Crash of a Piper PA-42-1000 Cheyenne 400LS in Mercedes

Date & Time: Aug 13, 2010 at 1530 LT
Type of aircraft:
Operator:
Registration:
LQ-BLU
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Mercedes - La Plata
MSN:
42-5527037
YOM:
1987
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4294
Captain / Total hours on type:
390.00
Copilot / Total flying hours:
2827
Copilot / Total hours on type:
14
Aircraft flight hours:
1526
Circumstances:
During the takeoff roll on runway 19 at Mercedes Airport, the twin engine aircraft deviated to the right then to the left. Control was lost and the aircraft veered off runway to the left, lost its undercarriage and came to rest in bushed with its left wing partially torn off. All four occupants escaped uninjured while the aircraft was damaged beyond repair. Both passengers were Ricardo Casal, Minister of Justice and Security, and Maria del Carmen Falbo, Attorney.
Probable cause:
Loss of control during takeoff following the crew's decision to perform the operation outside of the procedures established in the flight manual. The overconfidence of the crew as well as the operation of both engines at low regime were considered as contributing factors.
Final Report:

Crash of a McDonnell Douglas C-17A Globemaster III at Elmendorf AFB: 4 killed

Date & Time: Jul 28, 2010 at 1822 LT
Operator:
Registration:
00-0173
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Elmendorf AFB - Elmendorf AFB
MSN:
P-73
YOM:
2000
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The crew was engaged in a training exercise in preparation to the 'Thunder Air Show' taking part at Elmendorf-Richardson AFB on 31JUL2010. Shortly after take off from runway 06, the pilot-in-command initiated a first turn to the left then a steep turn to the right when the aircraft entered an uncontrolled descent and crashed in a huge explosion in a wooded area located some 3 km northwest of the airbase. The aircraft was totally destroyed by impact forces and a post crash fire and all four crew members were killed.
Probable cause:
The board president found clear and convincing evidence that the cause of the mishap was pilot error. The pilot violated regulatory provisions and multiple flight manual procedures, placing the aircraft outside established flight parameters at an attitude and altitude where recovery was not possible. Furthermore, the copilot and safety observer did not realize the developing dangerous situation and failed to make appropriate inputs. In addition to multiple procedural errors, the board president found sufficient evidence that the crew on the flight deck ignored cautions and warnings and failed to respond to various challenge and reply items. The board also found channelized attention, overconfidence, expectancy, misplaced motivation, procedural guidance, and program oversight substantially contributed to the mishap.

Crash of a De Havilland DHC-2 Beaver in La Grande: 2 killed

Date & Time: Jul 24, 2010 at 1053 LT
Type of aircraft:
Operator:
Registration:
C-FGYK
Flight Phase:
Survivors:
Yes
Schedule:
La Grande - Lac Eau Claire
MSN:
123
YOM:
1951
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3800
Captain / Total hours on type:
1000.00
Aircraft flight hours:
23808
Circumstances:
At approximately 1053 Eastern Daylight Time, de Havilland DHC-2 Mk. 1 amphibious floatplane (registration C-FGYK, serial number 123), operated by Nordair Québec 2000 Inc., took off from runway 31 at La Grande-Rivière Airport, Quebec, for a visual flight rules flight to l’Eau Claire Lake, Quebec, about 190 nautical miles to the north. The take-off run was longer than usual. The aircraft became airborne but was unable to gain altitude. At the runway end, at approximately 50 feet above ground level, the aircraft pitched up and banked left. It then nosed down and crashed in a small shallow lake. The pilot and 1 front-seat passenger were fatally injured and the 3 rear-seat passengers sustained serious injuries. The aircraft broke up on impact, and the forward part of the cockpit was partly submerged. The emergency locator transmitter activated on impact.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The aircraft was overloaded and its centre of gravity was beyond the aft limit. The aircraft pitched up and stalled at an altitude that did not allow the pilot to execute the stall recovery manoeuvre.
2. The baggage was not secured. Shifting of the baggage caused the triple seat to pivot forward, propelling the 3 rear-seat passengers against the pilot and front-seat passenger during impact.
3. Although the design of the triple seat met aviation standards, it separated from the floor at the time of impact, principally due to the fact that the heavy cargo shifted.
4. The action taken by TC did not have the desired outcomes to ensure regulatory compliance; consequently, unsafe practices persisted.
Finding as to Risk:
1. Operating an aircraft outside the limits and conditions under which a permit is issued can increase the risk of an accident
Final Report:

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

Date & Time: Jul 22, 2010 at 1100 LT
Operator:
Registration:
N601AT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cleburne - Mena
MSN:
61-0332-095
YOM:
1976
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
28000
Captain / Total hours on type:
332.00
Circumstances:
After takeoff, the right engine experienced a loss of power followed by the left engine losing power. The pilot maneuvered the airplane toward the nearest open field and the airplane impacted terrain during landing, resulting in a circumferential split in fuselage near the aft pressure bulkhead. The airplane was equipped with 4 fuel tanks: 2 located in each wing outboard of the engine nacelle (65-gallon capacity), 1 main fuselage tank (about 44-gallon capacity), and 1 auxiliary tank located in forward section of baggage compartment (45-gallon capacity). The airplane was capable of carrying 209.5 gallons usable fuel and the pilot stated that prior to departure he filled the main fuselage tank to capacity, added 20 gallons in the auxiliary tank and 25 gallons in each wing tank, which he equated to a total of 131 gallons on board. The fuselage contained two fuel filler necks, one for each fuselage tank (main and auxiliary). The auxiliary tank was clearly placarded with a red placard visibly standing out against a silver paint stripe; the main tank was not clearly placarded, with a red placard blending easily with red paint stripe. A salvage retriever recalled that during recovery the left wing contained 17 gallons of fuel, the right wing contained 57 gallons of fuel, the main fuselage tank contained 2.5 gallons of fuel, and the auxiliary fuselage tank contained 28 gallons of fuel. A postaccident examination of the airplane and engines revealed no anomalies that would have precluded normal operation. The main fuselage tank and auxiliary fuselage tank were not breached and the fuel sumps contained check valves which prevent the back-flow of fuel from one fuel tank to another. Based on the evidence it is likely that the pilot exhausted the airplane's fuel supply in the main fuselage tank, which resulted in the loss of power to both engines.
Probable cause:
A total loss of engine power due to fuel starvation as a result of the pilot’s improper fuel management. Contributing to the accident were the critical fuel placards that were difficult to see due to the airplane's paint scheme.
Final Report:

Crash of an Antonov AN-12BP in Keperveyem

Date & Time: Jul 21, 2010 at 0932 LT
Type of aircraft:
Operator:
Registration:
RA-11376
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Keperveem - Komsomolsk-on-Amur
MSN:
02 348 206
YOM:
1972
Flight number:
KBR9236
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
5136
Aircraft flight cycles:
3090
Circumstances:
During the takeoff roll on runway 27 at Keperveyem Airport, the four engine aircraft deviated to the left, went out of control and veered off runway. It lost its undercarriage and slid before coming to rest 120 metres to the left of the runway and after a course of 880 metres. All 8 occupants escaped uninjured while the aircraft was damaged beyond economical repair.
Probable cause:
Loss of control during takeoff following the failure of the nosewheel steering system due to the malfunction of the VG15-2S switch. The captain failed to check the nosewheel steering system prior to takeoff, which was considered as a contributing factor.
Final Report:

Crash of a Rockwell Shrike Commander 500S in Rankin Inlet

Date & Time: Jul 18, 2010 at 1330 LT
Operator:
Registration:
N5800H
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Portland - Rankin Inlet - Iqaluit - Bern
MSN:
500-3082
YOM:
1970
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
23100
Captain / Total hours on type:
40.00
Copilot / Total flying hours:
5400
Copilot / Total hours on type:
13
Circumstances:
The Aero Commander 500S had recently been purchased. The new owner of the aircraft retained the services of 2 experienced pilots to deliver the aircraft from Portland, Oregon, United States, to Bern, Switzerland. After having flown several positioning legs, the aircraft arrived at Rankin Inlet for refuelling. The aircraft was refuelled from two 45-gallon drums and was to continue on to Iqaluit, Nunavut. The pilot-in-command occupied the right seat and the pilot flying the aircraft occupied the left seat. The aircraft was at its maximum takeoff weight of 7000 pounds. Prior to take off, the crew conducted a run-up and all indications seemed normal. During the takeoff roll, the engines did not produce full power and the crew elected to reject the takeoff. After returning to the ramp, a second run-up was completed and once again all indications seemed normal. Shortly after second rotation, cylinder head temperatures increased and both Lycoming TIO-540-E1B5 engines began to lose power. The pilots attempted to return to the airport, but were unable to maintain altitude. The landing gear was extended and a forced landing was made on a flat section of land, approximately 1500 feet to the southwest of the runway 13 threshold. There were no injuries and the aircraft sustained substantial damage.
Probable cause:
Findings as to Causes and Contributing Factors:
1. At the fuel compound, the 45-gallon drum containing slops was located near the stock of sealed 45-gallon drums of 100LL AVGAS, contributing to the fuel handler selecting the drum of slops in error.
2. The 45-gallon drum of slops had similar markings to the stock of sealed 45-gallon drums of 100LL AVGAS, preventing ready identification of the contaminated drum.
3. The fuel handler did not notice that the large bung plug was not sealed on the second 45-gallon drum and, as a result, delivered the drum of slops to the aircraft.
4. The pilots did not notice that the large bung plug was not sealed on the second 45-gallon drum and, as a result, fuelled the aircraft with contaminated fuel.
5. The pilots were inexperienced with refuelling from 45-gallon drums and did not take steps to ascertain the proper fuel grade in the second 45-gallon drum. As a result, slops, rather than 100LL AVGAS, was pumped into the aircraft’s fuel system.
6. The fuel system design was such that the fuel from both wing fuel cells combined in the centre fuel cell and, as a result, contaminated fuel was fed to both engines.
7. The contaminated fuel resulted in engine power loss in both engines and the aircraft was unable to maintain altitude after takeoff.
Finding as to Risk:
1. The impact force angles were substantially different from that of the ELT’s G-switch orientation. As a result, the ELT did not activate during the impact. This could have delayed search and rescue (SAR) notification.
Final Report:

Ground accident of a Boeing 747-306M in Cairo

Date & Time: Jul 17, 2010 at 0730 LT
Type of aircraft:
Operator:
Registration:
HS-VAC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cairo - Jeddah
MSN:
23056/587
YOM:
1983
Flight number:
SV9302
Country:
Region:
Crew on board:
22
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a positioning flight from Cairo to Jeddah. During the takeoff roll, the engine n°4 experienced an uncontained failure. The takeoff procedure was rejected and the aircraft came to a halt and later transferred to a hangar. All 22 crew members escaped uninjured while the aircraft was considered as damaged beyond repair.
Probable cause:
Failure of the n°4 engine during takeoff following the failure of the high pressure compressor.

Crash of a PZL-Mielec AN-2T in Tuzla: 12 killed

Date & Time: Jul 5, 2010 at 1740 LT
Type of aircraft:
Operator:
Registration:
53
Flight Phase:
Survivors:
Yes
Schedule:
Tuzla - Tuzla
MSN:
1G194-53
YOM:
1982
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
12
Circumstances:
Shortly after takeoff from Tuzla Airport, the single engine aircraft stalled and crashed in an open field, bursting into flames. Two passengers survived while 12 other occupants were killed. The aircraft was carrying 4 crew and 10 members of the Romanian Navy engaged in a paratroopers mission.
Those killed were:
Cdr Nicolae Jianu,
Lt Cdr Cătălin Vicenţiu Antoche,
Lt Lavinia Guită,
Lt Răzvan Rîngheţ,
Lt Liviu Antim,
Florin Claudiu Cişmaşu,
Cătălin Rădoi,
Băduţ Papuc,
Vlăduţ Sărman,
Marius Cătălin Chioveanu,
Cosmin Furtună,
Cosmin Florescu.
The Captain Daniel Bâlsanu and the foreman Marius Nazare were injured.

Crash of a Cessna 421B Golden Eagle II in Alpine: 5 killed

Date & Time: Jul 4, 2010 at 0015 LT
Operator:
Registration:
N31AS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Alpine - Odessa
MSN:
421B-0473
YOM:
1973
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
1650
Captain / Total hours on type:
160.00
Aircraft flight hours:
2302
Circumstances:
The airplane impacted terrain shortly after takeoff. The wreckage distribution was consistent with a high airspeed, low angle-of-attack impact. Examination of the ground scars and wreckage indicated that the landing gear was down, the flaps were down, and the engines were operating at a high power setting at the time of impact. An examination of the airframe, engines, and related systems revealed no mechanical malfunctions or failures. According to the owner’s manual for the airplane, the flaps should have been retracted and the landing gear should have been brought up as soon as a climb profile was established. Based upon the location of the wreckage, the direction of the impact, and the location of the airport, it is likely that the airplane crashed within one or two minutes after takeoff. The extended landing gear and flaps degraded the climb performance of the airplane. The pilot held an airline transport pilot certificate and had recent night flight experience. Toxicological results were positive for azacyclonol and ibuprofen but were not at levels that would have affected his performance. According to family members, the pilot normally slept from 2230 or 2300 to 0700; the accident occurred at 0015. Although the investigation was unable to determine how long the pilot had been awake before the accident or his sleep schedule in the three days prior to the accident, it is possible that the pilot was fatigued, as the accident occurred at a time when the pilot was normally asleep. The company did not have, and was not required to have guidance or a policy addressing fatigue management.
Probable cause:
The degraded performance of the airplane due to the pilot not properly setting the flaps and retracting the landing gear after takeoff. Contributing to the accident was the pilot’s fatigue.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Kukaklek Lake

Date & Time: Jun 27, 2010 at 1730 LT
Type of aircraft:
Operator:
Registration:
N9RW
Flight Phase:
Survivors:
Yes
Schedule:
Kukaklek Lake - Kukaklek Lake
MSN:
1095
YOM:
1957
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5000
Captain / Total hours on type:
2000.00
Circumstances:
The commercial pilot was taking off on a passenger flight in conjunction with a remote lodge operation under Title 14, CFR Part 91. The pilot said he picked up passengers in the float-equipped airplane on a beach, and water-taxied out into the lake for takeoff. He said he taxied out about 1,200 feet, reversed course into the wind, and initiated a takeoff. He said when the airplane reached his predetermined abort point, the airplane was still on the water, and might not lift off in time to avoid the terrain ahead. The pilot said rather than abort the takeoff he elected to apply full power and continue the takeoff. He said the airplane collided with the bank, and nosed over. The pilot said there were no preaccident mechanical anomalies with the airplane. The owner of the company said the lake was about 1 mile wide where the pilot elected to takeoff. He said the airplane received substantial damage to the wings and fuselage. He also said the passengers related to him that the engine sounded fine, but they did not think the pilot taxied out very far into the lake.
Probable cause:
The pilot's decision to use only a portion of the available takeoff area, which resulted in a collision with terrain during takeoff.
Final Report: