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:

Crash of a Cessna 404 Titan II near Merugwayi

Date & Time: Jul 30, 2013
Type of aircraft:
Operator:
Registration:
5Y-DOC
Flight Phase:
Survivors:
Yes
Schedule:
Merugwayi - Arusha
MSN:
404-0433
YOM:
1979
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from a remote airstrip in Merugwayi, while flying in bad weather conditions, the twin engine aircraft crashed in a wilderness located in Kapingiro, near Merugwayi. All seven occupants were injured, the copilot aged 23 seriously. The aircraft was damaged beyond repair. Among passengers were several doctors who provided medical services to locals leaving in the remote district.

Crash of a PZL-Mielec AN-2P in Shakhty

Date & Time: Jul 28, 2013
Type of aircraft:
Operator:
Registration:
FLA-3618K
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Shakhty - Shakhty
MSN:
1G151-37
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Shakhty Airport, Rostov oblast, the pilot encountered engine problem. He elected to make an emergency landing in an open field located 500 metres from the airport. On touchdown, the aircraft lost its undercarriage, wings and tail before coming to rest in bushes. The pilot, uninjured, fled the scene but was arrested by police few hours later. Technician by a Plant at the Shakhty Airport, he was the owner of this aircraft since seven months and was performing a local test flight despite he was not in possession of any valid pilot licence according to Russian authorities.

Crash of a De Havilland DHC-3T Turbo Otter in Soldotna: 10 killed

Date & Time: Jul 7, 2013 at 1120 LT
Type of aircraft:
Operator:
Registration:
N93PC
Flight Phase:
Survivors:
No
Schedule:
Soldotna - Bear Mountain Lodge
MSN:
280
YOM:
1958
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
7765
Captain / Total hours on type:
155.00
Aircraft flight hours:
22831
Circumstances:
Before picking up the nine passengers, the pilot loaded the accident airplane at the operator's base in Nikiski with cargo (food and supplies for the lodge). The operator of the lodge where the passengers were headed estimated the cargo weighed about 300 pounds (lbs) and that the passengers' baggage weighed about 80 lbs. Estimates of the passengers' weights were provided to the lodge operator in preparation for the trip, which totaled 1,350 lbs. The load manifest listed each of these weight estimates for a total weight of 1,730 lbs and did not contain any balance data. The cargo was not weighed, and the pilot did not document any weight and balance calculations nor was he required to do so. The airplane operator did not keep fueling records for each flight. A witness who was present during the fueling operations at the operator's base reported that he saw the pilot top off the front tank then begin fueling the center tank. The first leg of the trip from the operator's base to pick up the passengers was completed uneventfully. According to witnesses at Soldotna Airport, after loading the passengers and their baggage, the pilot taxied for departure. There were no witnesses to the accident. The airplane impacted the ground about 2,320 feet from the threshold of the departure runway and about 154 feet right of the runway centerline. An extensive postcrash fire consumed most of the airplane's cockpit and cabin area, including an unknown quantity of the baggage and cargo. Impact signatures were consistent with a nose- and right-wing-low attitude at impact. The entire airplane was accounted for at the wreckage site. Disassembly and examination of the engine and propeller revealed that both were operating during impact. Examination of the structure and flight control systems found no preimpact malfunctions or failures that would have precluded normal operation. The pilot was properly certificated and qualified in accordance with applicable federal regulations. Toxicological testing of specimens from the pilot was negative for any carbon monoxide, alcohol, or drugs. The airplane was not equipped, and was not required to be equipped, with any type of crashresistant recorder. A video recovered from a passenger's smartphone showed the accident sequence looking out of the row 4 left seat window; the left wing and flaps are in view for most of the sequence and the flap position does not change. The investigation found that the flaps were set to the full-down (or landing) position during takeoff, contrary to recommended procedures in the airplane flight manual (AFM). The recovered video was used to estimate the airplane speed, altitude, and orientation for the portion of the flight where ground references were visible, about 22.5 seconds after the start of the takeoff roll. For the first 12 seconds, the airplane accelerated linearly from the beginning of the takeoff roll through liftoff. The pitch angle decreased slightly in the first 8 seconds as the tail lifted, remained essentially constant for about 4 seconds, and began to slightly increase as the airplane lifted off. Beginning about 14 seconds after the start of the takeoff roll, the speed began decreasing and the pitch angle began increasing. The pitch angle increased at a constant rate (about 2.8 degrees/second), reaching a maximum value of about 30 degrees, and the ground speed decreased from its maximum of about 68 mph to about 44 mph at the end of the analyzed time. The ground references disappeared from the video frame as the airplane experienced a sharp right roll before impacting the ground several seconds later. The low speed, rapid right roll, and pitch down of the airplane is consistent with an aerodynamic stall. The constant pitch rate before the stall is consistent with an aft center of gravity (CG) condition of sufficient magnitude that the elevator pitch down authority was insufficient to overcome the pitching moment generated by the aft CG. Additionally, the flaps setting at the full-down (or landing) position, contrary to procedures contained in the AFM, would have exacerbated the nose-up pitching moment due to the increased downwash on the tail and aft shift of the center of pressure; the additional aerodynamic drag from the fully extended flaps would have altered the airplane's acceleration. Using the data available, the airplane was within weight and balance limitations for the first leg of the trip. However, the cargo loaded was about 2.4 times the weight indicated on the load manifest. Further, the total weight of cargo and baggage in the cargo area, as estimated during the investigation, exceeded the installed cargo net's load limit of 750 lbs by more than 50 lbs. Although the loaded cargo actual weight was higher than indicated on the load manifest, the flight from Nikiski to Soldotna was completed without any concerns noted by the pilot, indicating that even with the higher cargo load, the airplane was within the normal CG range for that leg of the flight. Thus, based on the investigation's best estimate and a calculation of the airplane's weight and balance using the recovered passenger weights, weights and location of the luggage recovered on scene, weight of the cargo recovered on scene, and weights accounting for the liquid cargo destroyed in the postimpact fire, once the passengers were loaded, the airplane weight would have exceeded the maximum gross weight of 8,000 lbs by about 21 lbs and the CG would have been at least 5.5 inches aft of the 152.2-inch limit (a more definitive calculation could not be performed because the exact location of the cargo was not known). Additionally, the kinematics study of the accident airplane's weight and motion during initial climb and up to the point of stall found that with the pilot applying full pitch-down control input, the CG required to produce the motion observed in the video was likely just past 161 inches. Thus, the only way for the airplane motion to match the motion observed in the video was for the CG to be considerably aft of the 152.2-inch limit, which provides additional support to the results from the weight and balance study. Based on the video study, the weight and balance study constructed from available weight and balance information, and the kinematics study, the airplane exceeded the aft CG limit at takeoff, which resulted in an uncontrollable nose-up pitch leading to an aerodynamic stall. The CG was so far aft of the limit that the airplane likely would have stalled even with the flaps in the correct position. Neither 14 CFR Part 135 nor the operator's operations specifications (OpSpec) require that the aircraft weight and balance be physically documented for any flights. However, according to Section A096 of the OpSpec, when determining aircraft weight and balance, the operator should use either the actual measured weights for all passengers, baggage, and cargo or the solicited weights for passengers plus 10 lbs and actual measured weights for baggage and cargo. The operator did not comply with federal regulations that require adherence to the weighing requirements or the takeoff weight limitations in the AFM. Additionally, although the inaccurate estimate of 300 lbs for the cargo resulted in a calculated CG that was within limits for both legs of the flight, the actual weight of the cargo was significantly higher. Once loaded in Soldotna, the combination of the passengers, their baggage, and the actual cargo weight and its location resulted in the CG for the accident flight being significantly aft of the limit. With the CG so far aft, even with full nose-down input from the pilot, the nose continued to pitch up until the airplane stalled. For each flight in multiengine operations, 14 CFR 135.63(c) requires the preparation of a load manifest that includes, among other items the number of passengers, total weight of the loaded aircraft, the maximum allowable takeoff weight, and the CG location of the loaded aircraft; one copy of the load manifest should be carried in the airplane and the operator is required to keep the records for at least 30 days. Single-engine operations are excluded from this requirement. The NTSB attempted to address this exclusion with the issuance of Safety Recommendations A-89-135 and A-99-61, which asked the Federal Aviation Administration (FAA) to amend the record-keeping requirements of 14 [CFR] 135.63(c) to apply to single-engine as well as multiengine aircraft. The FAA did not take the recommended action in either instance, and the NTSB classified Safety Recommendations A-89-135 and A-99-61 "Closed—Unacceptable Action" in 1990 and 2014, respectively.
Probable cause:
The operator's failure to determine the actual cargo weight, leading to the loading and operation of the airplane outside of the weight and center of gravity limits contained in the airplane flight manual, which resulted in an aerodynamic stall. Contributing to the accident was the Federal Aviation Administration's failure to require weight and balance documentation for each flight in 14 Code of Federal Regulations Part 135 single-engine operations.
Final Report:

Crash of a Canadair CL-415 in Moosehead Lake

Date & Time: Jul 3, 2013 at 1415 LT
Type of aircraft:
Operator:
Registration:
C-FIZU
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Wabush - Wabush
MSN:
2076
YOM:
2010
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12500
Captain / Total hours on type:
120.00
Copilot / Total flying hours:
1700
Copilot / Total hours on type:
138
Aircraft flight hours:
461
Circumstances:
On 03 July 2013, at about 1415 Atlantic Daylight Time, the Government of Newfoundland and Labrador Air Services Division Bombardier CL-415 amphibious aircraft (registration C-FIZU, serial number 2076), operating as Tanker 286, departed Wabush, Newfoundland and Labrador, to fight a nearby forest fire. Shortly after departure, Tanker 286 touched down on Moosehead Lake to scoop a load of water. About 40 seconds later, the captain initiated a left-hand turn and almost immediately lost control of the aircraft. The aircraft water-looped and came to rest upright but partially submerged. The flight crew exited the aircraft and remained on the top of the wing until rescued by boat. There was an insufficient forward impact force to activate the onboard 406-megahertz emergency locator transmitter. There were no injuries to the 2 crew members. The aircraft was destroyed. The accident occurred during daylight hours.
Probable cause:
Findings as to causes and contributing factors:
- It is likely that the PROBES AUTO/MANUAL switch was inadvertently moved from the AUTO to the MANUAL selection when the centre pedestal cover was removed.
- The PROBES AUTO/MANUAL switch position check was not included on the Newfoundland and Labrador Government Air Services CL-415 checklist.
- The flight crew was occupied with other flight activities during the scooping run and did not notice that the water quantity exceeded the predetermined limit until after the tanks had filled to capacity.
- The flight crew decided to continue the take-off with the aircraft in an overweight condition.
- The extended period with the probes deployed on the water resulted in a longer take-off run, and the pilot flying decided to alter the departure path to the left.
- The left float contacted the surface of the lake during initiation of the left turn. Aircraft control was lost and resulted in collision with the water.
Findings as to risk:
- If safety equipment is installed in a manner that hampers its access and removal, then there is an increased risk that occupants may not be able to retrieve the safety equipment in a timely manner to ensure their survival.
- If individuals are not trained on safety equipment installed on the aircraft, then there is an increased risk that the individuals may not be aware of how to effectively use the equipment.
- If a checklist does not include a critical item, and flight crews are expected to rely on their memory, then there is a risk that that item will be missed, which could jeopardize the safety of flight.
- If flight crews do not adhere to standard operating procedures, then there is a risk that errors and omissions can be introduced, which could jeopardize the safety of flight.
- If a person is not restrained during flight and the aircraft either makes an abrupt manoeuvre or loses control, then that person is at a much greater risk of injury or death.
- If an overweight take-off is carried out, there may be an adverse effect on the aircraft’s performance, which could jeopardize the safety of flight.
- If companies do not have procedures for recording overweight take-offs and flight crews do not report them, then the overall condition of the aircraft’s structures will not be accurately known, which could jeopardize the safety of flight.
- If organizations do not use formal and documented processes to manage operational risks, there is an increased risk that hazards will not be identified and mitigated.
- If organizations do not have measures in place to raise awareness of the potential impact of stress on performance or to promote the early recognition and mitigation of stress, then there is an increased risk that errors will occur when an individual is affected by stress that has become chronic.
Other findings:
- Utilizing the locking position of the PROBES AUTO/MANUAL switch for the MANUAL selection allows the switch to be inadvertently moved from the AUTO to the MANUAL position.
Final Report:

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

Date & Time: Jun 19, 2013 at 1745 LT
Type of aircraft:
Operator:
Registration:
HA-MDP
Flight Phase:
Survivors:
Yes
Schedule:
Fertöszentmiklós - Fertöszentmiklós
MSN:
1G185-44
YOM:
1979
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2700
Captain / Total hours on type:
1714.00
Aircraft flight hours:
4327
Aircraft flight cycles:
18172
Circumstances:
The single engine aircraft departed Fertöszentmiklós Airport on a local spraying mission against mosquitos, carrying two pilots. Shortly after takeoff from runway 16, while in initial climb in a 15° flaps down configuration, the crew encountered problems with the engine that lost power and started to vibrate. While completing a left turn, the aircraft lost height, impacted ground and crashed in a cornfield. Both pilots escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
The accident was the result of a turn at low altitude and insufficient speed under the circumstances. The following contributing factors were identified:
- High ambient temperatures,
- The static load on the airplane at its maximum permissible level,
- Dust filter switched on unnecessarily,
- Unjustified use of carburetor heating,
- Increase propeller angle in the given flight position,
- Reducing engine power in the given flight position by taking back the throttle.
Final Report:

Crash of a Beechcraft B200GT Super King Air in Baker: 1 killed

Date & Time: Jun 7, 2013 at 1310 LT
Operator:
Registration:
N510LD
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Baton Rouge - McComb
MSN:
BY-24
YOM:
2007
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
15925
Captain / Total hours on type:
5200.00
Aircraft flight hours:
974
Circumstances:
The accident pilot and two passengers had just completed a ferry flight on the recently purchased airplane. A review of the airplane’s cockpit voice recorder audio information revealed that, during the ferry flight, one of the passengers, who was also a pilot, was pointing out features of the new airplane, including the avionics suite, to the accident pilot. The pilot had previously flown another similar model airplane, but it was slightly older and had a different avionics package; the new airplane’s avionics and flight management system were new to the pilot. After completing the ferry flight and dropping off the passengers, the pilot departed for a short cross-country flight in the airplane. According to air traffic control recordings, shortly after takeoff, an air traffic controller assigned the pilot a heading and altitude. The pilot acknowledged the transmission and indicated that he would turn to a 045 heading. The radio transmission sounded routine, and no concern was noted in the pilot’s voice. However, an audio tone consistent with the airplane’s stall warning horn was heard in the background of the pilot’s radio transmission. The pilot then made a radio transmission stating that he was going to crash. The audio tone was again heard in the background, and distress was noted in the pilot’s voice. The airplane impacted homes in a residential neighborhood; a postcrash fire ensued. A review of radar data revealed that the airplane made a climbing right turn after departure and then slowed and descended. The final radar return showed the airplane at a ground speed of 102 knots and an altitude of 400 feet. Examination of the engines and propellers indicated that the engines were rotating at the time of impact; however, the amount of power the engines were producing could not be determined. The examination of the airplane did not reveal any abnormalities that would have precluded normal operation. It is likely that the accident pilot failed to maintain adequate airspeed during departure, which resulted in an aerodynamic stall and subsequent impact with terrain, and that his lack of specific knowledge of the airplane’s avionics contributed to the accident.
Probable cause:
The pilot’s failure to maintain adequate airspeed during departure, which resulted in an aerodynamic stall and subsequent impact with terrain. Contributing to the accident was the pilot’s lack of specific knowledge of the airplane’s avionics.
Final Report:

Crash of a Beechcraft D18S off Red Lake: 2 killed

Date & Time: May 30, 2013 at 1727 LT
Type of aircraft:
Registration:
C-FWWV
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Red Lake - Red Lake
MSN:
A-618
YOM:
1951
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The pilot and his wife, a couple from Phoenix, were performing a flight from the Red Lake Seaplane base to a tourist Camp located north of Red Lake. The twin engine aircraft took off at 1727LT in marginal weather conditions consisting of wind and rain showers. Shortly after departure, the aircraft crashed into the Bruce Channel located between Cochenour and McKenzie Island. The aircraft sank and both occupants were killed.

Crash of a Comp Air CA-8 in Sorocaba: 2 killed

Date & Time: May 29, 2013 at 1540 LT
Type of aircraft:
Operator:
Registration:
PP-XLR
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Sorocaba - Jundiaí
MSN:
0204CA8
YOM:
2006
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after take off from Sorocaba Airport, while climbing, the pilot encountered technical problems and elected to return. While trying to land in a wasteland, the single engine aircraft crashed in a street and was destroyed by impact forces and a post impact fire. Both occupants were killed as a house was also destroyed.

Crash of a Boeing KC-137E Stratoliner in Port-au-Prince

Date & Time: May 26, 2013 at 1430 LT
Type of aircraft:
Operator:
Registration:
2404
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Port-au-Prince - Manaus
MSN:
19870/702
YOM:
1968
Country:
Crew on board:
12
Crew fatalities:
Pax on board:
131
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was returning to Manaus (Ponta Pelada AFB) with a crew of 12 and 131 Brazilian soldiers who took part of the United Nations Stabilization Mission In Haiti (UNSTAMIH). During the takeoff roll on runway 28, an engine caught fire. The Captain aborted the takeoff procedure and started an emergency braking manoeuvre. The aircraft veered off runway to the left and entered a grassy area. The nose gear was torn off and the aircraft slid for several metres before coming to rest. All 143 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
An engine caught fire during takeoff for unknown reasons.