Crash of a Piper PA-42-720 Cheyenne III off Grand Case: 4 killed

Date & Time: May 5, 2012 at 0240 LT
Type of aircraft:
Registration:
F-GXES
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Grand Case - Fort-de-France
MSN:
42-8001043
YOM:
1980
Flight number:
TIF520
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3950
Captain / Total hours on type:
513.00
Aircraft flight hours:
7593
Aircraft flight cycles:
7830
Circumstances:
The twin engine aircraft was engaged in an ambulance flight between Grand Case and Fort-de-France and was carrying a pilot, a nurse, a doctor and a patient, a Greek citizen in honeymoon in Saint Martin who suffered a heart attack. He normally should be transferred to Fort-de-France from Saint Martin-Princess Juliana Airport with another Operator but the aircraft suffered technical problem prior to departure and the patient was transferred to Grand Case Airport. Piper PA-42 left Grand Case-L'Espérance runway 12 at 02H39. One minute later, during initial climb, it lost height and crashed into the Caribbean Sea, some three NM off the airport, off Tintamarre Island. Around 1000LT in the morning, a wheel and some others debris were found floating in water and no trace of the four occupants was found. They were later considered as deceased.
Probable cause:
The French BEA said in its final report that no technical anomaly to affect significantly the performance of the airplane or its pitch control could be demonstrated. It appears that the pilot had consumed alcohol before the flight and was awake since 0630LT and did not sleep over 20 hours, which could affect his capabilities. In conclusion, the investigation did not determine the cause of the accident, but the following factors may have contributed:
- aircraft's operation with one pilot only,
- absence of regulation does not allow the Civil Aviation Authority to ensure the adequacy of the operational objectives of an operator and its capacity to maintain its activity. This failure could not ensure that the pilot was able to conduct the flight.
- the presence of a flight recorder would probably help to understand the circumstances of the accident with more precision. Important data failed to the investigation, which was not able to identify all possible measures to avoid a similar accident in the future.
Final Report:

Crash of a Un PZL-Mielec AN-2R in Knyazhichi

Date & Time: Apr 23, 2012 at 1335 LT
Type of aircraft:
Operator:
Registration:
UR-81515
Flight Phase:
Survivors:
Yes
Schedule:
Knyazhichi - Knyazhichi
MSN:
1G208-15
YOM:
1984
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was engaged in a spraying mission in the region of Knyazhichi, Sumy Oblast, Ukraine. Following 15 successful sorties that day, the crew was ready for the 16th and started the takeoff procedure from the third of the runway which is 768 metres long. After a course of 577 metres, the single engine aircraft failed to get airborne and overran. The crew decided to abort but this was too late. The aircraft sank in muddy field and rolled for about 56 metres before coming to rest upside down. Both occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The following factors were identified:
- The crew did not use the entire runway length for the takeoff procedure (577 metres instead of the 768 metres available),
- The decision of the crew to reject takeoff was taken too late,
- The wind direction changed during the takeoff procedure and became a tailwind component.

Crash of an IAI Arava 201 in Guadalupe y Calvo

Date & Time: Apr 20, 2012 at 1247 LT
Type of aircraft:
Operator:
Registration:
3010
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
0039
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from El Zorrillo Airport, while in initial climb, an engine failed. The crew attempted a forced landing in an open field located near the airport when the aircraft crashed. All seven occupants were injured and the aircraft was destroyed.

Crash of a De Havilland DHC-8-Q311 in Kigoma

Date & Time: Apr 9, 2012 at 1014 LT
Operator:
Registration:
5H-MWG
Flight Phase:
Survivors:
Yes
Schedule:
Kigoma - Tabora - Dar es-Salaam
MSN:
462
YOM:
1997
Flight number:
ATC119
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
35
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll on runway 34, the right engine failed. The captain rejected takeoff and initiated an emergency braking procedure. Unable to stop within the remaining distance (runway 34 is 1,767 metres long), the aircraft overran when the right main gear hit a pot hole, causing the right wing to be torn off. The aircraft slid for few dozen metres before coming to rest in a pasture. Two passengers were injured while 37 other occupants escaped unhurt. The aircraft was destroyed.

Crash of a Comp Air CA-8 in Everglades City: 1 killed

Date & Time: Apr 6, 2012 at 1645 LT
Type of aircraft:
Operator:
Registration:
N548SF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Everglades City - Merritt Island
MSN:
0585552921
YOM:
2006
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1208
Circumstances:
Witnesses observed the airplane depart the airport to the north and make an abrupt right turn at an altitude of about 150 feet. One witness, who was also a pilot, described the wings as “shimmying,” appearing as if the airplane stalled before it banked to the right in a nose-down attitude. The airplane crashed and was nearly consumed during the postcrash fire. A postaccident examination was conducted with no preimpact mechanical anomalies noted. Records indicate that the pilot built the airplane from a kit about 6 years before the accident. The pilot and airplane logbooks were not located during the investigation; therefore, the maintenance history for the airplane, and the pilot’s recent (and total) flight experience could not be determined. Postaccident toxicological testing revealed metabolites of the drug diazepam (Valium) in the pilot’s blood and urine. Valium is a prescription benzodiazepine classed as a central nervous system depressant and tranquilizer, used as a sleep aid and to inhibit anxiety. The amount noted in the pilot’s blood suggested he took the drug 12 to 24 hours before the accident, and, as a result, it would not have affected his performance.
Probable cause:
The pilot’s failure to maintain sufficient airspeed during the initial climb after takeoff, which resulted in an aerodynamic stall and loss of airplane control.
Final Report:

Crash of an ATR72-201 in Tyumen: 33 killed

Date & Time: Apr 2, 2012 at 0735 LT
Type of aircraft:
Operator:
Registration:
VP-BYZ
Flight Phase:
Survivors:
Yes
Schedule:
Tyumen - Surgut
MSN:
332
YOM:
1992
Flight number:
UT120
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
39
Pax fatalities:
Other fatalities:
Total fatalities:
33
Captain / Total flying hours:
2602
Captain / Total hours on type:
2522.00
Copilot / Total flying hours:
1825
Copilot / Total hours on type:
1765
Aircraft flight hours:
35523
Aircraft flight cycles:
49663
Circumstances:
On 01.04.2012 the the UTAir Air Division 1 crew (based at Surgut AP) was conducting a scheduled passenger flight UTA-119 on the АТR 72-201 VP-BYZ A/C from Surgut to Tyumen. The landing at Tyumen (Roschino) AP was performed at 17:41 (23:41 local time). Descending for landing at Roschino (Tyumen) AD was conducted in extended cloudiness with icing conditions. According to the FDR records, the flight crew used the aircraft ice protection system. At the time of flight UTA-119 landing at Roschino (Tyumen) AD the weather was as follows: surface wind 090°-7 m/s, visibility 1600 m, showers of moderate snow with rain, significant cumulonimbus (5-7 oct.) clouds, fractonimbus, cloud base at 140 m, temperature + 0.2°C, dew point + 0.2°C, QFE 735 mmhg (980 hPa), friction coefficient 0.6; moderate icing at cloud layer from 140 m to 4800 m. Forecast for landing: tempo visibility 500 m, showers of heavy snow with rain, vertical visibility 90 m. Weather at Roschino (Tyumen) AD at day time on 01.04.2012 and at night from 01.04.2012 to 02.04.2012 was formed by the cyclone trough forward part with the widespread precipitation area associated with warm front. A passage of the warm front through Roschino (Tyumen) AD was expected in the period from 20:00 to 21:00, with a temperature of 0°C and relative humidity 100% precipitations were fallen from the cumulonimbus and fractonimbus clouds in form of showers of snow with rain. Visibility in precipitations was 1200–1600 m with individual charges of heavy wet snow with visibility 600–700 m and vertical visibility 100 m. Precipitation was followed by east wind 9–10 m/s, direction 90–110°, with individual gusts up to 13–14 m/s. This direction of wind remained till 21:00. After the passage of front through the region of Roschino (Tyumen) AD, at 21:05 the surface wind changed its direction to the west 250° – 260° with gradual increase of wind speed from 2–4 m/s to 7–10 m/s. Precipitation in the form of showers of moderate snow with rain at Roschino (Tyumen) AD went on till 22:00, 01.04.2012. From 22:00, 01.04.2012 to 01:00, 02.04.2012 precipitation turned into showers of slight snow with rain with a temperature of 0°C and relative humidity 100%. According to the observations of weather stations situated at a distance of about 200– 250 km from Roschino (Tyumen) AD and affected by the cyclone on 01.04.2012 as well as on 02.04.2012 storm detecting information was sent to the Roschino (Tyumen) AD AMC about glaze-ice accretion of wet snow. After the landing the A/C was placed at stand 3 heading to the air terminal (MH 30°). According to the flight shift work schedule, the crew left for rest to the Liner Hotel at Roschino AP and had a rest till 23:30 (05:30 local time). After having their rest, the crew members arrived to the AP and started the preflight preparation for the UTA120 scheduled passenger flight from Tyumen to Surgut with visiting AMC where at 00:15 they got weather briefing and documentation. The Nizhnevartovsk AD had been appointed as the alternate AP. At the end of the weather briefing the PIC received Form АВ-11 No.1 and put his signature at the sheet of the "Log of flight crews’ weather briefings at Tyumen-Roschino AMC" indicating the flight number and the A/C number. The weather forecast and actual weather at the departure AD, destination AD and alternate AD as well as their technical conditions did not imply any hazard for the flight operation. At 00:20 the crew passed a medical examination at the AP pre-start medical station and was cleared for the flight. According to the intra-airport radio conversation, around the same time the PIC made his decision to fly. After the medical examination, the F/O visited the aeronautical information office and received a navigator’s briefcase and flight plan; which is recorded in pertinent logbooks. Further, the crew continued the preflight preparation in the briefing room. According to the load documents there were 39 passengers, 133 kg of cargo, 143 kg of passengers’ luggage, and 1 kg of mail registered for the UTA120 flight. The fuel on board was 2000 kg, the A/C TOW was 18730 kg, the A/C weight balance was 30.72% mean aerodynamic chord. The TOW and weight balance were inside the AFM (FCOM) limitations. According to an avionics technician's statements the crew arrived to the A/C around 00:30. By the external observation video camera records it can be seen that the PIC performed the preflight inspection very briefly. He lingered for a few minutes by the right engine then moved along the fuselage sides, then stopped by the left main gear, and finally went into the cockpit. The after-inspection FTLB entry made by the PIC was: "LC PERFORMED BY CDR", the PIC also put the time of inspection which was 00:40 and quantity of fuel 2000 kg. There were no remarks made against the A/C condition in the FTLB. By the records of the external observation video camera, it can be seen that at 01:13 the boarding had been completed and the entrance door was closed. So, the A/C had been remaining at the AD under the influence of precipitations in the form of rain and wet snow with ambient temperature around zero degrees Celsius and wind velocity more than 10 m/s for more than 7 hours. There was no de/anti-icing treatment performed for the A/C before the flight. At 01:20 the flight crew performed the engine start, and after that passed through the Before Taxi checklist. At 01:24:46 the flight crew obtained clearance for holding position. At 01:32:08 after clearance for lineup position the flight crew reported: “Lining up”. At 01:32:58 the A/C started taking off. The takeoff was performed with flaps extended at 15°. The A/C lift-off occurred at 01:33:28 with a speed of around ≈127 kt. At 01:33:56 at height 600 ft2 and speed of 135 kt the A/P was engaged. At 01:34:00 at height 640 ft and speed of 139 kt the flaps retraction was started. At 01:34:08 after the retraction had been completed, at 690 ft and at a speed of 150 kt uncommanded development of right bank started. At 01:34:10 the A/P was disengaged. The bank angle reached around 40° to the right within 3 s and after that was counteracted by ailerons and rudder deflection. Further, the A/C banked to the left, which the flight crew was not able to compensate with full deflection of ailerons to the right. The A/C collision into terrain occurred at 01:34:35 with a pitch down angle ≈11°, left bank angle ≈55° and vertical rate of descent over 20 m/s. The ASL elevation of the accident area is about ≈110 m. The accident resulted in the A/C full destruction and partial damage by the ground fire. From the 43 persons onboard 4 crew members and 29 passengers were killed. Others sustained serious injuries.
Probable cause:
The immediate cause of the АТR 72-201 VP-BYZ aircraft accident was the PIC’s decision to takeoff without de/anti-icing treatment despite the fact that snow and ice deposits were present on aircraft surface and were discovered by the crew members during taxi which resulted in degradation of aircraft aerodynamic performance and stall during climbing after takeoff as well as inability of the crew to recognize stall and, consequently, failure to undertake recovery procedure. The aircraft stall occurred at the operational angles of attack right after flaps retraction with engaged autopilot before stall warning system activation and was caused by the loss of the wing lift effectiveness due to takeoff with non-removed ground icing. The system cause of the accident were shortcomings in ground handling activities and staff training in UTAir-Technik that became possible because of absence of due monitoring by the Technical and Operation Supervising Directorates of UTAir airline for compliance with airline requirements regarding ground handling and aircraft ground icing protection which resulted in erroneous evaluation of aircraft conditions by the PIC and aircraft mechanic (the shift head kept himself aloof from monitoring mechanic’s activities) after the aircraft has been on ground in icing conditions for a long time and in release the aircraft to fly without de/anti-icing treatment.
The contributing factors were:
- The shortcomings in the UTAir safety management system, which contains, all in all, general issues only and is not adopted for the implementation of Airline activities in particular areas, which did not allow to reveal and correct existing safety risks in a timely manner.
- The shortcomings in the UTAir-Technic quality management system, resulted in neglecting of certain requirements of the UTAir ground handling management manual regarding staff training and monitoring for aircraft de/anti-icing treatment which led to the situation when not sufficiently-qualified staff performed the evaluation of the aircraft surface conditions and made the decision on need for the aircraft to be de-iced/anti-iced.
- The absence at the time of the accident of basic regulations in force that establish state requirements for ground handling (de/anti-icing treatment in particular) including staff training and organization licensing.
- The shortcomings in crew members initial and recurrent training as far as the danger of ground icing, its influence on the aircraft aerodynamic performance together with aircraft anti-icing system operation features and design are concerned that did not allow the crew to make the only appropriate decision to return for de-icing/anti-icing treatment after the observation of the snow and ice contamination on the wing after anti-icing system activation in de-icing mode while taxiing for takeoff.
- The methodological imperfection of the crew computer based and simulator training programs concerning the prevention of aircraft stall, identification of approach to stall and taking timely actions for recovery.
- The increasing need for number of flight crews to perform highly growing flights schedule which, with ineffective SMS, resulted in flight instructor work deficiencies during PIC training and absence of PIC skills to take correct decisions and to strictly comply with the regulations in force.
- The possible fatigue of the crew members due to the violation of the work and rest balance while performing split flight shifts together with a large number of unused days-off.
Final Report:

Crash of a Piper PA-46-500TP Malibu Meridian in Wellington

Date & Time: Mar 23, 2012 at 1745 LT
Operator:
Registration:
N21EP
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Wellington – Vero Beach
MSN:
46-97479
YOM:
2012
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10651
Aircraft flight hours:
40
Circumstances:
A witness reported that the airplane veered left during the takeoff roll and headed toward a large ditch that surrounded the runway. It appeared that the pilot did not attempt to stop the airplane or abort the takeoff. The airplane continued toward the ditch, and, upon reaching the ditch's edge, the airplane rotated and reached an altitude of about 50 feet. The airplane's left wing collided with trees. The airplane rolled left and then right before stalling and crashing. The pilot stated that the airplane seemed to pull left on takeoff, possibly due to a right quartering tailwind, and that he did not realize where he was positioned on the runway. Examination of the airplane and engine did not reveal any preimpact anomalies that would have precluded normal operation.
Probable cause:
The pilot's failure to maintain directional control of the airplane during the takeoff roll, which resulted in a collision with a tree.
Final Report:

Crash of a Convair CV-440-38 in San Juan: 2 killed

Date & Time: Mar 15, 2012 at 0738 LT
Operator:
Registration:
N153JR
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
San Juan - Sint Marteen
MSN:
117
YOM:
1953
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
22586
Captain / Total hours on type:
9000.00
Copilot / Total flying hours:
2716
Copilot / Total hours on type:
700
Circumstances:
The airplane, operated by Fresh Air, Inc., crashed into a lagoon about 1 mile east of the departure end of runway 10 at Luis Muñoz Marín International Airport (SJU), San Juan, Puerto Rico. The two pilots died, and the airplane was destroyed by impact forces. The airplane was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 1251 as a cargo flight. Visual meteorological conditions prevailed at the time of the accident, and a visual flight rules flight plan was filed. The flight had departed from runway 10 at SJU destined for Princess Juliana International Airport, St. Maarten. Shortly after takeoff, the first officer declared an emergency, and then the captain requested a left turn back to SJU and asked the local air traffic controllers if they could see smoke coming from the airplane (the two tower controllers noted in postaccident interviews that they did not see more smoke than usual coming from the airplane). The controllers cleared the flight to land on runway 28, but as the airplane began to align with the runway, it crashed into a nearby lagoon (Laguna La Torrecilla). Radar data shows that the airplane was heading south at an altitude of about 520 ft when it began a descending turn to the right to line up with runway 28. The airplane continued to bank to the right until radar contact was lost. The estimated airspeed at this point was only 88 knots, 9 knots below the published stall speed for level flight and close to the 87-knot air minimum control speed. However, minimum control speeds increase substantially for a turn into the inoperative engine as the accident crew did in the final seconds of the flight. As a result, the airplane was operating close to both stall and controllability limits when radar contact was lost. Pilots flying multiengine aircraft are generally trained to shut down the engine experiencing a problem and feather that propeller; thus, the flight crew likely intended to shut down the right engine by bringing the mixture control lever to the IDLE CUTOFF position and feathering the right propeller, as called out in the Engine Fire In Flight Checklist. This would have left the flight crew with the left engine operative to return to the airport. However, postaccident examinations revealed that the left propeller was found feathered at impact, with the left engine settings consistent with the engine at takeoff or climb setting. The right engine settings were generally consistent with the engine being shut down; however, the right propeller’s pitch was consistent with a high rotation/takeoff power setting. The accident airplane was not equipped with a flight data recorder or a cockpit voice recorder (nor was it required to be so equipped); hence, the investigation was unable to determine at what point in the accident sequence the flight crew shut down the right engine and at what point they feathered the left propeller, or why they would have done so. Post accident examination of the airplane revealed fire and thermal damage to the airframe on the airplane’s right wing rear spar, nacelle aft of the power section, and in the vicinity of the junction between the augmentor assemblies and the exhaust muffler assembly. While the investigation was unable to determine the exact location of the ignition source, it appears to have been aft of the engine in the vicinity of the junction between the augmentor assemblies and exhaust muffler assembly. The investigation identified no indication of a fire in the engine proper and no mechanical failures that would have prevented the normal operation of either engine.
Probable cause:
The flight crew's failure to maintain adequate airspeed after shutting down the right engine due to an in-flight fire in one of the right augmentors. The failure to maintain airspeed resulted in either an aerodynamic stall or a loss of directional control.
Final Report:

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

Date & Time: Feb 28, 2012 at 0715 LT
Type of aircraft:
Operator:
Registration:
PT-PTB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Manaus - Manaus
MSN:
208B-0766
YOM:
1999
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12000
Captain / Total hours on type:
158.00
Circumstances:
The pilot was performing a positioning flight from Manaus-Aeroclube de Flores Airport to the international Airport of Manaus-Eduardo Gomes. Shortly after takeoff from runway 11 which is 860 metres long, the single engine aircraft failed to gain sufficient altitude. It collided with an electric pole, stalled and crashed in a wooded area. The pilot, sole occupant, was killed.
Probable cause:
It was determined that the loss of control results from the fact that the flight controls were locked. Investigations show that the pilot failed to prepare the flight properly, that he did not follow the pre takeoff checklist and that he rushed the departure. It was reported that the operator was using since two years a control lock that had not been approved by the Civil Aviation Authority, and that no procedure had been put in place place concerning this lock system.
Final Report:

Crash of a Learjet 55 Longhorn in Brooksville

Date & Time: Feb 13, 2012 at 2200 LT
Type of aircraft:
Operator:
Registration:
N75LJ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Brooksville - Houston
MSN:
55-065
YOM:
1982
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from runway 27 at Brooksville-Hernando County Airport, control was lost. The aircraft veered off runway and came to rest. All three crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
NTSB did not proceed to any investigation regarding this incident.