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

Date & Time: Nov 25, 2012 at 1120 LT
Type of aircraft:
Registration:
RA-33589
Flight Phase:
Survivors:
Yes
Schedule:
Yugorsk - Yugorsk
MSN:
1G230-31
YOM:
1988
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12116
Captain / Total hours on type:
3068.00
Aircraft flight hours:
1250
Circumstances:
The single engine aircraft was engaged in a local skydiving mission, carrying one pilot and 9 skydivers. Shortly after take off from runway 31, while climbing to a height of about 80 meters, the engine suffered a power loss. The pilot initiated a left turn to reach the airport when the aircraft rolled to an angle of 60° then stalled and crashed in a snow covered field near a forest, bursting into flames. The aircraft was destroyed by a post impact fire. Nine occupants escaped injured and a passenger was killed.
Probable cause:
Most probably the accident with and An-2 RA-33589 aircraft was caused by aircraft beyond stall angle of attack entry during dynamic turn for emergency landing with reverse runway heading due to engine failure after take-off at low-altitude followed by shaking and its power loss resulted in aircraft ground impact with bank angle more than 60°. Engine failure was caused by high-temperature damage and destruction of cylinder-piston group details due to it inadequate technical operation and using motor gasoline in aircraft fuel flow system which quality didn't comply with requirements for preferred AI-95 gasoline in accordance with aeronautical equipment flight service evaluation program, Order of Ministry of Transport of the Russian Federation № НА-131-р from April 11, 2001 and engineering solution № АБ-1236-2003 from May 22, 2003. Most probably the contributing factor was partial skill loss of An-2 aircraft control by aircraft pilot in command (PIC). Flight operation was performed by PIC, meteorological minimas and which authorizations written in Private-Pilot License and the fact of medical flight-expert commission procedure were not documented. PIC's decision to perform straight-ahead landing most probably didn't allow to reduce the severity of accident consequences.
Final Report:

Crash of an Antonov AN-26 in Sanaa: 10 killed

Date & Time: Nov 21, 2012
Type of aircraft:
Operator:
Registration:
420
Flight Phase:
Flight Type:
Survivors:
No
Site:
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
10
Circumstances:
After takeoff from Sana'a Airport, while climbing, the crew informed ATC about technical problems and elected to make an emergency landing in a wasteland. The aircraft went out of control and crashed in an abandoned market building located in the Al-Hasaba District, some 9 km south of Sanaa' Airport. All 10 occupants were killed. According to Yemen Officials, the aircraft was registered 420 but no AN-26 seems to be operated in Yemen under this registration.

Crash of a Cessna 208B Grand Caravan in Snow Lake: 1 killed

Date & Time: Nov 18, 2012 at 0956 LT
Type of aircraft:
Operator:
Registration:
C-GAGP
Flight Phase:
Survivors:
Yes
Schedule:
Snow Lake - Winnipeg
MSN:
208B-1213
YOM:
2006
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2865
Captain / Total hours on type:
1020.00
Aircraft flight hours:
1487
Circumstances:
The Gogal Air Services Limited Cessna 208B (registration C-GAGP, serial number 208B1213) departed Runway 21 at Snow Lake en route to Winnipeg, Manitoba, with the pilot and 7 passengers on board. At approximately 0956 Central Standard Time, shortly after take-off, the aircraft descended and struck the terrain in a wooded area approximately 0.9 nautical miles beyond the departure end of the runway. The pilot was fatally injured, and the 7 passengers sustained serious injuries. The aircraft was destroyed by impact forces, and a small fire ensued near the engine. The aircraft’s emergency locater transmitter activated. First responders attended the scene, and the injured passengers were taken to area hospitals. The aircraft’s fuel cells ruptured, and some of the onboard fuel spilled at the site.
Probable cause:
Findings as to causes and contributing factors:
1. The aircraft departed Snow Lake overweight and with an accumulation of ice on the leading edges of its wings and tail from the previous flight. As a result, the aircraft had reduced take-off and climb performance and increased stall speed, and the protection afforded by its stall warning system was impaired.
2. A breakdown in the company’s operational control resulted in the flight not operating in accordance with the Canadian Aviation Regulations and the company operations manual.
3. As a result, shortly after departure, the aircraft stalled at an altitude from which recovery was not possible.
Findings as to risk:
1. If companies operate in instrument meteorological conditions for which they are not authorized, there is an increased risk that accidents may occur.
2. If Transport Canada does not provide the same degree of oversight for repetitive charter operations as it does for a scheduled operator, the risks in the operator’s activities may not be fully evaluated.
3. If passenger briefings are not provided and passengers are not properly seated and restrained, there is an increased risk of injuries to those passengers and the other occupants in the event of an accident.
4. If flights are conducted without ensuring an ice-free airframe, there is a risk of decreased aircraft performance and of loss of control and collision with terrain.
Other findings:
1. On impact, the aircraft’s seats and cabin deformed as designed, and this deformation partially attenuated the impact forces.
Final Report:

Crash of a Britten-Norman BN-2A-26 Islander in Saint John's: 3 killed

Date & Time: Oct 7, 2012 at 1610 LT
Type of aircraft:
Operator:
Registration:
VP-MON
Flight Phase:
Survivors:
Yes
Schedule:
Saint John’s – Montserrat
MSN:
82
YOM:
1969
Flight number:
MNT107
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
710
Captain / Total hours on type:
510.00
Aircraft flight hours:
22064
Aircraft flight cycles:
55851
Circumstances:
The aircraft was operating a VFR scheduled commercial air transport flight from VC Bird International Airport, Antigua (TAPA), to John A Osborne Airport, Montserrat (TRPG). The accident occurred during the aircraft’s fourth sector of the day. Prior to the accident flight, another pilot had flown two sectors in it, from John A Osborne to VC Bird and return, before going off duty. The accident pilot reported for duty at 1130 hrs, completed pre-flight preparations, and operated the aircraft to VC Bird. After the aircraft’s arrival at VC Bird, the airport closed to VFR traffic because of cumulonimbus activity and heavy rain. The airport re-opened for VFR operations shortly before the aircraft’s departure. A cumulonimbus cloud was present on the approach to Runway 07, and although the surface wind was westerly, Runway 07 was in use for departures. On board the aircraft were the pilot, three passengers, and bags weighing 150 lb. The fuel load on departure was 65 USG of AVGAS. The takeoff mass was shown on the load sheet as 5,540 lb, which was below the structural maximum takeoff weight of 6,600 lb; the performance-regulated takeoff weight at the ambient temperature of 24 °C was greater than the structural limit. The passengers and pilot travelled in a bus from the airport terminal to the aircraft. The passengers boarded the aircraft, and the baggage was loaded into the compartment behind the rear-most seats. The pilot then boarded the aircraft. The pilot was not observed to carry out a drain of the fuel system’s water traps (the operations manual did not stipulate that a drain check should be carried out). The pilot called the VC Bird Ground Movement Control (GMC) controller for permission to start engines, and was instructed to wait while the controller contacted Montserrat ATC to enquire about the weather there. The pilot then asked for surface wind information for VC Bird and was informed it was from 240° at 10 kts. The controller gave permission for start and passed the Montserrat weather, which was suitable for the operation. The pilot was instructed to taxi to holding position Bravo. The pilot contacted the Tower controller and was instructed to enter, backtrack, and line up on Runway 07. The controller described the weather observed from the Tower to the pilot, and the pilot requested a left-hand turn-out after departure. The surface wind was transmitted as from 270° at 10 kts and the aircraft was cleared for takeoff. The aircraft entered the runway at Bravo but did not backtrack. No power checks were carried out (other evidence indicated that power checks were routinely not carried out other than on each pilot’s first flight of the day). The aircraft took off, and the early part of the climb appeared normal. Analysis of the eye witness reports, and consideration of their locations and fields of view, led to a deduction that this normal climb continued to a height of between 200 and 300 ft above the ground. The aircraft then appeared to ‘sink’, losing a small amount of height without yawing or rolling, before yawing to the right, then rolling to the right, and pitching nose down into an incipient spin to the right. The surviving passenger recalled that the stall warning sounded, and its accompanying red light (which was mounted on the right-hand side of the instrument panel and in his line of sight) illuminated throughout this period and until impact. Witnesses described that the (incipient) spin continued until the aircraft struck the ground. ATC staff in the visual control room activated the airport’s crash alarm. The rescue and fire-fighting service (RFFS) responded promptly from their station; the crew of one RFFS vehicle, working on the airport, observed the accident and responded directly to it. The pilot and one passenger were fatally injured on impact. Another passenger succumbed to her injuries before she could be extricated from the wreckage, and the third passenger, who had sustained serious injuries, was taken to hospital.
Probable cause:
The investigation identified the following causal factors:
1. Significant rainfall, and anomalies in the aircraft’s fuel filler neck and cap, led to the presence of water in the right-hand fuel tank,
2. Shortly after takeoff, the water in the right-hand fuel tank entered the engine fuel system causing the engine to stop running,
3. Control of the aircraft was not retained after the right-hand engine stopped.
Contributing factors:
1. No pre-flight water drain check was carried out; such a check would have allowed the presence of water in the right-hand fuel tank to be detected and corrective action taken.
2. It is possible that performance-reducing windshear, encountered during the downwind departure, contributed to a reduction in airspeed shortly before the aircraft stalled.
Final Report:

Crash of a Cessna 414A Chancellor in Ellbögen: 6 killed

Date & Time: Sep 30, 2012 at 0658 LT
Type of aircraft:
Operator:
Registration:
N738W
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Innsbruck - Valencia
MSN:
414A-0027
YOM:
1978
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
12000
Captain / Total hours on type:
1200.00
Aircraft flight hours:
8600
Circumstances:
The twin engine aircraft departed Innsbruck-Kranebitten Airport at 0654LT on a private flight to Valencia, Spain, carrying seven passengers and one pilot. VFR conditions prevailed at the time of departure. After takeoff from runway 26, the pilot turn to the south when he encountered limited visibility due to foggy conditions. In IMC conditions, the aircraft contacted trees, lost height and crashed in a wooded area located near the village of Ellbögen, about 15 km southeast of Innsbruck Airport, bursting into flames. The wreckage was found at an altitude of 1,612 metres. Two passengers were seriously injure while six other occupants were killed. The aircraft was totally destroyed by a post impact fire.
Probable cause:
Controlled flight into terrain after the pilot continued under VFR mode in IMC conditions.
Final Report:

Crash of a Dornier DO228-202 in Kathmandu: 19 killed

Date & Time: Sep 28, 2012 at 0618 LT
Type of aircraft:
Operator:
Registration:
9N-AHA
Flight Phase:
Survivors:
No
Schedule:
Kathmandu - Lukla
MSN:
8123
YOM:
1987
Flight number:
SIT601
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
19
Captain / Total flying hours:
8308
Captain / Total hours on type:
7112.00
Copilot / Total flying hours:
772
Copilot / Total hours on type:
519
Circumstances:
A Dornier 228 aircraft, registration 9N-AHA, was planned to operate a flight from Tribhuvan International Airport (TIA), Kathmandu, to Tensing/Hillary Airport, Lukla with 16 passengers and 3 crews. The Commander was the Pilot Flying (PF) which was in accordance with common practice for flight crews operating this route. The 0020Z METAR for TIA reported calm wind, 3,000 m visibility in mist, scattered cloud at 2,000 ft AAL, broken cloud at 10,000 ft AAL, a temperature of 19° C and a QNH of 1017 HPa. ATC broadcast a change in the QNH to 1018 HPa at 0029 hrs. At 0028 hrs (0613 am), the Co-pilot asked ATC for taxi clearance and 9N-AHA taxied towards Intersection 2 for Runway 20. While taxiing towards the runway the flight crew carried out the before takeoff checklist during which the Commander confirmed that Flaps 1 was set and all four booster pumps were ON. There was no emergency brief or discussion about the reference speeds to be used during the takeoff. The flight crew changed frequency and contacted the tower controller who gave them clearance to enter Runway 20 from the intersection and wait for clearance to takeoff. The Commander asked for the line-up checks to be completed during which the Speed Lever was selected to HIGH. After lining up, the Commander said "THERE IS A BIRD" and, three seconds later "I WILL TAKE FLAPS TWO" which was acknowledged by the co-pilot. The aircraft was cleared for departure and began its takeoff run at 0032 hrs. Two seconds after beginning the takeoff roll, the Commander said "WATCH OUT THE BIRD". The Co-pilot called "50 KNOTS " as the aircraft approached 50 kt and the Commander replied "CHECK". Two seconds later, the co-pilot called "BIRD CLEAR SIR" as the aircraft accelerated through 58 kt. Approaching 70 kt, approximately 13 kt below V1 and Vr , the first officer called "VEE ONE ROTATE". The aircraft began to rotate but did not lift off the ground and the nose was briefly lowered again. As the aircraft reached 86 kt, it lifted off the ground and the landing gear was raised immediately. As the aircraft began to climb, it accelerated to 89 kt over approximately 2 seconds. It continued to climb to 100 ft above the runway over the next 11 seconds but, during this time, the speed decreased to 77 kt. The aircraft then flew level for 14 seconds during which time the following occurred: the speed decreased to 69 kt; the air traffic controller asked "ANY TECHNICAL?" to which the pilot replied "[uncertain]….DUE BIRD HIT"; it's heading changed slowly from 200 °M to approximately 173 °M; and the stall warning was triggered for three seconds as the aircraft decelerated through 71 kt. Two seconds after the stall warning ended, it was triggered again for approximately six seconds with the airspeed at 69 kt. The aircraft began a gentle descent at 69 kt with the stall warning sounding and the rate of turn to the left increased rapidly. It departed controlled flight, most probably left wing low, and crashed into a small open area 420 m south-east of the end of Runway 20. A runway inspection found the remains of a bird, identified as a "Black Kite", at a position 408 m from Intersection 2. No bird strike was reported in relation to any other departure.
Probable cause:
Causal Factors:
The investigation identified the following causal factors:
1. During level flight phase of the aircraft, the drag on the aircraft was greater than the power available and the aircraft decelerated. That resulted in excessive drag in such critical phase of ascent lowering the required thrust. The investigation was unable to determine the reason for the reduced thrust.
2. The flight crew did not maintain the airspeed above the stall speed and there was insufficient height available to recover when the aircraft departed controlled flight.
Contributory Factors:
The investigation identified the following contributory factors:
1. The flight crew did not maintain V2 during the climb and so the power required to maintain the level flight was greater than it would otherwise have been.
2. The flight crew did not maintain the runway centreline which removed the option of landing the aircraft on the runway remaining.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Constanza: 2 killed

Date & Time: Sep 27, 2012 at 1545 LT
Registration:
N711WX
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Constanza - Santo Domingo
MSN:
31-7552131
YOM:
1975
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Constanza-14 de Junio Airport, bound to Las Américas Airport in Santo Domingo, the twin engine aircraft went out of control and crashed in a wooded area, bursting into flames. The burnt wreckage was found near the village of Tireo, about 3 km northeast of the airport. The aircraft was destroyed and both occupants were killed. The exact circumstances of the accident are unclear. It is believed that the flight was illegal and that a load of 11 of cocaine was found at the crash site.

Crash of a Cessna 402B in Rome: 2 killed

Date & Time: Sep 7, 2012 at 1300 LT
Type of aircraft:
Operator:
Registration:
I-ERJA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Rome - Brescia
MSN:
402B-0918
YOM:
1975
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Rome-Ciampino Airport, while in initial climb, the twin engine aircraft went out of control and crashed in a car demolition, bursting into flames. The aircraft was totally destroyed by impact forces and a post impact fire as well as more than 30 cars. Both crew were killed.

Crash of a Cessna 421B Golden Eagle II in Fort Worth

Date & Time: Sep 5, 2012 at 0949 LT
Operator:
Registration:
N69924
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Fort Worth - San Antonio
MSN:
421B-0553
YOM:
1973
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3800
Captain / Total hours on type:
897.00
Aircraft flight hours:
10056
Circumstances:
The commercial pilot was distracted by the nose cargo door popping open during takeoff; the airplane stalled and collided with trees off the end of the runway. The pilot said there were no mechanical problems with the airplane or engines and that he was fixated on the cargo door and lost control of the airplane. He also said that due to stress, he was not mentally prepared to handle the emergency situation.
Probable cause:
The pilot's failure to maintain airplane control on takeoff, which resulted in an inadvertent stall. Contributing to the accident were the unlatched nose cargo door, the pilot’s diverted attention, and the pilot's mental ability to handle the emergency situation.
Final Report:

Crash of a Cessna 421A Golden Eagle I at Annino AFB: 2 killed

Date & Time: Aug 22, 2012 at 1517 LT
Type of aircraft:
Operator:
Registration:
RA-0879G
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Annino - Annino
MSN:
421A-0075
YOM:
1968
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
In the afternoon, the crew departed Annino AFB (Gorelovo) to complete a local training mission consisting of touch-and-go maneuvers. After two circuits, the aircraft landed normally and the crew took off and started the rotation without informing ATC. After liftoff, at a height of about 10-15 metres, the aircraft rolled to the right to an angle of 70° then stalled and crashed in a kindergarten located one km from the airport, bursting into flames. The aircraft was destroyed and both pilots were killed.
Probable cause:
Most probably the accident with С-421 (FVSP) RA-0879G aircraft was caused by right and then left engine flameout during touch-and-go landing, flight speed decrease and aircraft stall entry resulted in aircraft ground impact with bank angle over 70°. Most probably engines flameout midair was caused by fuel-air mixture depletion due to low level of fuel in aircraft tanks that in combination with its inadequate quality resulted in engines trouble.
Combination of the following factors could contribute to the accident:
- Flight operation with low level of fuel on board.
- Inadequate fuel quality.
- Inadequate crew training for forthcoming flight.
- Inadequate maintenance prior to aircraft familiarization flight after its long-term parking.
- Touch-and-go landing and continued takeoff with engines trouble during run operation.
- Non-feathering of switched-off engine propeller midair (non compliance with requirement of clause "2" of subsection 3 of «ENGINE INOPERATIVE PROCEDURE» section aircraft FOM).
- Possible on position failure of fuel booster pump switches by crew before aircraft take-off.
- Inadequate flight operation management, aircraft maintenance and efficiency discipline in "Aviator" Airclub" LLC, weak monitoring from senior staff over maintenance operation on accident prevention.
- The flight was performed by crew on aircraft without airworthiness certificate (violation of clause 1 article 35 of Air Code of RF and clause 1 of FAR-118).