Crash of a Learjet 35A off Fort Lauderdale: 4 killed

Date & Time: Nov 19, 2013 at 1956 LT
Type of aircraft:
Operator:
Registration:
XA-USD
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Fort Lauderdale - Cozumel
MSN:
35A-255
YOM:
1979
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
10091
Captain / Total hours on type:
1400.00
Copilot / Total flying hours:
1235
Copilot / Total hours on type:
175
Aircraft flight hours:
6842
Circumstances:
During takeoff to the east over the ocean, after the twin-engine jet climbed straight ahead to about 2,200 ft and 200 knots groundspeed, the copilot requested radar vectors back to the departure airport due to an "engine failure." The controller assigned an altitude and heading, and the copilot replied, "not possible," and requested a 180-degree turn back to the airport, which the controller acknowledged and approved. However, the airplane continued a gradual left turn to the north as it slowed and descended. The copilot subsequently declared a "mayday" and again requested vectors back to the departure airport. During the next 3 minutes, the copilot requested, received, and acknowledged multiple instructions from the controller to turn left to the southwest to return to the airport. However, the airplane continued its slow left turn and descent to the north. The airplane slowed to 140 knots and descended to 900 ft as it flew northbound, parallel to the shoreline, and away from the airport. Eventually, the airplane tracked in the direction of the airport, but it continued to descend and impacted the ocean about 1 mile offshore. According to conversations recorded on the airplane's cockpit voice recorder (CVR), no checklists were called for, offered, or used by either flight crewmember during normal operations (before or during engine start, taxi, and takeoff) or following the announced in-flight emergency. After the "engine failure" was declared to the air traffic controller, the pilot asked the copilot for unspecified "help" because he did not "know what's going on," and he could not identify the emergency or direct the copilot in any way with regard to managing or responding to the emergency. At no time did the copilot identify or verify a specific emergency or malfunction, and he did not provide any guidance or assistance to the pilot. Examination of the recovered wreckage revealed damage to the left engine's thrust reverser components, including separation of the lower blocker door, and the stretched filament of the left engine's thrust reverser "UNLOCK" status light, which indicated that the light bulb was illuminated at the time of the airplane's impact. Such evidence demonstrated that the left engine's thrust reverser became unlocked and deployed (at least partially and possibly fully) in flight. Impact damage precluded testing for electrical, pneumatic, and mechanical continuity of the thrust reverser system, and the reason the left thrust reverser deployed in flight could not be determined. No previous instances of the inflight deployment of a thrust reverser on this make and model airplane have been documented. The airplane's flight manual supplement for the thrust reverser system contained emergency procedures for responding to the inadvertent deployment of a thrust reverser during takeoff. For a deployment occurring above V1 (takeoff safety speed), the procedure included maintaining control of the airplane, placing the thrust reverser rocker switch in the "EMER STOW" position, performing an engine shutdown, and then performing a single-engine landing. Based on the wreckage evidence and data recovered from the left engine's digital electronic engine control (DEEC), the thrust reverser rocker switch was not placed in the "EMER STOW" position, and the left engine was not shut down. The DEEC data showed a reduction in N1 about 100 seconds after takeoff followed by a rise in N1 about 35 seconds later. The data were consistent with the thrust reverser deploying in flight (resulting in the reduction in N1) followed by the inflight separation of the lower blocker door (resulting in the rise in N1 as some direct exhaust flow was restored). Further, the DEEC data revealed full engine power application throughout the flight. Although neither flight crewmember recognized that the problem was an inflight deployment of the left thrust reverser, certification flight test data indicated that the airplane would have been controllable as it was configured on the accident flight. If the crew had applied the "engine failure" emergency procedure (the perceived problem that the copilot reported to the air traffic controller), the airplane would have been more easily controlled and could have been successfully landed. The airplane required two fully-qualified flight crewmembers; however, the copilot was not qualified to act as second-in-command on the airplane, and he provided no meaningful assistance to the pilot in handling the emergency. Further, although the pilot's records indicated considerable experience in similar model airplanes, the pilot's performance during the flight was highly deficient. Based on the CVR transcript, the pilot did not adhere to industry best practices involving the execution of checklists during normal operations, was unprepared to identify and handle the emergency, did not refer to the appropriate procedures checklists to properly configure and control the airplane once a problem was detected, and did not direct the copilot to the appropriate checklists.
Probable cause:
The pilot's failure to maintain control of the airplane following an inflight deployment of the left engine thrust reverser. Contributing to the accident was the flight crew's failure to perform the appropriate emergency procedures, the copilot's lack of qualification and capability to act as a required flight crewmember for the flight, and the inflight deployment of the left engine thrust reverser for reasons that could not be determined through postaccident investigation.
Final Report:

Mishap of a Fokker F27 Friendship 500F in Paris-Roissy-CDG

Date & Time: Oct 25, 2013 at 0125 LT
Type of aircraft:
Operator:
Registration:
I-MLVT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Paris - Dole
MSN:
10373
YOM:
1968
Flight number:
MNL5921
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing a night mail flight from Paris-Roissy-CDG Airport to Dole-Jura (Tavaux) Airport on behalf of Europe Airpost. Shortly after takeoff, while climbing to an altitude of 1,000 feet, the left propeller detached and impacted the left part of the fuselage, causing a large hole. The crew declared an emergency and was cleared for an immediate return. The aircraft landed safely less than 10 minutes later and was parked on the apron. Both pilots were uninjured and the aircraft was damaged beyond repair. The propeller was found in an open field in Mesnil-Amelot, near the airport. Nobody on ground was injured.
Probable cause:
The n°2 propeller blade root on the left engine failed due to fatigue, resulting in separation from the propeller hub and then interaction with the n°1 blade and its disconnection from the propeller hub. The imbalance created by the loss of these two blades led to the front part of the engine being torn off. The cause of the fatigue cracking could not be determined with certainty. The following may have contributed to the fatigue fracture of the propeller blade root:
- Insufficient preloading of the propeller, increasing the stress exerted on it. The lack of maintenance documentation made it impossible to determine the preload values of the bearings during the last general overhaul;
- The presence of manganese sulphide in a heavily charged area of the propeller. The presence of this sulphide may have generated a significant stress concentration factor, raising the local stress level.
The tests and research carried out as part of this investigation show that the propeller blade root is made of a steel whose microstructure and composition are not optimal for fatigue resistance. However, the uniqueness of the rupture more than 50 years after commissioning makes it unlikely that the rate of inclusions, their distribution, size, or sulphur content of the propeller is a contributing factor in the accident.
Final Report:

Crash of an ATR42-320F in Madang

Date & Time: Oct 19, 2013 at 0915 LT
Type of aircraft:
Operator:
Registration:
P2-PXY
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Madang – Tabubil – Kiunga
MSN:
87
YOM:
1988
Flight number:
PX2900
Location:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7110
Captain / Total hours on type:
3433.00
Copilot / Total flying hours:
3020
Copilot / Total hours on type:
2420
Aircraft flight hours:
24375
Circumstances:
On 19 October 2013, an Avions de Transport Régional ATR42-320 freighter, registered P2-PXY (PXY) and operated by Air Niugini, was scheduled to fly from Madang to Tabubil, Western Province, as flight PX2900 carrying a load tobacco for a client company. There were three persons on board; the pilot in command (PIC), a copilot, and a PNG experienced DHC-8 captain whose function was to provide guidance during the approach into Tabubil. The PIC was the handling pilot and the copilot was the support monitoring pilot. The flight crew taxied to the threshold end of runway 25 intending to use the full length of the runway. The take-off roll was normal until the PIC tried to rotate at VR (speed for rotation, which the flight crew had calculated to be 102 knots). He subsequently reported that the controls felt very heavy in pitch and he could not pull the control column back in the normal manner. Flight data recorder (FDR) information indicated that approximately 2 sec later the PIC aborted the takeoff and selected full reverse thrust. He reported later that he had applied full braking. It was not possible to stop the aircraft before the end of the runway and it continued over the embankment at the end of the runway and the right wing struck the perimeter fence. The aircraft was substantially damaged during the accident by the impact, the post-impact fire and partial immersion in salt water. The right outboard wing section was completely burned, and the extensively damaged and burnt right engine fell off the wing into the water. Both propellers were torn from the engine shafts and destroyed by the impact forces.
Probable cause:
The following findings were identified:
- The investigation found that Air Niugini’s lack of robust loading procedures and supervision for the ATR 42/72 aircraft, and the inaccurate weights provided by the consignor/client company likely contributed to the overload.
- The mass and the centre of gravity of the aircraft were not within the prescribed limits.
- The aircraft total load exceeded the maximum permissible load and the load limit in the forward cargo zone ‘A’ exceeded the zone ‘A’ structural limit.
- There was no evidence of any defect or malfunction in the aircraft that could have contributed to the accident.
Final Report:

Crash of a Cessna 208B Grand Caravan in Likawage

Date & Time: Oct 11, 2013
Type of aircraft:
Operator:
Registration:
5H-KEN
Flight Phase:
Survivors:
Yes
Schedule:
Likawage – Dar es Salaam
MSN:
208B-0384
YOM:
1994
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft was engaged in a charter flight from Likawage to Dar es Salaam, carrying one passenger and two pilots. Ready for takeoff at threshold, the crew applied full power and maintained brakes. Despite the engine did not reach the takeoff power, the captain released brakes and initiated the takeoff roll. The aircraft rolled for about three-quarters of the runway when the engine reached the takeoff power. But the aircraft failed to rotate, continued, overran and eventually collided with trees, bursting into flames. All three occupants were slightly injured and the aircraft was partially destroyed by fire.

Crash of an Embraer EMB-120ER Brasília in Lagos: 16 killed

Date & Time: Oct 3, 2013 at 0932 LT
Type of aircraft:
Operator:
Registration:
5N-BJY
Flight Phase:
Survivors:
Yes
Schedule:
Lagos - Akure
MSN:
120-174
YOM:
1990
Flight number:
SCD361
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
16
Captain / Total flying hours:
20068
Captain / Total hours on type:
1309.00
Copilot / Total flying hours:
4660
Copilot / Total hours on type:
3207
Aircraft flight hours:
27362
Aircraft flight cycles:
34609
Circumstances:
The crew discussed some concerns about the aircraft prior to departure but at this time we are not prepared to elaborate on those concerns as there remains a lot of work to complete on the CVR analysis in order to determine the specific nature of the crew’s concerns. Associated 361 was cleared for take-off on runway one eight left at Lagos international airport. The wind was calm and weather is not considered a factor in this accident. Approximately 4 seconds after engine power was advanced to commence the take-off roll, the crew received an automated warning from the onboard computer voice which consisted of three chimes followed by “Take-off Flaps…Take-off Flaps”. This is a configuration warning that suggests that the flaps were not in the correct position for take-off and there is some evidence that the crew may have chosen not to use flaps for the take-off. The warning did not appear to come as any surprise to the crew and they continued normally with the take-off. This warning continues throughout the take-off roll. As we are in the process of verifying the accuracy of the flight data, we have not yet been able to confirm the actual flap setting however we expect to determine this in the fullness of time. It was determined from the CVR that the pilot flying was the Captain and the pilot monitoring and assisting was the First Officer. The ‘set power‘ call was made by the Captain and the ‘power is set’ call was confirmed by the First Officer as expected in normal operations. Approximately 3 seconds after the ‘power is set’ call, the First Officer noted that the aircraft was moving slowly. Approximately 7 seconds after the ‘power is set’ call, the internal Aircraft Voice warning system could be heard stating ‘Take off Flaps, Auto Feather’. Auto feather refers to the pitch of the propeller blades. In the feather position, the propeller does not produce any thrust. The FDR contains several engine related parameters which the AIB is studying. At this time, we can state that the Right engine appears to be producing considerably less thrust than