Crash of a Beechcraft 65 Queen Air in Lawrenceville: 1 killed

Date & Time: Feb 8, 2010 at 1705 LT
Type of aircraft:
Registration:
N130SP
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lawrenceville - Lawrenceville
MSN:
LF-17
YOM:
1960
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10099
Captain / Total hours on type:
1332.00
Aircraft flight hours:
9234
Circumstances:
During the preflight inspection, some water was present in the fuel sample; it was drained until a clear sample was observed. Subsequently, the fuel tanks were topped off, and the remaining preflight inspection revealed no other anomalies. The pilot initiated a takeoff and upon reaching rotation speed, the airplane became airborne and the landing gear was retracted. The right engine immediately lost power, and the pilot feathered the engine and attempted to return to the airport. Shortly thereafter, the left engine lost power. The pilot informed the air traffic controller that the airplane had lost all power. The airplane subsequently collided with trees and terrain and a post crash fire ensued. A postaccident examination of the airframe and engine revealed no mechanical malfunctions or failures that would have precluded normal operation. Examination of fuel retrieved from the right main fuel tank, as well as fuel from the fixed base operator, revealed no anomalies. The left fuel selector valve was observed in the plugged port (no fluid flow) position, but it was most likely moved to that position during the accident sequence. The right fuel selector valve was partially aligned with the main fuel passageway and was unobstructed. The reason for the loss of engine power to both engines was not determined.
Probable cause:
The failure of both engines for undetermined reasons.
Final Report:

Crash of a GAF Nomad N.22B in Cotabato City: 9 killed

Date & Time: Jan 28, 2010 at 1138 LT
Type of aircraft:
Operator:
Registration:
18
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Cotabato City - Zamboanga
MSN:
18
YOM:
1975
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
Shortly after takeoff from Cotabato City Airport, while in initial climb, the twin engine aircraft lost height and crashed in a residential area near the airport. The aircraft was destroyed and all 8 occupants were killed as well as one person on ground. It it believed that one of the engine failed shortly after rotation.

Crash of a Boeing 737-8AS off Beyrouth: 90 killed

Date & Time: Jan 25, 2010 at 0241 LT
Type of aircraft:
Operator:
Registration:
ET-ANB
Flight Phase:
Survivors:
No
Schedule:
Beirut - Addis Ababa
MSN:
29935/1061
YOM:
2002
Flight number:
ET409
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
82
Pax fatalities:
Other fatalities:
Total fatalities:
90
Captain / Total flying hours:
10233
Captain / Total hours on type:
188.00
Copilot / Total flying hours:
673
Copilot / Total hours on type:
350
Aircraft flight hours:
26459
Aircraft flight cycles:
17823
Circumstances:
On 25 January 2010, at 00:41:30 UTC, Ethiopian Airlines flight ET 409, a Boeing 737-800 registered ET-ANB, crashed into the Mediterranean Sea about 5 NM South West of Beirut Rafic Hariri International Airport (BRHIA), Beirut, Lebanon. ET 409 was being operated under the provisions of the Ethiopian Civil Aviation Regulations (ECAR) and as a scheduled international flight between BRHIA and Addis Ababa Bole International Airport (ADD) - Ethiopia. It departed Beirut with 90 persons on board: 2 flight crew (a Captain and a First Officer), 5 cabin crew, an IFSO and 82 regular passengers. The flight departed at night on an instrument flight plan. Low clouds, isolated cumulonimbus (CB) and thunderstorms were reported in the area. The flight was initially cleared by ATC on a LATEB 1 D departure then the clearance was changed before take-off to an “immediate right turn direct Chekka”. After take-off ATC (Tower) instructed ET 409 to turn right on a heading of 315°. ET 409 acknowledged and heading 315° was selected on the Mode Control Panel (MCP). As the aircraft was on a right turn, Control suggested to ET 409 to follow heading 270° “due to weather”. However, ET 409 continued right turn beyond the selected heading of 315° and Control immediately instructed them to “turn left now heading 270°”. ET 409 acknowledged, the crew selected 270° on the MCP and initiated a left turn. ET 409 continued the left turn beyond the instructed/selected heading of 270° despite several calls from ATC to turn right heading 270° and acknowledgment from the crew. ET 409 reached a southerly track before sharply turning left until it disappeared from the radar screen and crashed into the sea 4‟ 59” after the initiation of the take-off roll (4‟17” in the air). The aircraft impacted the water surface around 5 NM South West of BRHIA and all occupants were fatally injured. Search and Rescue (S&R) operations were immediately initiated. The DFDR and CVR were retrieved from the sea bed and were read, as per the Lebanese Government decision, at the BEA facility at Le Bourget, France. The recorders data revealed that ET 409 encountered during flight two stick shakers for a period of 27” and 26”. They also recorded 11 “Bank Angle” aural warnings at different times during the flight and an over-speed clacker towards the end of the flight. The maximum recorded AOA was 32°, maximum recorded bank angle was 118° left, maximum recorded speed was 407.5 knots, maximum recorded G load was 4.76 and maximum recorded nose down pitch value 63.1°. The DFDR recording stopped at 00:41:28 with the aircraft at 1291‟. The last radar screen recording was at 00:41:28 with the aircraft at 1300‟. The last CVR recording was a loud noise just prior to 00:41:30.
Probable cause:
Probable Causes:
1- The flight crew's mismanagement of the aircraft's speed, altitude, headings and attitude through inconsistent flight control inputs resulting in a loss of control.
2- The flight crew failure to abide by CRM principles of mutual support and calling deviations hindered any timely intervention and correction.
Contributing Factors:
1- The manipulation of the flight controls by the flight crew in an ineffective manner resulted in the aircraft undesired behavior and increased the level of stress of the pilots.
2- The aircraft being out of trim for most of the flight directly increased the workload on the pilot and made his control of the aircraft more demanding.
3- The prevailing weather conditions at night most probably resulted in spatial disorientation to the flight crew and lead to loss of situational awareness.
4- The relative inexperience of the Flight Crew on type combined with their unfamiliarity with the airport contributed, most likely, to increase the Flight Crew workload and stress.
5- The consecutive flying (188 hours in 51 days) on a new type with the absolute minimum rest could have likely resulted in a chronic fatigue affecting the captain's performance.
6- The heavy meal discussed by the crew prior to take-off has affected their quality of sleep prior to that flight.
7- The aircraft 11 bank angle aural warnings, 2 stalls and final spiral dive contributed in the increase of the crew workload and stress level.
8- Symptoms similar to those of a subtle incapacitation have been identified and could have resulted from and/or explain most of the causes mentioned above. However, there is no factual evidence to confirm without any doubt such a cause.
9- The F/O reluctance to intervene did not help in confirming a case of captain's subtle incapacitation and/or to take over control of the aircraft as stipulated in the operator's SOP.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Aurora: 2 killed

Date & Time: Jan 23, 2010 at 1852 LT
Registration:
N222AQ
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Aurora – Broomfield
MSN:
61-0164-004
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
555
Circumstances:
The visibility at the time of the accident was 1/2 mile with fog and the vertical visibility was 100 feet. A witness stated that the pilot checked the weather, but that he appeared to be in a hurry and took off without performing a preflight inspection of the aircraft. After takeoff, air traffic control instructed the pilot to turn left to a heading of 270 degrees. The pilot reported to the controller that he was at 1,300 feet climbing to 3,000 feet and the controller cleared the pilot to climb to 4,000 feet; the pilot acknowledged the clearance. Witnesses on the ground noted that the airplane was loud; one witness located about 1.5 miles from the departure airport reported that the airplane flew overhead at treetop height. The airplane impacted trees and a residence about 2.3 miles north-northeast of the departure airport. The airplane's turning ground track and the challenging visibility conditions were conducive to the onset of pilot spatial disorientation. Post accident inspection failed to reveal any mechanical failure that would have resulted in the accident. The pilot purchased the airplane about three months prior to the accident; at that time he reported having 72.6 hours of instrument flight experience and 25 hours of multi-engine experience, with none in the accident airplane make and model. After purchasing the airplane, the pilot received 52 hours of flight instruction in the accident airplane in 7 days. Logbook records were not located to establish subsequent flight experience.
Probable cause:
The pilot's spatial disorientation and subsequent failure to maintain airplane control.
Final Report:

Crash of a Beechcraft 1900C-1 off Sand Point: 2 killed

Date & Time: Jan 21, 2010 at 2345 LT
Type of aircraft:
Operator:
Registration:
N112AX
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sand Point - Anchorage
MSN:
UC-45
YOM:
1988
Flight number:
AER22
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3700
Captain / Total hours on type:
3080.00
Copilot / Total flying hours:
1000
Copilot / Total hours on type:
280
Aircraft flight hours:
56184
Aircraft flight cycles:
45158
Circumstances:
The crew departed on a commercial cargo flight during dark night, visual meteorological conditions on an instrument flight rules flight plan. The departure end of the runway is adjacent to an ocean bay, and wind gusts up to 26 knots were reported. Local residents north of the airport reported stronger wind, estimated between 50 and 60 knots. A fuel truck operator, who was familiar with the crew’s normal routine, reported that, before the airplane taxied to the runway, it remained on the ramp for 6 or 8 minutes with both engines operating, which he described as very unusual. There were no reports of radio communications with the flight crew after the airplane departed. The airplane crashed about 1 mile offshore, and the fragmented wreckage sank in ocean water. Because of the fragmented nature of the wreckage and ocean current, the complete wreckage was not recovered. The cockpit area forward of the wings was extensively fragmented, thus the validity of any postaccident cockpit and instrument findings was unreliable. Likewise, structural damage to the airframe precluded determining flight control continuity. Both propellers had witness marks consistent with operating under engine power and within their normal operating range. A postaccident examination of the engines and recovered components did not disclose any evidence of a mechanical malfunction. Due to the lack of mechanical deficiencies of the engines and propellers, and the extensive airframe fragmentation consistent with a high-speed water impact, it is likely that the crew had an in-flight loss of control of an unknown origin before impact.
Probable cause:
An in-flight loss of control for an undetermined reason, which resulted in an uncontrolled descent.
Final Report:

Crash of a Piper PA-31P-425 Pressurized Navajo in Oxford: 2 killed

Date & Time: Jan 15, 2010 at 1407 LT
Type of aircraft:
Operator:
Registration:
N95RS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Oxford - Oxford
MSN:
31-7400221
YOM:
1974
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
12500
Circumstances:
The aircraft had recently been purchased in Germany and was flown to the United Kingdom on 11 December 2009 by the pilot of the accident flight. The new owner, who accompanied him for the flight from Germany, was a private pilot himself and was the passenger in the accident. The aircraft landed at Oxford on the evening of 11 December. The pilot reported to a maintenance organisation that there had been a problem with the brakes after landing and the aircraft was left parked outside a hangar. Minor maintenance was carried out on 20 December 2009 and on 9 January 2010 the aircraft was refuelled, but it was not flown again until the accident flight. On the morning of 15 January 2010 the pilot and his passenger met at Oxford Airport and prepared the aircraft for flight. The plan was to carry out an air test, although its exact nature was not established. The flight was pre‑notified to Royal Air Force (RAF) Brize Norton as an air test with a requested level of FL190. At 1344 hrs the aircraft taxied out to Holding Point C for Runway 19 at Oxford. The pilot reported ‘READY FOR DEPARTURE’ at 1400 hrs and was given a clearance for a right turn after takeoff with a climb initially to FL80. The pilot then requested the latest weather information and the tower controller provided the following information: ‘........TWO THOUSAND METRES IN MIST AND CLOUD IS BROKEN AT 200 FEET.’ At 1403 hrs the takeoff commenced and shortly after liftoff Oxford ATC suggested that the pilot should contact Brize Radar on 124.275 Megahertz (MHz). The pilot made contact with Brize Radar at 1404 hrs, two-way communication was established and the provision of a Deconfliction Service was agreed. On the radar screen the Brize Norton controller observed the ‘Mode C’ (altitude) return increase to around 1,500 ft and then noticed it decrease, seeing returns of 1,300 ft and 900 ft, before the secondary return disappeared. At 1406 hrs the Brize Norton controller contacted Oxford ATC to ask if the aircraft had landed back there and was advised that it had not done so, but that it could be heard overhead. The Brize Norton controller told Oxford ATC that they had a continuing contact, but no Secondary Surveillance Radar (SSR). The Oxford controller could still hear an aircraft in the vicinity and agreed with the Brize Norton controller to attempt to make contact. At 1407 hrs Oxford ATC made several calls to the aircraft but there was no reply. The Oxford controller told the Brize Norton controller there was no reply and was informed in return that there was no longer any radar contact either. The Brize Norton controller also attempted to call the aircraft at 1407 hrs but without success. At 1410 hrs the Oxford controller advised the Brize Norton controller that there was smoke visible to the west of the airfield and they would alert both the airport and local emergency services. In the meantime several witnesses saw the aircraft crash into a field to the west of Oxford Airport. A severe fire started soon afterwards and bystanders who arrived at the scene were not able to get close to the aircraft. The local emergency services were notified of the accident by witnesses at 1407 hrs.
Probable cause:
The post-mortem examination showed that the pilot had severe coronary heart disease and there was evidence to suggest that he may have been incapacitated, or died, prior to the collision with the ground. The passenger was a qualified private pilot but was not experienced with either the aircraft or flight in IMC.
Final Report:

Crash of a Beechcraft C90GTi King Air in Les Éplatures

Date & Time: Jan 15, 2010 at 1407 LT
Type of aircraft:
Operator:
Registration:
HB-GPL
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Les Éplatures - Dole
MSN:
LJ-1936
YOM:
2009
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
920
Captain / Total hours on type:
62.00
Aircraft flight hours:
89
Aircraft flight cycles:
68
Circumstances:
The crew was departing Les Eplatures Airport on a training flight to Dole-Tavaux, Jura. During the takeoff roll on runway 24, the pilot-in-command realized that the aircraft' speed did not increase after 88 knots then dropped to 85 knots. He decided to reject the takeoff procedure and initiated an emergency braking procedure. Unable to stop within the remaining distance, the aircraft overran and collided with concrete blocks and the ILS equipment. All four occupants were injured, two seriously. The aircraft was damaged beyond repair.
Probable cause:
The accident was caused by a collision with obstacles after the runway end due to a late take off run interruption decision, most probably due to an involuntary braking action on behalf of the pilot.
The following contributing factors were identified:
- Poor pilot experience on this aircraft model.
- Inadequate take off configuration (flaps).
- Initial multi engine training performed on a different aircraft model.
- Pilot not familiarized with short runway.
Final Report:

Crash of a Dassault Falcon 20C in Vail

Date & Time: Jan 8, 2010 at 1225 LT
Type of aircraft:
Registration:
XA-PCC
Flight Phase:
Survivors:
Yes
Schedule:
Vail - Chihuahua
MSN:
159
YOM:
1968
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11000
Captain / Total hours on type:
5000.00
Circumstances:
During taxi the airplane was observed to run over a tire chock with the left main gear tire. During a turn out of the ramp, the left main gear was observed to run over the nose gear chock that had been removed from the nose gear by the pilot during pre-flight. During the departure roll, the left main gear tire failed and the pilot elected to abort the takeoff attempt. The airplane did not stop on the remaining runway surface and departed the runway overrun area, coming to rest in snow-covered terrain. An examination of the airplane's systems revealed no anomalies.
Probable cause:
The flight crew’s improper preflight inspection and failure to remove the main landing gear wheel chock, resulting in damage and subsequent failure of the main landing gear tire during the takeoff roll.
Final Report:

Crash of a Fletcher FU-24-950 in Ketapang: 2 killed

Date & Time: Dec 31, 2009 at 0826 LT
Type of aircraft:
Operator:
Registration:
PK-PNX
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Ujung Tanjung - Jambi - Pangkal Pinang - Ketapang - Tangar
MSN:
187
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2892
Captain / Total hours on type:
641.00
Circumstances:
The aircraft was completing a ferry flight from Ujung Tanjung/Pekanbaru home base to Tangar airstrip, Center of Kalimantan, with reference flight approval number D09-038960 and Security Clearance number AU05-033328, person on board was one pilot and one engineer. On 29 December 2009, the aircraft departed from Ujung Tanjung, transit at Jambi and stop overnight at Pangkal Pinang Airport, Bangka with total flight time was 3 hours. On the next day 30 December 2009, the aircraft continuing flight from Pangkal Pinang to Rahadi Oesman Airport, Ketapang, West Kalimantan and overnight at Ketapang with total flight time is 1:40 hours. On the next day 31 December 2009, the aircraft plan to continued flight to Tangar Airstrip. The aircraft was airworthy prior departure and dispatched from Ketapang with the following sequence:
a. The pilot requested for start the engine at 01:17 UTC4 (08:17 Local Time);
b. At 01:24 the pilot requested for taxi, and the ATC gave clearance via taxiway “A”. The pilot requested intersection runway 17 and approved by ATC
c. The ATC requested for reported when ready for departure, and the pilot reported ready for departure, then the ATC gave the departure clearance.
d. At 01:25, the aircraft was departed and crashed at 01:26 striking the roof of the hospital and broken down into pieces at the parking area in which have had approximate 1.5 Kilometer to the left side from the flight path centreline. The aircraft was substantially damage and the crew on board consist of one pilot in command and one aircraft maintenance engineer; both of them were fatally injured.
Probable cause:
The investigation concluded that the aircraft engine was not in power during impact with the hospital roof. There was a corroded fuel pump, that indicated of contaminated fuel.
Findings:
• The aircraft was airworthy prior departure.
• The pilot was fit for flight.
• The booster pump was found of an evident of surface corrosion on the spring, plate and van pump indicated that contaminated fuel.
• Referred to the Fletcher Flight Manual and Pilot Operating Handbook chapter 3.10. Fuel System Failure, the booster pump must have been operated prior to flight.
• The propeller blades were on fine pitch and no sign of rotating impact. The engine was not in powered when hit the ground.
• No evidence damage related to the engine prior to the occurrence.
Final Report:

Crash of a Technoavia SM-92T Turbo Finist in Kalachevo: 8 killed

Date & Time: Dec 13, 2009 at 1100 LT
Operator:
Registration:
RA-0257G
Flight Phase:
Survivors:
No
Schedule:
Kalachevo - Kalachevo
MSN:
02-005
YOM:
1997
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
4658
Captain / Total hours on type:
98.00
Aircraft flight hours:
536
Aircraft flight cycles:
1378
Circumstances:
The single engine was completing local skydiving sorties at Kalachevo Airport, about 24 kkm south of Chelyabinsk. Shortly after takeoff, while climbing to a height of about 100 metres, the aircraft stalled and crashed in a snow covered field located 1,5 km north of the airfield. The aircraft was totally destroyed upon impact and all 8 occupants were killed.
Probable cause:
The accident was the consequence of a stall during initial climb due to the combination of the following factors:
- Violation of the climb procedures regarding the speed,
- Flight performances were not met as the aircraft was operated for skydiving purposes but not intended for such type of flight,
- The total weight of the aircraft was above the MTOW,
- The aircraft was not equipped with a system that could inform the pilot of the imminence of a stall,
- The aircraft stalled at a relative low altitude that could not allow the pilot to expect recovery.
Final Report: