected takeoff after the airplane's speed was beyond V1 and the nosewheel was off the runway when he should have been committed to the takeoff. The flight crewmembers' performance was indicative of poor crew resource management in that they failed to assess their situation when an error was discovered, to request a delayed takeoff, to communicate effectively, and to follow SOPs. Specifically, the captain's decision to abort the takeoff after rotation, the flight crew's failure to verify the correct departure runway before gate departure, and the captain's failure to move the thrust levers to the TO/GA detent in response to the ECAM message were all contrary to the operator's SOPs. Member Weener filed a statement, concurring in part and dissenting in part, that can be found in the public docket for this accident. Chairman Hart, Vice Chairman Dinh-Zarr, and Member Sumwalt joined the statement.

The airplane departed during dark (moonless) night conditions over remote terrain with few ground-based light sources to provide visual cues. Weather reports indicated strong gusting wind from the northeast. According to a surviving passenger, shortly after takeoff, the pilot started a right turn; the bank angle continued to increase, and the airplane impacted terrain in a steep right bank. The accident site was about 1 mile from the airport at a location consistent with the airplane departing to the northeast and turning right about 180 degrees before ground impact. The operator's chief pilot reported that the pilot likely turned right after takeoff to fly direct to the navigational aid located southwest of the airport in order to escape the terrain induced turbulence (downdrafts) near the mountain range northeast of the airport. Examination of the airplane wreckage revealed damage and ground scars consistent with a high-energy, low-angle impact during a right turn. No evidence was found of preimpact mechanical malfunctions or failures that would have precluded normal operation. It is likely that the pilot became spatially disoriented during the right turn. Although visual meteorological conditions prevailed, no natural horizon and few external visual references were available during the departure. This increased the importance for the pilot to monitor the airplane's flight instruments to maintain awareness of its attitude and altitude. During the turn, the pilot was likely performing the additional task of engaging the autopilot, which was located on the center console below the throttle quadrant. The combination of conducting a turn with few visual references in gusting wind conditions while engaging the autopilot left the pilot vulnerable to visual and vestibular illusions and reduced his awareness of the airplane's attitude, altitude, and trajectory. Based on toxicology findings, the pilot most likely had symptoms of an upper respiratory infection but the investigation was unable to determine what effects these symptoms may have had on his performance. A therapeutic level of doxylamine, a sedating antihistamine, was detected, and impairment by doxylamine most likely contributed to the development of spatial disorientation.

On 29 January 2014, at about 1100 Central Daylight-savings Time, the pilot prepared a Piper PA-31 aircraft, registered VHOFF, for a private flight from Aldinga aeroplane landing area (ALA) to Kangaroo Island, South Australia. To check fuel quantities, the pilot entered the cockpit, turned on the master switch and placed the left and right fuel selectors onto the main tank (inboard) position. The gauge for each tank showed just under half full. He then placed each fuel selector onto the auxiliary (outboard) tank position, where the gauge indicated the right and left auxiliary tanks were each about a quarter full. He did not return the selectors to the main tanks. He estimated that refuelling the main tanks would allow sufficient fuel for the flight with over an hour in reserve. He exited the aircraft while it was refuelled and continued preparing for the flight. Once refuelling was completed, the pilot conducted a pre-flight inspection, and finished loading the aircraft. The pilot and passenger then boarded. The pilot was familiar with Aldinga ALA, which is a non-controlled airport. At uncontrolled airports, unless a restriction or preference is listed for a certain runway in either the Airservices en route supplement Australia (ERSA), or other relevant publications, selection of the runway is the responsibility of the pilot. Operational considerations such as wind direction, other traffic, runway surface and length, performance requirements for the aircraft on that day, and suitable emergency landing areas in the event of an aircraft malfunction are all taken into consideration. On this day, the pilot assessed the wind to be favoring runway 14, which already had an aircraft in the circuit intending to land. However, he decided to use runway 03 due to the availability of a landing area in case of an emergency. He then completed a full run-up check of the engines, propellers and magnetos prior to lining up for departure. The pilot reported that all of the pre-take-off checks were normal. Once the aircraft landing on runway 14 was clear of the runway, the pilot went through his usual memory checklist prior to take-off. He scanned and crosschecked the flight and panel instruments, power quadrant settings and trims, but did not complete his usual final check, which was to reach down with his right hand and confirm that the fuel selector levers were on the main tanks. After broadcasting on the common traffic advisory frequency (CTAF) he commenced the take-off. At the appropriate speed, he rotated the aircraft as it passed the intersection of the 14 and 03 runways. Almost immediately both engines began surging, there was a loss of power, the power gauges fluctuated and the aircraft yawed from side to side. Due to the surging, fluctuating gauges and aircraft yaw, the pilot found it difficult to identify what he thought was a non-performing engine. He reported there were no warning lights so he retracted the landing gear, with the intent of getting the aircraft to attain a positive rate of climb, so he could trouble shoot further at a safe altitude. When a little over 50 ft above ground level (AGL), he realized the aircraft was not performing sufficiently, so he selected a suitable landing area. He focused on maintaining a safe airspeed and landed straight ahead. The aircraft touched down and slid about another 75-100 metres before coming to rest. The impact marks of the propellers suggest the aircraft touched the ground facing north-easterly and rotated to the north-west prior to stopping. The pilot turned off the master switch and both he and the passenger exited the aircraft. After a few minutes he re-entered the cockpit and completed the shutdown. Police and fire service attended shortly after the accident.

On 17th January, 2014, the day before the accident, the pilot departed from his company base, Ogle International Airport (SYGO) with another aircraft, a Cessna 208B, Registration – 8R-GHT. He was tasked to do two days of shuttling; the first day between Olive Creek and Ekereku Bottom Airstrips, and the second day between Olive Creek and Imbaimadai Airstrips. The pilot was accompanied by a third crew/loader, whose duty was to ensure that the aircraft was properly loaded for each trip, and an aircraft engineer who was assigned to carry out minor maintenance duties and refuel the aircraft as required for the duration of the shuttle operations. It was reported that on the first day, during a landing at Ekereku Bottom, the aircraft encountered severe wind conditions that resulted in a hard landing. The pilot was very concerned about the hard landing and expressed this to several individuals. He was concerned enough to log the hard landing in the Aircraft Technical Log. After the hard landing the aircraft was visually inspected by the engineer who declared the aircraft fit for flight. However while taxying prior to takeoff the aircraft suffered a right brake seizure. The engineer freed and bled the brake line. Tests were done on the brakes and the aircraft was flown to Olive Creek. The hard landing and the brake failure were reported to base and an instruction was passed that this aircraft should be brought back to Ogle by another pilot. Another Cessna 208B aircraft, 8R-GHS, the accident aircraft, was left with the pilot for him to complete his shuttle schedule the next day. On the afternoon of the first day, the pilot flew this aircraft, 8R-GHS to Kamarang Airstrip, where he overnighted. On the second day, 18th January, 2014, he departed Kamarang at 10:30hrs UTC for Olive Creek with the engineer and the loader. The engineer was left at Olive Creek. The pilot, with the loader, did one shuttle from Olive Creek to Imbaimadai. He returned to Olive Creek where the aircraft was refueled and then did three shuttles between Olive Creek and Imbaimadai. After these three shuttles the aircraft was again refueled. He completed one shuttle, Olive Creek/Imbaimadai/Olive Creek and had just taken off on the second in this series of shuttles when the accident occurred during midmorning. Both the pilot and the third crew were killed in the crash.

The single engine aircraft departed Cayenne-Rochambeau-Félix Éboué Airport runway 08 at 1448LT on a cargo flight to Maripasoula, carrying one female passenger and one pilot. About three minutes into the flight, while cruising at an altitude of 1,500 feet, the plot encountered engine problems, declared an emergency and was cleared for an immediate return. The aircraft landed back at 1452LT. Some controls were performed on the engine and the aircraft took off again at 1507LT. Less than a minute later, the engine lost power. The pilot again declared an emergency and returned to the airport. On short final, the aircraft lost height and crashed in bushes some 800 metres short of runway 26. The passenger was seriously injured and the pilot was slightly injured. The aircraft was destroyed.

The pilot and passenger departed on a night personal flight. A review of the cockpit voice recorder (CVR) transcript revealed that, immediately after departure, the passenger asked the pilot if he had turned on the heat. The pilot subsequently informed the tower air traffic controller that he needed to return to the airport. The controller then cleared the airplane to land and asked the pilot if he needed assistance. The pilot replied "negative" and did not declare an emergency. The pilot acknowledged to the passenger that it was hot in the cabin. The CVR recorded the enhanced ground proximity warning system (EGPWS) issue 11 warnings, including obstacle, terrain, and stall warnings; these warnings occurred while the airplane was on the downwind leg for the airport. The airplane subsequently impacted trees and terrain and was consumed by postimpact fire. Postaccident examination of the airplane revealed no malfunctions or anomalies that would have precluded normal operation. During the attempted return to the airport, possibly to resolve a cabin heat problem, the pilot was operating in a high workload environment due to, in part, his maneuvering visually at low altitude in the traffic pattern at night, acquiring inbound traffic, and being distracted by the reported high cabin temperature and multiple EGPWS alerts. The passenger was seated in the right front seat and in the immediate vicinity of the flight controls, but no evidence was found indicating that she was operating the flight controls during the flight. Although the pilot had a history of coronary artery disease, the autopsy found no evidence of a recent cardiac event, and an analysis of the CVR data revealed that the pilot was awake, speaking, and not complaining of chest pain or shortness of breath; therefore, it is unlikely that the pilot's cardiac condition contributed to the accident. Toxicological testing detected several prescription medications in the pilot's blood, lung, and liver, including one to treat his heart disease; however, it is unlikely that any of these medications resulted in impairment. Although the testing revealed that the pilot had used marijuana at some time before the accident, insufficient evidence existed to determine whether the pilot was impaired by its use at the time of the accident. Toxicology testing also detected methylone in the pilot's blood. Methylone is a stimulant similar to cocaine and Ecstasy, and its effects can include relaxation, euphoria, and excited calm, and it can cause acute changes in cognitive performance and impair information processing. Given the level of methylone (0.34 ug/ml) detected in the pilot's blood, it is likely that the pilot was impaired at the time of the accident. The pilot's drug impairment likely contributed to his failure to maintain control of the airplane.

The airline transport pilot was conducting an air taxi commuter flight between two Hawaiian islands with eight passengers on board. Several passengers stated that the pilot did not provide a safety briefing before the flight. One passenger stated that the pilot asked how many of the passengers had flown over that morning and then said, “you know the procedures.” The pilot reported that, shortly after takeoff and passing through about 500 ft over the water, he heard a loud “bang,” followed by a total loss of engine power. The pilot attempted to return to the airport; however, he realized that the airplane would not be able to reach land, and he subsequently ditched the airplane in the ocean. All of the passengers and the pilot exited the airplane uneventfully. One passenger swam to shore, and rescue personnel recovered the pilot and the other seven passengers from the water about 80 minutes after the ditching. However, one of these passengers died before the rescue personnel arrived. Postaccident examination of the recovered engine revealed that multiple compressor turbine (CT) blades were fractured and exhibited thermal damage. In addition, the CT shroud exhibited evidence of high-energy impact marks consistent with the liberation of one or more of the CT blades. The thermal damage to the CT blades likely occurred secondary to the initial blade fractures and resulted from a rapid increase in fuel flow by the engine fuel control in response to the sudden loss of compressor speed due to the blade fractures. The extent of the secondary thermal damage to the CT blades precluded a determination of the cause of the initial fractures. Review of airframe and engine logbooks revealed that, about 1 1/2 years before the accident, the engine had reached its manufacturer-recommended time between overhaul (TBO) of 3,600 hours; however, the operator obtained a factory-authorized, 200-hour TBO increase. Subsequently, at an engine total time since new of 3,752.3 hours, the engine was placed under the Maintenance on Reliable Engines (MORE) Supplemental Type Certificate (STC) inspection program, which allowed an immediate increase in the manufacturer recommended TBO from 3,600 to 8,000 hours. The MORE STC inspection program documents stated that the MORE STC was meant to supplement, not replace, the engine manufacturer’s Instructions for Continued Airworthiness and its maintenance program. Although the MORE STC inspection program required more frequent borescope inspections of the hot section, periodic inspections of the compressor and exhaust duct areas, and periodic power plant adjustment/tests, it did not require a compressor blade metallurgical evaluation of two compressor turbine blades; however, this evaluation was contained in the engine maintenance manual and an engine manufacturer service bulletin (SB). The review of the airframe and engine maintenance logbooks revealed no evidence that a compressor turbine metallurgical evaluation of two blades had been conducted. The operator reported that the combined guidance documentation was confusing, and, as a result, the operator did not think that the compressor turbine blade evaluation was necessary. It is likely that, if the SB had been complied with or specifically required as part of the MORE STC inspection program, possible metal creep or abnormalities in the turbine compressor blades might have been discovered and the accident prevented. The passenger who died before the first responders arrived was found wearing a partially inflated infant life vest. The autopsy of the passenger did not reveal any significant traumatic injuries, and the autopsy report noted that her cause of death was “acute cardiac arrhythmia due to hyperventilation.” Another passenger reported that he also inadvertently used an infant life vest, which he said seemed “small or tight” but “worked fine.” If the pilot had provided a safety briefing, as required by Federal Aviation Administration regulations, to the passengers that included the ditching procedures and location and usage of floatation equipment, the passengers might have been able to find and use the correct size floatation device.

Shortly after takeoff from The Pikany Indian Reserve Airfield, while in initial climb, the twin engine aircraft lost height, collided with trees and crashed in a wooded area located on km from the airstrip. The aircraft was destroyed and all five occupants were killed, among them Indian Kayapo who were flying to Novo Progresso to have urgent care.