the Left engine. The left engine appeared to be working normally. The aircraft automated voice continued to repeat ‘Take-off Flaps, Auto Feather’. The physical examination of the wreckage revealed that the right engine propeller was in the feather position and the engine fire handle was pulled/activated. The standard ‘eighty knots’ call was made by the First Officer. The first evidence that the crew indicated that there was a problem with the take-off roll was immediately following the ‘eighty knots’ call. The First Officer asked if the take- off should be aborted approximately 12 seconds after the ‘eighty knots’ callout. Our investigation team estimates the airspeed to be approximately 95 knots. Airspeed was one of the parameters that, while working in the cockpit, appeared not to be working on the Flight Data Recorder. We were able to estimate the speed based on the radar data that we synchronized to the FDR and CVR but it is very approximate because of this. In response to the First Officer’s question to abort, the Captain indicated that they should continue and they continued the take-off roll. The crew did not make a ‘V1’ call or a Vr’ call. V1 is the speed at which a decision to abort or continue a take-off is made. Vr is the speed at which it is planned to rotate the aircraft. Normally the non-flying pilot calls both the V1 and the Vr speeds. When Vr is called the flying pilot pulls back on the control column and the aircraft is rotated (pitched up) to climb away from the runway. During the rotation, the First Officer stated ‘gently’, which we believe reflects concern that the aircraft is not performing normally and therefore needs to be rotated very gently so as not to aerodynamically stall the aircraft. The First Officer indicated that the aircraft was not climbing and advised the Captain who was flying not to stall the aircraft. Higher climb angles can cause an aerodynamic stall. If the aircraft is not producing enough overall thrust, it is difficult or impossible to climb without the risk of an aerodynamic stall. Immediately after lift-off, the aircraft slowly veered off the runway heading to the right and was not climbing properly. This aircraft behavior appears to have resulted in the Air Traffic Controller asking Flight 361 if operation was normal. Flight 361 never responded. Less than 10 seconds after rotation of the aircraft to climb away from the runway, the stall warning sounded in the cockpit and continued to the end of the recording. The flight data shows characteristics consistent with an aerodynamic stall. 31 seconds after the stall warning was heard, the aircraft impacted the ground in a nose down near 90° right bank.
Probable cause:
The accident was the consequence of the decision of the crew to continue the take-off despite the abnormal No. 2 Propeller rpm indication and a low altitude stall as a result of low thrust at start of roll for take-off from No. 2 Engine caused by an undetermined malfunction of the propeller control unit.
The following contributing factors were identified:
- The aircraft was rotated before attaining V1.
- The decision to continue the take-off with flap configuration warning and auto- feather warning at low speed.
- Poor professional conduct of the flight crew.
- Inadequate application of Crew Resource Management (CRM) principles.
- Poor company culture.
- Inadequate regulatory oversight.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Lyon-Bron: 4 killed

Date & Time: Sep 24, 2013 at 1045 LT
Operator:
Registration:
N556MB
Flight Phase:
Survivors:
No
Schedule:
Lyon - Aix-les-Milles
MSN:
421C-00468
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
410
Captain / Total hours on type:
12.00
Copilot / Total flying hours:
579
Copilot / Total hours on type:
3
Aircraft flight hours:
3661
Circumstances:
After takeoff from runway 34 at Lyon-Bron Airport, while in initial climb at a height of 200 feet, the twin engine airplane deviated to the left, rolled to the left and then veered to the left with a low rate of climb. Shortly after passing the end of the runway, the airplane lost height then struck the ground and caught fire. The airplane was destroyed by a post crash fire and all four occupants were killed. For unknown reasons, the pilot-in-command was seating in the right seat.
Probable cause:
The accident probably occurred as a result of an asymmetrical flight starting from the rotation that the pilot was not able to control. As technical examinations and observations from the wreckage could not give any conclusive malfunction of the engines or systems, the initial cause is most likely an improper adjustment of the steering trim before takeoff. The poor experience of the pilot on this high powered and complex aircraft as well as the low height reached did not allow the pilot to understand and manage the situation quickly and avoid the loss of control.
Final Report:

Crash of a Cessna T207 Turbo Skywagon in Colorado Springs

Date & Time: Sep 4, 2013 at 0758 LT
Registration:
N211AS
Flight Phase:
Survivors:
Yes
Schedule:
Colorado Springs – Lubbock
MSN:
207-0259
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5200
Captain / Total hours on type:
18.00
Aircraft flight hours:
13482
Circumstances:
The pilot reported that he performed the takeoff with the airplane at gross weight and with the flaps up and the engine set for maximum power, which he verified by reading the instruments. During the takeoff, the airplane accelerated and achieved liftoff about 65 to 70 mph and then climbed a couple hundred feet before the pilot began to lower the nose to accelerate to normal climb speed (90 to 100 mph). The airplane then stopped climbing and would not accelerate more than 80 mph. While the pilot attempted to maintain altitude, the airplane decelerated to 70 mph with the engine still at the full-power setting. With insufficient runway remaining to land, the pilot made a shallow right turn toward lower terrain and subsequently made a hard landing in a field. The pilot likely allowed the airplane to climb out of ground effect before establishing a proper pitch attitude and airspeed for the climb, which resulted in the airplane inadvertently entering a “region of reversed command” at a low altitude. In this state, the airplane may be incapable of climbing and would require either more engine power or further lowering of the airplane’s nose to increase airspeed. Because engine power was already at its maximum and the airplane was at a low altitude, the pilot was unable to take remedial action to fly out of the region of reversed command.
Probable cause:
The pilot’s failure to establish the proper pitch attitude and airspeed during takeoff with the engine at maximum power, which resulted in the exceedance of the airplane’s climb performance capability.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Paris: 1 killed

Date & Time: Aug 27, 2013 at 1120 LT
Operator:
Registration:
N229H
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Paris - Terre Haute
MSN:
421C-0088
YOM:
1976
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8600
Captain / Total hours on type:
2000.00
Aircraft flight hours:
3000
Circumstances:
Company personnel reported that, in the weeks before the accident, the airplane's left engine had been experiencing a problem that prevented it from initially producing 100 percent power. The accident pilot and maintenance personnel attempted to correct the discrepancy; however, the discrepancy was not corrected before the accident flight, and company personnel had previously flown flights in the airplane with the known discrepancy. Witnesses reported observing a portion of the takeoff roll, which they described as slower than normal. However, the airplane was subsequently blocked from their view. Examination of the runway environment showed that, during the takeoff roll, the airplane traveled the entire length of the 4,501-ft runway, continued to travel through a 300-ft-long grassy area and a 300- ft-long soybean field, and then impacted the top of 10-ft-tall corn stalks for about 50 ft before it began to climb. About 1/2 mile from the airport, the airplane impacted several trees in a leftwing, nose-low attitude, consistent with the airplane being operated below the minimum controllable airspeed. The main wreckage was consumed by postimpact fire. Postaccident examinations revealed no evidence of mechanical anomalies with the airframe, right engine, or propellers that would have precluded normal operation. Given the left engine's preexisting condition, it is likely that its performance was degraded; however, postimpact damage and fire preluded a determination of the cause of the problem.
Probable cause:
The pilot's failure to abort the takeoff during the ground roll after detecting the airplane's degraded performance. Contributing to the accident was the pilot's decision to attempt a flight with a known problem with the left engine and the likely partial loss of left engine power for reasons that could not be determined during the postaccident examination of the engine.
Final Report:

Crash of a Piper PA-46R-350T Matrix off Cat Cay

Date & Time: Aug 25, 2013 at 1406 LT
Registration:
N720JF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cat Cay - Kendall-Miami
MSN:
46-92004
YOM:
2008
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12250
Captain / Total hours on type:
210.00
Aircraft flight hours:
1000
Circumstances:
According to the pilot, he applied full power, set the flaps at 10 degrees, released the brakes, and, after reaching 80 knots, he rotated the airplane. The pilot further reported that the engine subsequently lost total power when the airplane was about 150 ft above ground level. The airplane then impacted water in a nose-down, right-wing-low attitude about 300 ft from the end of the runway. The pilot reported that he thought that the runway was 1,900 ft long; however, it was only 1,300 ft long. Review of the takeoff ground roll distance charts contained in the Pilot’s Operating Handbook (POH) revealed that, with flap settings of 0 and 20 degrees, the ground roll would have been 1,700 and 1,150 ft, respectively. Takeoff ground roll distances were not provided for use of 10 degrees of flaps; however, the POH stated that 10 degrees of flaps could be used. Although the distance was not specified, it is likely that the airplane would have required more than 1,300 ft for takeoff with 10 degrees of flaps. Examination of the engine revealed saltwater corrosion throughout it; however, this was likely due to the airplane’s submersion in water after the accident. No other mechanical malfunctions or abnormalities were noted. Examination of data extracted from the multifunction display (MFD) and primary flight display (PFD) revealed that the engine parameters were performing in the normal operating range until the end of the recordings. The data also indicated that, 7 seconds before the end of the recordings, the airplane pitched up from 0 to about 17 degrees and then rolled 17 degrees left wing down while continuing to pitch up to 20 degrees. The airplane then rolled 77 degrees right wing down and pitched down about 50 degrees. The highest airspeed recorded by the MFD and PFD was about 70 knots, which occurred about 1 second before the end of the recordings. The POH stated that, depending on the landing gear position, flap setting, and bank angle, the stall speed for the airplane would be between 65 and 71 knots. Based on the evidence, it is likely that the engine did not lose power as reported by the pilot. As the airplane approached the end of the runway and the pilot realized that it was not long enough for his planned takeoff, he attempted to lift off at an insufficient airspeed and at too high of a pitch angle, which resulted in an aerodynamic stall at a low altitude. If the pilot had known the actual runway length, he might have used a flap setting of 20 degrees, which would have provided sufficient distance for the takeoff.
Probable cause:
The pilot’s attempt to rotate the airplane before obtaining sufficient airspeed and his improper pitch control during takeoff, which resulted in the airplane exceeding its critical angle-of-attack and subsequently experiencing an aerodynamic stall at a low altitude. Contributing to the accident was the pilot’s lack of awareness of the length of the runway, which led to his attempting to take off with the airplane improperly configured.
Final Report:

Crash of a De Havilland DHC-2 Beaver I in Hesquiat Lake: 2 killed

Date & Time: Aug 16, 2013 at 1023 LT
Type of aircraft:
Operator:
Registration:
C-GPVB
Flight Phase:
Survivors:
Yes
Schedule:
Hesquiat Lake - Gold River
MSN:
871
YOM:
1956
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
17000
Circumstances:
At 1015 Pacific Daylight Time, the de Havilland DHC-2 (Beaver) floatplane (registration CGPVB, serial number 871), operated by Air Nootka Ltd., departed Hesquiat Lake, British Columbia, with the pilot and 5 passengers for Air Nootka Ltd.’s water aerodrome base near Gold River, British Columbia. Visibility at Hesquiat Lake was about 2 ½ nautical miles in rain, and the cloud ceiling was about 400 feet above lake and sea level. Approximately 3 nautical miles west of the lake, while over Hesquiat Peninsula, the aircraft struck a tree top at about 800 feet above sea level and crashed. Shortly after the aircraft came to rest, a post-crash fire developed. All 6 persons on board survived the impact, but the pilot and 1 passenger died shortly after. A brief 406 megahertz emergency locator transmitter signal was transmitted, and a search and rescue helicopter recovered the survivors at about 1600.
Probable cause:
Findings as to causes and contributing factors:
1. The pilot flew just above the tree tops into instrument meteorological conditions and rising terrain, and the aircraft struck a tree that was significantly taller than the others.
2. The pilot and 1 passenger did not exit the aircraft before it was consumed in the postimpact fire.
3. Air Nootka did not have effective methods to monitor its pilots’ in-flight decision making and associated practices. As a result, Air Nootka had no way to detect and correct unsafe behavior or poor decision making such as occurred on this flight.
Findings as to risk:
1. If aircraft are not fitted with technology to reduce fuel leakage or to eliminate ignition sources, the risk of post-impact fire is increased.
2. If aircraft are not equipped with shoulder harnesses for all seating positions then there is an increased risk of injuries.
3. If aircraft are not equipped with some alternate means of escape such as push-out windows, then there is a risk that post-crash structural deformation will jam doors shut and restrict exit for the occupants.
4. If companies operating under self-dispatch do not monitor their operations, they risk not being able to identify unsafe practices that are a hazard to flight crew and passengers.
5. If flight data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.
Final Report: