Crash of a Let L-410UVP-E3 in Menzelinsk: 16 killed

Date & Time: Oct 10, 2021 at 0911 LT
Type of aircraft:
Operator:
Registration:
RF-94591
Flight Phase:
Survivors:
Yes
Schedule:
Menzelinsk - Menzelinsk
MSN:
87 18 26
YOM:
1987
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
16
Circumstances:
The twin engine aircraft departed Menzelinsk for a local skydiving mission, carrying 20 skydivers and two pilots. During initial climb, the crew reported technical problems with the left engine and elected to return for an emergency landing. The aircraft lost height and eventually struck a concrete wall before coming to rest on a wood piles. Six passengers were rescued while 14 other occupants were killed.

Crash of a Pilatus PC-12/47E in Milan: 8 killed

Date & Time: Oct 3, 2021 at 1307 LT
Type of aircraft:
Registration:
YR-PDV
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Milan - Olbia
MSN:
1532
YOM:
2015
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
1025
Captain / Total hours on type:
400.00
Aircraft flight hours:
504
Circumstances:
The single engine aircraft departed Milan-Linate Airport runway 36 at 1304LT, bound to Olbia with 8 people on board, seven passengers and one pilot. Ten seconds after takeoff, the pilot engaged the autopilot and the LNAV mode but both were disengaged about 1 minute and 40 seconds later. Instead of following the Standard Instrument Departure heading 130 after takeoff, the aircraft continued to turn to the west. Milano Area Control Center instructed the pilot to turn left heading 120 but instead, the aircraft turned right again then the altitude was stabilized. At an altitude of 5,300 feet, the aircraft entered an uncontrolled descent and crashed in a vertical attitude on an industrial building under construction and located about 1,8 km southwest of the runway 36 threshold. The aircraft disintegrated on impact and all 8 occupants were killed, among them the Romania businessman Dan Petrescu. The building suffered severe damages as well as few vehicles in the street. There were no injuries on the ground.
Probable cause:
The limitations imposed by the considerable level of destruction of the aircraft and the absence of data recorded by the LDR referable to the accident, did not allow to identify, with incontrovertible certainty, the cause of the event.
For the above reasons, it has not been possible to categorically exclude the occurrence of a failure that may have compromised the controlability of the aircraft; however, such hypothesis, on the basis of the evidence acquired, appears to be the least probable.
The cause of the event is reasonably attributable to the pilot's loss of control of the aircraft, which occurred during the execution of a SID in daytime IMC conditions, with the aircraft manually piloted.
It can be assumed that at the origin of the loss of control, there may have been a saturation of the pilot's cognitive processes, with consequent channeling of attention to the navigation system, which would have likely diverted the pilot's attention from the basic and manual conduct of the aircraft.
It cannot be excluded that a non-catastrophic technical issue may have contributed to this task saturation.
It is believed that a recurring lack of training may have contributed to the failure to control the aircraft, as well as an inadequate handling of a possible non-catastrophic technical failure
Due to the lack of flight data it was not possible to determine if the disengagement was voluntary by the pilot or caused by a failure.
Final Report:

Crash of a Beechcraft B250GT Super King Air in Piracicaba: 7 killed

Date & Time: Sep 14, 2021 at 0840 LT
Registration:
PS-CSM
Flight Phase:
Survivors:
No
MSN:
BY-364
YOM:
2019
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
Shortly after takeoff from Piracicaba Airport Runway 35, while climbing, the twin engine aircraft entered a right turn, descended to the ground and crashed in a eucalyptus forest located about 1,5 km north of the airport. The aircraft exploded on impact and was totally destroyed. All seven occupants were killed among them the Brazilian businessman Celso Silveira Mello Filho aged 73 who was travelling with his wife and three kids.
Crew:
Celso Elias Carloni, pilot,
Giovani Dedini Gulo, copilot.
Passengers:
Celso Silveira Mello Filho,
Maria Luiza Meneghel,
Celso Meneghel Silveira Mello,
Camila Meneghel Silveira Mello Zanforlin,
Fernando Meneghel Silveira Mello.

Crash of a Cessna 560XLS+ Citation Excel in Plainville: 4 killed

Date & Time: Sep 2, 2021 at 0951 LT
Registration:
N560AR
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Plainville – Manteo
MSN:
560-6026
YOM:
2009
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
17400
Copilot / Total flying hours:
5594
Aircraft flight hours:
2575
Circumstances:
The flight crew was conducting a personal flight with two passengers onboard. Before departure, the cockpit voice recorder (CVR) captured the pilots verbalizing items from the before takeoff checklist, but there was no challenge response for the taxi, before takeoff, or takeoff checklists. Further, no crew briefing was performed and neither pilot mentioned releasing the parking brake. The left seat pilot, who was the pilot flying (PF) and pilot-in-command (PIC), initiated takeoff from the slightly upsloping 3,665-ft-long asphalt runway. According to takeoff performance data that day and takeoff performance models, the airplane had adequate performance capability to take off from that runway. Flight data recorder (FDR) data indicated each thrust lever angle was set and remained at 65° while the engines were set and remained at 91% N1. During the takeoff roll, the CVR recorded the copilot, who was the pilot monitoring (PM) and second-in-command (SIC), making callouts for “airspeed’s alive,” “eighty knots cross check,” “v one,” and “rotate.” A comparison of FDR data from the accident flight with the previous two takeoffs showed that the airplane did not become airborne at the usual location along the runway, and the longitudinal acceleration was about 33% less. At the time of the rotate callout, the airspeed was about 104 knots calibrated airspeed, and the elevator was about +9° airplane nose up (ANU). Three seconds after the rotate callout, the CVR recorded the sound of physical straining, suggesting the pilot was likely attempting to rotate the airplane by pulling the control yoke. The CVR also captured statements from both the copilot and pilot expressing surprise that the airplane was not rotating as they expected. CVR and FDR data indicated that between the time of the rotate callout and the airplane reaching the end of the airport terrain, the airspeed increased to about 120 knots, the weight-on-wheels (WOW) remained in an on-ground state, and the elevator position increased to a maximum value of about +16° ANU. However, the airplane’s pitch attitude minimally changed. After the airplane cleared the end of the airport terrain where the ground elevation decreased 20 to 25 ft, FDR data indicate that the WOW transitioned to air mode with near-full ANU elevator control input, and the airplane pitched up nearly 22° in less than 2 seconds. FDR data depicted forward elevator control input in response to the rapid pitch-up, and the CVR recorded a stall warning then stick shaker activation. An off airport witness reported seeing the front portion of the right engine impact a nearby pole past the departure end of the runway. The airplane then rolled right to an inverted attitude, impacted the ground, then impacted an off airport occupied building. The airplane was destroyed by impact forces and a post crash fire and all four occupants were killed. On ground, four other people were injured, one seriously.
Probable cause:
The pilot-in-command’s failure to release the parking brake before attempting to initiate the takeoff, which produced an unexpected retarding force and airplane-nose-down pitching moment that prevented the airplane from becoming airborne within the takeoff distance available and not before the end of the airport terrain. Contributing to the accident were the airplane’s lack of a warning that the parking brake was not fully released and the Federal Aviation Administration’s process for certification of a derivative aircraft that did not identify the need for such an indication.
Final Report:

Crash of a Cirrus Vision SF50 in Lansing

Date & Time: Aug 24, 2021 at 1858 LT
Type of aircraft:
Operator:
Registration:
N1GG
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lansing – Melbourne
MSN:
0202
YOM:
2020
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2000
Captain / Total hours on type:
600.00
Aircraft flight hours:
293
Circumstances:
The airport tower controller initially assigned the pilot to take off from runway 28L, which presented a 7-knot headwind. Shortly afterward, the controller informed the pilot of “a storm rolling in . . . from west to east,” and offered runway 10R. The pilot accepted the opposite direction runway for departure and added, “we’re ready to go when we get to the end . . . before the storm comes.” About 4 seconds after the airplane began accelerating during takeoff, the controller advised the pilot of a wind shear alert of plus 20 knots (kts) at a 1-mile final for runway 28L, and the pilot acknowledged the alert. In a postaccident statement, the pilot stated that departing with a 7-kt tailwind was within the operating and performance limitations of the airplane. The pilot reported that after a takeoff ground roll of about 4,000 ft “the left rudder didn’t seem to be functioning properly” and he decided to reject the takeoff. However, when he applied full braking, the airplane tended to turn to the right. He used minimal braking consistent with maintaining directional control of the airplane. The airplane ultimately overran the runway, impacted the airport perimeter fence, and encountered a ditch before it came to a rest. A postimpact fire ensued and consumed a majority of the fuselage. All four occupants evacuated safely.
Probable cause:
The pilot’s decision to depart with a tailwind as a thunderstorm approached, which resulted in a loss of airplane performance due to an encounter with a significant tailwind gust and a subsequent runway excursion.
Final Report:

Crash of a Pilatus PC-6/C-H2 Turbo Porter in Maturín

Date & Time: Aug 21, 2021 at 1638 LT
Operator:
Registration:
YV1912
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Maturín – Higuerote
MSN:
2048
YOM:
1971
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5047
Aircraft flight hours:
5721
Circumstances:
Shortly after takeoff from Maturín-General José Tadeo Monagas Airport, while in initial climb, the engine failed. The pilot attempted an emergency when the airplane lost height, impacted trees and a concrete wall before coming to rest against a tree in a garden. The pilot was seriously injured.
Probable cause:
It was determined that the engine failed because the fuel was contaminated with a high amount of water. The malfunction of the engine regulator accessories was considered as a contributing factor.
Final Report:

Crash of a Gulfstream GIV in Fort Lauderdale

Date & Time: Aug 21, 2021 at 1340 LT
Type of aircraft:
Operator:
Registration:
N277GM
Flight Phase:
Survivors:
Yes
Schedule:
Fort Lauderdale – Las Vegas
MSN:
1124
YOM:
1989
Crew on board:
4
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
20053
Captain / Total hours on type:
3120.00
Copilot / Total flying hours:
1617
Copilot / Total hours on type:
204
Aircraft flight hours:
12990
Circumstances:
The flight crew, which consisted of the pilot- and second-in-command (PIC and SIC), and a non-type-rated observer pilot, reported that during takeoff near 100 knots a violent shimmy developed at the nose landing gear (NLG). The PIC aborted the takeoff and during the abort procedure, the NLG separated. The airplane veered off the runway, and the right wing and right main landing gear struck approach lights, which resulted in substantial damage to the fuselage and right wing. The passengers and flight crew evacuated the airplane without incident through the main cabin door. Postaccident interviews revealed that following towing operations prior to the flight crew’s arrival, ground personnel were unable to get the plunger button and locking balls of the NLG’s removable pip pin to release normally. Following a brief troubleshooting effort by the ground crew, the pip pin’s plunger button remained stuck fully inward, and the locking balls remained retracted. The ground crew re-installed the pip pin through the steering collar with the upper torque link arm connected. However, with the locking balls in the retracted position, the pin was not secured in position as it should have been. Further, the ground personnel could not install the safety pin through the pip pin because the pin’s design prevented the safety pin from being inserted if the locking balls and plunger were not released. The ground personnel left the safety pin hanging from its lanyard on the right side of the NLG. The ground personnel subsequently informed their ramp supervisor of the anomaly. The supervisor reported that he informed the first arriving crewmember at the airplane (the observer pilot) that the nose pin needed to be checked. However, all three pilots reported that no ground crewmember told them about any issues with the NLG or pins. Examination of the runway environment revealed that the first item of debris located on the runway was the pip pin. Shortly after this location, tire swivel marks were located near the runway centerline, which were followed by large scrape and tire marks, leading to the separated NLG. The safety pin remained attached to the NLG via its lanyard and was undamaged. Postaccident examination and testing of the NLG and its pins revealed no evidence of preimpact mechanical malfunctions or failures. The sticking of the pip pin plunger button that the ground crew reported experiencing could not be duplicated during postaccident testing. When installed on the NLG, the locking ball mechanism worked as intended, and the pip pin could not be removed by hand. Although the airplane’s preflight checklist called for a visual check of the NLG’s torque link to ensure that it was connected to the steering collar by the pip pin and that the safety pin was installed, it is likely that none of the pilots noticed that the pip pin did not have its safety pin installed during preflight. Subsequently, during the takeoff roll, without the locking balls extended, the pip pin likely moved outward and fell from its position holding the upper torque link arm. This allowed the upper torque link arm to move freely, which resulted in the violent shimmy and NLG separation. The location of the debris on the runway, tire marks, and postaccident examination and testing support this likely chain of events. Contributing to the PIC and SIC’s omission during preflight was the ground crew’s failure to directly inform the PIC or SIC that there was a problem with the NLG pip pin. The ground crew also failed to discard the malfunctioning pip pin per the airplane’s ground handling procedures and instead re-installed the pip pin. Although the observer pilot was reportedly informed of an issue with a nose gear pin, he was not qualified to act as a required flight crewmember for the airplane and was on his cell phone when he was reportedly informed of the issue by the ramp supervisor. These factors likely contributed to the miscommunication and the PIC’s and SIC’s subsequent lack of awareness of the NLG issue.
Probable cause:
The pilot-in-command’s (PIC) and second-in-command’s (SIC) failure during preflight inspection to ensure that the nose landing gear’s pip pin was properly installed, which resulted in separation of the pip pin during takeoff. Contributing to the accident was the ground crew supervisor’s failure to inform the PIC or SIC of the anomaly concerning the pip pin following a towing operation.
Final Report:

Crash of a Rockwell Grand Commander 690B in Thunder Bay: 1 killed

Date & Time: Aug 16, 2021 at 2109 LT
Operator:
Registration:
C-GYLD
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Thunder Bay – Dryden
MSN:
690-11426
YOM:
1977
Flight number:
BD160
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2662
Captain / Total hours on type:
230.00
Aircraft flight hours:
7620
Circumstances:
The airplane, operated by MAG Aerospace Canada Corp. as flight BD160, was conducting a visual flight rules flight from Thunder Bay Airport, Ontario, to Dryden Regional Airport, Ontario, with only the pilot on board. At 2109 Eastern Daylight Time, the aircraft began a takeoff on Runway 12. Shortly after rotation, the aircraft entered a left bank, continued to roll, and then struck the surface of Runway 07 in an inverted attitude. The pilot was fatally injured. The aircraft was destroyed by the impact and postimpact fire. The emergency locator transmitter activated on impact.
Probable cause:
Findings as to causes and contributing factors:
1. After takeoff from Runway 12 at Thunder Bay Airport, Ontario, as the pilot conducted a rapid, low-level, climbing steep turn, the aircraft entered an accelerated stall that resulted in a loss of control and subsequent collision with the surface of Runway 07 in an inverted attitude.
2. The decision to conduct the rapid, low-level, climbing steep turn was likely influenced by an altered perception of risk from previous similar takeoffs that did not result in any adverse consequences.

Findings as to risk:
1. If air traffic controllers engage in communications that may be perceived by pilots to encourage unusual flight manoeuvres, pilots may perceive this encouragement as a confirmation that the manoeuvres are acceptable to perform, increasing the risk of an accident.
2. If NAV CANADA’s reporting procedures do not contain specific criteria for situations where air traffic services personnel perceive aircraft to be conducting unsafe flight manoeuvres, there is a risk that these manoeuvres will continue and result in an accident.

Other findings
1. Most of the wires that comprised the elevator trim cable failed before the impact as a result of excessive wear; however, this did not contribute to the occurrence because the trim tab remained in the normal take-off position.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Monterey: 1 killed

Date & Time: Jul 13, 2021 at 1042 LT
Operator:
Registration:
N678SW
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Monterey – Salinas
MSN:
421C-1023
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
9337
Aircraft flight hours:
5818
Circumstances:
Before taking off, the pilot canceled an instrument flight rules (IFR) flight plan that she had filed and requested a visual flight rules (VFR) on-top clearance, which the controller issued via the Monterey Five departure procedure. The departure procedure included a left turn after takeoff. The pilot took off and climbed to about 818 ft then entered a right turn. The air traffic controller noticed that the airplane was in a right-hand turn rather than a left-hand turn and issued a heading correction to continue a right-hand turn to 030o , which the pilot acknowledged. The airplane continued the climbing turn for another 925 ft then entered a descent. The controller issued two low altitude alerts with no response from the pilot. No further radio communication with the pilot was received. The airplane continued the descent until it contacted trees, terrain, and a residence about 1 mile from the departure airport. Review of weather information indicated prevailing instrument meteorological conditions (IMC) in the area due to a low ceiling, with ceilings near 800 ft above ground level and tops near 2,000 ft msl. Examination of the airframe and engines did not reveal any anomalies that would have precluded normal operation. The airplane’s climbing right turn occurred shortly after the airplane entered IMC while the pilot was acknowledging a frequency change, contacting the next controller, and acknowledging the heading instruction. Track data show that as the right-hand turn continued, the airplane began descending, which was not consistent with its clearance. Review of the pilot’s logbook showed that the pilot had not met the instrument currency requirements and was likely not proficient at controlling the airplane on instruments. The pilot’s lack of recent experience operating in IMC combined with a momentary diversion of attention to manage the radio may have contributed to the development of spatial disorientation, resulting in a loss of airplane control.
Probable cause:
The pilot’s failure to maintain airplane control due to spatial disorientation during an instrument departure procedure in instrument meteorological conditions which resulted in a collision with terrain. Contributing to the accident was the pilot’s lack of recent instrument flying experience.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Longmont

Date & Time: Jul 10, 2021 at 0845 LT
Operator:
Registration:
N66NC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Longmont – Aspen
MSN:
421C-0519
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2801
Captain / Total hours on type:
169.00
Aircraft flight hours:
5476
Circumstances:
The pilot reported that he performed the “before starting engine” and “starting engine” checklists and everything was normal before taking off in the twin-engine airplane. He performed an engine runup and then started his takeoff roll. The pilot reported that about halfway down the runway the airplane was not accelerating as fast as it should. He attempted to rotate the airplane; however, “the airplane mushed off the runway.” The airplane settled back onto the runway, then exited the departure end of the runway, where it sustained substantial damage to the wings and fuselage. The airplane engine monitor data indicated the airplane’s engines were operating consistent with each other at takeoff power at the time of the accident. Density altitude at the time of the accident was 7,170 ft and according to performance charts, there was adequate runway for takeoff. The reason for the loss of performance could not be determined.
Probable cause:
The loss of performance for reasons that could not be determined.
Final Report: