Crash of a Saab 2000 in Craiova

Date & Time: Feb 13, 2012 at 1108 LT
Type of aircraft:
Operator:
Registration:
YR-SBK
Flight Phase:
Survivors:
Yes
Schedule:
Craiova – Timişoara
MSN:
33
YOM:
1996
Flight number:
KRP2385
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
51
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6623
Copilot / Total flying hours:
700
Circumstances:
The crew started the takeoff procedure from runway 09 at Craiova Airport in a visibility of 500 metres due to freezing fog. During the course, the aircraft deviated to the right, causing the right engine to struck a snow berm (one meter high). The right propeller was torn off then aircraft rolled for few metres before coming to rest in snow. All 55 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
It was determined that the runway has not been properly cleared of snow prior to takeoff. This caused the lights ont both edges to be not visible to the crew. The crew failed to assess the takeoff conditions, the runway conditions and weather conditions.
The following contributing factors were identified:
- The takeoff conditions exceeded the training level of the crew,
- Change of takeoff procedure without prior training.
Final Report:

Crash of a Piper PA-61P Aerostar (Ted Smith 601P) in Philadelphia

Date & Time: Jan 16, 2012 at 1242 LT
Operator:
Registration:
N700PS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Philadelphia – Meridian
MSN:
61-0427-157
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6200
Aircraft flight hours:
2857
Circumstances:
On the day of the accident, a mechanic taxied the airplane onto the runway and performed a full power check of both engines, exercised both propellers, and checked each magneto drop with no discrepancies reported. Following the engine run, the mechanic taxied the airplane to the fuel ramp where the fuselage fuel tank was filled; after fueling, the fuselage tank had 41.5 gallons of usable fuel. The mechanic then taxied the airplane to the ramp where the engines were secured and the fuel selector switches were placed to the off position. The mechanic reported that, at that time, the left fuel tank had 4 to 5 gallons of fuel, while the right fuel tank had about 2 to 3 gallons of fuel; the unusable fuel amount for each wing tank is 3 gallons. The pilot taxied the airplane to the approach end of runway 18 and was heard to apply takeoff power. A pilot-rated witness noted that, at the point of rotation, the airplane pitched up fairly quickly to about 20 degrees and rolled left to about 10 to 15 degrees of bank. The airplane continued rolling left to an inverted position and impacted the ground in a 40 degree nose-low attitude. A postcrash fire consumed most of the cockpit, cabin, both wings, and aft fuselage, including the vertical stabilizer, rudder, and fuselage fuel tank. Postaccident inspection of the flight controls, which were extensively damaged by impact and fire, revealed no evidence of preimpact failure or malfunction. Although the flap actuators were noted to be asymmetrically extended and no witness marks were noted to confirm the flap position, a restrictor is located at each cylinder’s downline port by design to prevent a rapid asymmetric condition. Therefore, it is likely that the flap actuators changed positions following impact and loss of hydraulic system pressure and did not contribute to the left roll that preceded the accident. Examination of the engines and propellers revealed no evidence of preimpact failure or malfunction that would have precluded normal operation. Postaccident examination of the fuselage fuel sump revealed the left fuel selector was in the crossfeed position, while the right fuel selector was likely positioned to the on position. (The as-found positions of the fuel selector knobs were unreliable due to postaccident damage.) The starting engines checklist indicates that the pilot is to move both fuel selectors from the on position to the crossfeed position, and back to the on position while listening for valve actuation/movement. The before takeoff checklist indicates that the pilot is to verify that the selectors are in the on position. Although the left engine servo fuel injector did not meet flow tests during the postaccident investigation, this was attributed to postaccident heat damage. Calculations to determine engine rpm based on ground scars revealed that the left engine was operating just above idle, and the right engine was operating about 1,315 rpm, which is consistent with a left engine loss of power and the pilot reducing power on the right engine during the in-flight loss of control. Examination of both propellers determined that neither was feathered at impact. Although the as-found position of the left fuel selector knob could be considered unreliable because of impact damage during the accident sequence, given that right wing fuel tank had no usable fuel, it is unlikely that the experienced pilot would have moved the left fuel selector to the crossfeed position in response to the engine power loss. It is more likely that the pilot failed to return the left fuel selector to the on position during the starting engines checklist and also failed to verify its position during the before takeoff checklist; thus, the left engine was being fed only from the right fuel tank, which had very little fuel. There was likely enough fuel in the right tank and lines for the pilot to taxi and takeoff before the left engine failed, causing the airplane to turn to the left, from which the pilot did not recover.
Probable cause:
The pilot’s failure to maintain directional control during takeoff following loss of power to the left engine due to fuel starvation. Contributing to the loss of control was the pilot’s failure to feather the left propeller following the loss of left engine power.
Final Report:

Crash of a Let L-410UVP-E9 in Kichwa Tembo

Date & Time: Jan 12, 2012 at 1955 LT
Type of aircraft:
Operator:
Registration:
5Y-BSA
Flight Phase:
Survivors:
Yes
Schedule:
Kichwa Tembo – Musiara
MSN:
89 23 23
YOM:
1989
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft was returning to Mombasa with a scheduled stop in Musiara to pickup 15 additional passengers. On departure from Kichwa Tembo, there were four passengers and two pilots on board. During the takeoff roll from runway 08, the aircraft hit a bump half way down the runway and bounced. The aircraft hit a second bump shortly later and as the crew heard the stall alarm, he decided to reject takeoff. Unable to stop within the remaining distance, the aircraft overran, lost its nose gear and came to rest 300 metres further. All six occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Cessna 650 Citation VII in Fort Lauderdale

Date & Time: Dec 28, 2011 at 0951 LT
Type of aircraft:
Registration:
N877G
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lauderdale – Teterboro
MSN:
650-7063
YOM:
1995
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14950
Captain / Total hours on type:
190.00
Copilot / Total flying hours:
19000
Copilot / Total hours on type:
100
Aircraft flight hours:
5616
Aircraft flight cycles:
4490
Circumstances:
The crew stated that the preflight examination, takeoff checks, takeoff roll, and rotation from runway 26 were "normal." However, once airborne, and with the landing gear down and the flaps at 20 degrees, the airplane began a roll to the right. The captain used differential thrust and rudder to keep the airplane from rolling over, and as he kept adjusting both. He noted that as the airspeed increased, the airplane tended to roll more; as the airspeed decreased, the roll would decrease. The captain also recalled thinking that the airplane might have had an asymmetrical flap misconfiguration. Both pilots stated that there were no lights or warnings. As the airplane continued a right turn, runway 13 came into view. The captain completed a landing to the right of that runway, landing long and in the grass with a 9-knot, left quartering tailwind. The airplane then paralleled the runway and ran into an airport perimeter fence beyond the runway's end. The cockpit voice recorder revealed that the crew initially used challenge and reply checklists and that after completing the takeoff checklist, engine power increased. About 7 seconds after the first officer called "V1," the captain stated an expletive, and the first officer announced "positive rate." During the next 50 seconds, the captain repeated numerous expletives, an automated voice issued numerous "bank angle" warnings, and the first officer asked what he could do, to which the captain later told him to declare an emergency. There were no calls by either pilot for an emergency checklist nor were there callouts of any emergency memory items. Each of the airplane's wings incorporated four hydraulically-actuated spoiler segments. The outboard segment, the roll control spoiler, normally extends in conjunction with its wing aileron after the aileron has traveled more than about 3 degrees, and extends up to 50 degrees at full control wheel rotation. When the airplane was subsequently examined in a hangar, hydraulic power was applied to the airplane via a ground hydraulic power unit, and the right roll spoiler elevated to 7.9 degrees above the flush wing level. Multiple left/right midrange turns of the yoke, with the hydraulic ground power unit both on and off, resulted in the roll spoiler being extended normally, but still returning to a resting position of 7.8 to 7.9 degrees above the flush position. When the yoke was turned full right and left, whether the aileron boost was on or off, both wings' roll spoilers extended to their full positions per specifications; however, once the full deflection testing was completed, the right roll spoiler returned to 6.1 degrees above the flush position. A final yoke turn resulted in the roll spoiler being elevated to 5.5 degrees. The right wing roll spoiler actuator was subsequently examined at the airplane manufacturer, and the roll spoiler was found to jam. The roll spoiler actuator was disassembled, but no specific reason(s) for the jamming were found. The roll spoiler parts were also examined and no indications of why the actuator may have jammed were found. According to the flight manual, if any of the spoiler segments should float, moving the spoiler hold down switch to "Spoiler Hold Down" locks all spoiler panels down. The roll control spoilers may then be used in the roll mode by turning on the auxiliary hydraulic pump. Also, an "Aileron/Spoiler Disconnect" T-handle is available to release the tie between the ailerons and the roll control spoilers in the event of a jam in either system. When used, the pilot's yoke controls only the ailerons, and the copilot's yoke controls only the roll control spoilers. Although the jamming of the right spoiler initiated the event, the crew's proper application of emergency procedures should have negated the adverse effects. Memory items for an uncommanded roll include moving the spoiler hold-down switch to the "on" position, which was not done; the spoiler hold-down switch was found in the "off" position. (The captain thought that he may have had an asymmetrical flap configuration; however, if an asymmetry had been the initiating event, the flap system would have been automatically disabled and the flap segments would have been mechanically locked in their positions.) The aileron/spoiler disconnect T-handle was found pulled up, which the crew indicated had occurred when the first officer's shoe hit it as he evacuated the airplane. While pulling the aileron/spoiler disconnect T-handle would have been appropriate for a different emergency procedure to release the tie between the ailerons and the roll control spoilers in the event of a jam in either system, it would have actually hindered the captain's attempts to control the airplane in this case because it would have disconnected the left roll spoiler from the captain's yoke, making it more difficult to counter the effects of the displaced right roll spoiler. Although the crew indicated that the t-handle was pulled during the first officer's exit of the airplane, its position, safety cover, and means of activation make this unlikely. In addition, precertification testing of the airplane showed that even with the right roll spoiler fully deployed, as long as the pilot had the use of the left roll spoiler in conjunction with that aileron, the airplane should have been easily controlled.
Probable cause:
The crew's failure to use proper emergency procedures during an uncommanded right roll after takeoff, which led to a forced landing with a quartering tailwind. Contributing to the accident was a faulty right roll spoiler actuator, which allowed the right roll spoiler to deploy but not close completely.
Final Report:

Crash of a Socata TBM-700 in Morristown: 5 killed

Date & Time: Dec 20, 2011 at 1005 LT
Type of aircraft:
Operator:
Registration:
N731CA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Teterboro - Atlanta
MSN:
332
YOM:
2005
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
1400
Aircraft flight hours:
702
Circumstances:
Although the pilot filed an instrument flight rules flight plan through the Direct User Access Terminal System (DUATS), no evidence of a weather briefing was found. The flight departed in visual meteorological conditions and entered instrument meteorological conditions while climbing through 12,800 feet. The air traffic controller advised the pilot of moderate rime icing from 15,000 feet through 17,000 feet, with light rime ice at 14,000 feet. The controller asked the pilot to advise him if the icing worsened, and the pilot responded that he would let them know and that it was no problem for him. The controller informed the pilot that he was coordinating for a higher altitude. The pilot confirmed that, while at 16,800 feet, "…light icing has been present for a little while and a higher altitude would be great." About 15 seconds later, the pilot stated that he was getting a little rattle and requested a higher altitude as soon as possible. About 25 seconds after that, the flight was cleared to flight level 200, and the pilot acknowledged. About one minute later, the airplane reached a peak altitude of 17,800 feet before turning sharply to the left and entering a descent. While descending through 17,400 feet, the pilot stated, "and N731CA's declaring…" No subsequent transmissions were received from the flight. The airplane impacted the paved surfaces and a wooded median on an interstate highway. A postaccident fire resulted. The outboard section of the right wing and several sections of the empennage, including the horizontal stabilizer, elevator, and rudder, were found about 1/4 mile southwest of the fuselage, in a residential area. Witnesses reported seeing pieces of the airplane separating during flight and the airplane in a rapid descent. Examination of the wreckage revealed that the outboard section of the right wing separated in flight, at a relatively low altitude, and then struck and severed portions of the empennage. There was no evidence of a preexisting mechanical anomaly that would have precluded normal operation of the airframe or engine. An examination of weather information revealed that numerous pilots reported icing conditions in the general area before and after the accident. At least three flight crews considered the icing "severe." Although severe icing was not forecasted, an Airmen's Meteorological Information (AIRMET) advisory included moderate icing at altitudes at which the accident pilot was flying. The pilot operating handbook warned that the airplane was not certificated for flight in severe icing conditions and that, if encountered, the pilot must exit severe icing immediately by changing altitude or routing. Although the pilot was coordinating for a higher altitude with the air traffic controller at the time of the icing encounter, it is likely that he either did not know the severity of the icing or he was reluctant to exercise his command authority in order to immediately exit the icing conditions.
Probable cause:
The airplane’s encounter with unforecasted severe icing conditions that were characterized by high ice accretion rates and the pilot's failure to use his command authority to depart the icing conditions in an expeditious manner, which resulted in a loss of airplane control.
Final Report:

Crash of an Antonov AN-2 in Arua

Date & Time: Dec 12, 2011 at 1420 LT
Type of aircraft:
Operator:
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Arua - Nzara
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft was leased by the Uganda Peoples Defence Force Air Wing to carry a group of four Officer to Nzara, South Sudan. Shortly after takeoff from Arua Airport, the aircraft encountered difficulties to gain altitude, hit a tree and crashed in an open field located near the village of Mingoro, bursting into flames. All seven occupants evacuated with minor injuries and the aircraft was destroyed by a post crash fire.
Probable cause:
Engine failure for unknown reasons.

Crash of a Beechcraft 65-80 Queen Air in Manila: 13 killed

Date & Time: Dec 10, 2011 at 1415 LT
Type of aircraft:
Registration:
RP-C824
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Manila - San Jose
MSN:
LD-21
YOM:
1962
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
13
Circumstances:
On December 10, 2011, BE-65-80QA (Queen Air) with Registry RP-C824 took off from RWY 13, Manila Domestic Airport on/or about 0610 UTC (1410H) southbound for San Jose, Mindoro. There were three (3) persons on board, the PIC and two (2) other persons; one was seated at the right-hand cockpit seat and the other one at the passenger seat. After airborne, the ATC gave instructions to the pilot o turn right and report five (5) miles out. After performing the right turn, the pilot requested for a reland which was duly acknowledged but the ATC with instructions to cross behind traffic on short final Rwy 06 (a perpendicular international runway) and to confirm if experiencing difficulty. However, there was no more response from the pilot. From a level flight southward at about 200 feet AGL, three (3) loud sputtering/burst sounds coming from the aircraft were heard (by people on the ground) then the aircraft was observed making a left turn that progressed into a steep bank and roll-over on a dive. After about one complete roll on a dive the aircraft hit ground at point of impact (Coordinates 14.48848 N 121.025811 E), a confined area beside a creek surrounded by shaties where several people were in a huddle. Upon impact, the aircraft exploded and fire immediately spread to surrounding shanties and a nearby elementary school building. The aircraft was almost burned into ashes and several shanties were severely burned by post-crash fire. A total of thirteen (13) persons were fatality injured composed of: the 3 aircraft occupants who died due to non survivable impact and charred by post-crash fire, and ten (10) other persons on the ground, all residents at vicinity of impact point, incurred non-fatal injuries and were rushed to a nearby hospital for medical treatment. About 20 houses near the impact point were completely burnt and the adjacent Elementary School building was severely affected by fire.
Probable cause:
The Aircraft Accident Investigation and Inquiry Board determined that the probable cause of this accident was:
- Immediate Cause:
(1) Pilot’s Lack of event proficiency in emergency procedures for one (1) engine in-operative condition after-off. Pilot Error (Human Factor)
While a one engine in-operative condition during take-off after V1 is a survivable emergency event during training, the pilot failed to effectively maintain aircraft control the aircraft due to inadequate event proficiency.
- Contributing Cause:
(1) Left engine failure during take-off after V1. (Material Factor)
The left engine failed due to oil starvation as indicated by the severely burnt item 7 crankshaft assembly and frozen connecting rods 5 & 6. This triggered the series of events that led to the failure of the pilot to manage a supposedly survivable emergency event.
- Underlying Causes:
(1) Inadequate Pilot Training for Emergency Procedure. Human Factor
Emergency event such as this (one engine inoperative event – twin engine aircraft) was not actually or properly performed (discussed only) in actual training flights/check-ride and neither provided with corresponding psycho-motor training on a simulator. Hence, pilot’s motor skill/judgment recall was not effective (not free-flowing) during actual emergency event.
(2) Inadequate engine overhaul capability of AMO. Human Factor
There was no document to prove that engine parts scheduled to be overhauled aboard were complied with or included in the overhaul activity. The presence unauthorized welding spot in the left-hand engine per teardown inspection report manifested substandard overhaul activity.
(3) Inadequate regulatory oversight (airworthiness inspection) on the overhaul activity of the AMO (on engine overhaul). Human Factor
The airworthiness inspection on this major maintenance activity (engine overhaul) failed to ensure integrity and quality of replacement parts and work done (presence of welding spots).
(4) Unnecessary Deviation by ATC from the AIP provision on Runway 13 Standard VFR Departure Southbound.
The initiative of the AY+TC for an early right turn southbound after airborne was not in accord with the standard departure in the AIP which provides the safest corridor for takeoff and the ample time to stabilize aircraft parameters in case of a one engine inoperative emergency event for a successful re-land or controlled emergency landing.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Sioux Falls: 4 killed

Date & Time: Dec 9, 2011 at 1424 LT
Operator:
Registration:
N421SY
Flight Phase:
Survivors:
No
Schedule:
Sioux Falls - Rapid City
MSN:
421C-0051
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3848
Captain / Total hours on type:
357.00
Aircraft flight hours:
4882
Circumstances:
Shortly after the airplane lifted off, the tower controller informed the pilot that a plume of smoke was visible behind the airplane. No communications were received from the pilot after he acknowledged the takeoff clearance. Witnesses reported that white smoke appeared to be trailing from the area of the left engine during takeoff. The witnesses subsequently observed flames at the inboard side of the left engine. The airplane began a left turn. As the airplane continued the turn, the flames and trail of white smoke were no longer visible. When the airplane reached a southerly heading, the nose dropped abruptly, and the airplane descended to the ground. Witnesses stated that they heard an increase in engine sound before impact. A postimpact fire ensued. The accident site was located about 3/4 mile from the airport. A postaccident examination determined that the left engine fuel selector and fuel valve were in the OFF position, consistent with the pilot shutting down that engine after takeoff. However, the left engine propeller was not feathered. Extensive damage to the right engine propeller assembly was consistent with that engine producing power at the time of impact. The landing gear and wing flaps were extended at the time of impact. Teardown examinations of both engines did not reveal any anomalies consistent with a loss of engine power. The left engine oil cap was observed to be unsecured at the accident site; however, postaccident comparison of the left and right engine oil caps revealed disproportionate distortion of the left oil cap, likely due to the postimpact fire. As a result, no determination was made regarding the security of left engine oil cap before the accident. Emergency procedures outlined in the pilot’s operating handbook (POH) noted that when securing an engine, the propeller should be feathered. Performance data provided in the POH for single-engine operations were predicated on the propeller of the inoperative engine being feathered, and the wing flaps and landing gear retracted. Thus, the pilot did not follow the emergency procedures outlined in the POH for single-engine operation.
Probable cause:
The pilot’s failure to maintain adequate airspeed after shutting down one engine, which resulted in an inadvertent aerodynamic stall and impact with terrain. Contributing to the accident was the pilot’s failure to follow the guidance contained in the pilot’s operating handbook, which advised feathering the propeller of the secured engine and retracting the flaps and landing gear.
Final Report:

Crash of a Gulfstream GII in Huambo

Date & Time: Nov 26, 2011
Type of aircraft:
Registration:
N811DE
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Huambo – Saurimo
MSN:
244
YOM:
1979
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Huambo-Albano Machado Airport, the crew decided to reject takeoff for unknown reasons. The aircraft veered off runway and came to rest. All 10 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Rockwell Grand Commander 690A near Mesa: 6 killed

Date & Time: Nov 23, 2011 at 1831 LT
Operator:
Registration:
N690SM
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Mesa - Safford
MSN:
690-11337
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
2500
Captain / Total hours on type:
951.00
Aircraft flight hours:
8188
Circumstances:
The aircraft was destroyed when it impacted terrain in the Superstition Mountains near Apache Junction, Arizona. The commercial pilot and the five passengers were fatally injured. The airplane was registered to Ponderosa Aviation, Inc. (PAI) and operated by PAI under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Night visual meteorological conditions (VMC) prevailed, and no flight plan was filed. The airplane had departed Falcon Field (FFZ), Mesa, Arizona, about 1825 and was destined for Safford Regional Airport (SAD), Safford, Arizona. PAI’s director of maintenance (DOM) and the director of operations (DO), who were co owners of PAI along with the president, conducted a personal flight from SAD to FFZ. The DO flew the leg from SAD to FFZ under visual flight rules (VFR) in night VMC. After arriving at FFZ and in preparation for the flight back to SAD, the DOM moved to the left front seat to act as the pilot flying. The airplane departed FFZ about 12 minutes after it arrived. According to a witness, engine start and taxi-out appeared normal. Review of the recorded communications between the pilot and the FFZ tower air traffic controllers revealed that when the pilot requested taxi clearance, he advised the ground controller that he was planning an "eastbound departure." The flight was cleared for takeoff on runway 4R, and the pilot was instructed to maintain runway heading until advised, due to an inbound aircraft. About 90 seconds later, when the airplane was about 1.1 miles from the departure end of the runway, the tower local controller issued a "right turn approved" advisory to the flight, which the pilot acknowledged. Radar data revealed that the airplane flew the runway heading for about 1.5 miles then began a right turn toward SAD and climbed through an altitude of about 2,600 feet mean sea level (msl). About 1828, after it momentarily climbed to an altitude of 4,700 feet, the airplane descended to an altitude of 4,500 feet, where it remained and tracked in an essentially straight line until it impacted the mountain. The last radar return was received at 1830:56 and was approximately coincident with the impact location. The impact location was near the top of a steep mountain that projected to over 5,000 feet msl. Witnesses reported seeing a fireball, and law enforcement helicopters were dispatched.
Probable cause:
The pilot's failure to maintain a safe ground track and altitude combination for the moonless night visual flight rules flight, which resulted in controlled flight into terrain. Contributing to the accident were the pilot's complacency and lack of situational awareness and his failure to use air traffic control visual flight rules flight following or minimum safe altitude warning services. Also contributing to the accident was the airplane's lack of onboard terrain awareness and warning system equipment.
Final Report: