Crash of a Cessna 510 Citation Mustang in El Monte

Date & Time: Aug 31, 2019 at 1105 LT
Operator:
Registration:
N551WH
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
El Monte - Thermal
MSN:
510-0055
YOM:
2008
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2217
Captain / Total hours on type:
477.00
Circumstances:
The pilot reported that, while holding short of the runway, he set the parking brake while waiting for his takeoff clearance. Upon receiving takeoff clearance, he reached down to the parking brake handle and, "quickly pushed the parking brakes back in"; however, he did not visually verify that he disengaged the parking brake. During the takeoff roll, he noticed that the airplane was not accelerating beyond about 70 knots and decided to abort the takeoff. The airplane subsequently veered to the left, exited the departure end of the runway, and impacted an airport perimeter fence. The pilot reported that he must have not fully disengaged the parking brake before takeoff and that there were no mechanical issues with the airplane that would have precluded normal operation. Postaccident examination of the airplane revealed that the parking brake handle was partially extended, which likely resulted in the airplane’s decreased acceleration during the takeoff roll.
Probable cause:
The pilot's failure to disengage the parking brake before takeoff, which resulted in decreased acceleration and a subsequent runway overrun following an aborted takeoff.
Final Report:

Crash of a Cessna 560XL Citation Excel in Oroville

Date & Time: Aug 21, 2019 at 1132 LT
Operator:
Registration:
N91GY
Flight Phase:
Survivors:
Yes
Schedule:
Oroville - Portland
MSN:
560-5314
YOM:
2003
Flight number:
DPJ91
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6482
Captain / Total hours on type:
192.00
Copilot / Total flying hours:
4748
Copilot / Total hours on type:
858
Aircraft flight hours:
9876
Circumstances:
The crew was conducting an on-demand charter flight with eight passengers onboard. As the flight crew taxied the airplane to the departure runway, the copilot called air traffic control using his mobile phone to obtain the departure clearance and release. According to the pilot, while continuing to taxi, he stopped the airplane short of the runway where he performed a rudder bias check (the last item in the taxi checklist) and applied the parking brake without verbalizing the parking brake or rudder bias actions because the copilot was on the phone. After the pilot lined up on the runway and shortly before takeoff, the flight crew discussed and corrected a NO TAKEOFF annunciation for an unsafe trim setting. After the copilot confirmed takeoff power was set, he stated that the airplane was barely moving then said that something was not right, to which the pilot replied the airplane was rolling and to call the airspeeds. About 16 seconds later, the pilot indicated that the airplane was using more runway than he expected then made callouts for takeoff-decision speed and rotation speed. The pilot stated that he pulled the yoke back twice, but the airplane did not lift off. Shortly after, the pilot applied full thrust reversers and maximum braking, then the airplane exited the departure end of the runway, impacted a ditch, and came to rest 1,990 ft beyond the departure end of the runway. The airplane was destroyed by a postcrash fire, and the crew and passengers were not injured.
Probable cause:
The pilot’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. Also causal was the flight crew’s delayed decision to abort the takeoff, which resulted in a runway excursion. Contributing to the accident was the lack of a NO TAKEOFF annunciation warning that the parking brake was engaged, and lack of a checklist item to ensure the parking brake was fully released immediately before takeoff.
Final Report:

Crash of a Cessna T303 Crusader in Lagrangeville: 2 killed

Date & Time: Aug 17, 2019 at 1613 LT
Type of aircraft:
Registration:
N303TL
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Sky Acres - Farmingdale
MSN:
303-00286
YOM:
1984
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1586
Captain / Total hours on type:
358.00
Aircraft flight hours:
2932
Circumstances:
After flying one flight leg earlier in the day, the pilot flew to an intermediate stop on the way to his home base to purchase fuel. A surveillance video recording from the fueling airport showed the airplane land and taxi to the self-serve fuel pump where the engines were shut down for about 10 minutes while the airplane was fueled. The pilot then had difficulty starting both engines over several minutes. After the engines were running, the airplane taxied to the runway and did not appear to stop for an engine run-up. The pilot performed a rolling takeoff, and the airplane lifted off after a roll of about 2,100 ft, slightly more than half the available runway length. A passenger reported that after liftoff, at an altitude of about 50 to 100 ft above ground level (agl), both engines lost partial power and began “stuttering,” which continued for the remainder of the flight. He further reported that the engines did not stop, but they were “not producing full RPM.” The airplane drifted left of centerline, which a witness described as a left yawing motion. The pilot corrected the drift and flew the runway heading over the grass on the left side of the runway; however, the airplane would not climb. After crossing the end of the runway, the pilot pitched the airplane up to avoid obstacles. Automatic dependent surveillance-broadcast data indicated that the airplane climbed from about 20 to 120 ft agl in a gradual left turn. During this time the groundspeed decreased from about 80 knots to about 69 knots. The altitude then decreased to about 50 ft agl, the groundspeed decreased to about 66 knots, and the left turn decreased in radius until the recorded data ended about 100 ft west of the accident site. The airplane descended and
impacted a house. Witness descriptions of the airplane yawing to the left while over the runway and again during its final left turn suggest that the loss of engine power may not have been symmetric (that is, one engine may have suffered more of a loss than the other).
Probable cause:
A partial loss of engine power in both engines during initial climb for reasons that could not be determined based on the available information.
Final Report:

Crash of a Cessna 680A Citation Latitude in Elizabethton

Date & Time: Aug 15, 2019 at 1537 LT
Operator:
Registration:
N8JR
Flight Type:
Survivors:
Yes
Schedule:
Statesville - Elizabethton
MSN:
680A-0010
YOM:
2015
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5800
Captain / Total hours on type:
765.00
Copilot / Total flying hours:
11000
Copilot / Total hours on type:
1165
Aircraft flight hours:
1165
Circumstances:
The pilots were conducting a visual flight rules cross-country flight with three passengers onboard. The preflight, departure, and cruise portions of the flight were uneventful. During the initial approach to the airport, the flight crew discussed having some difficulty visually acquiring the airport. They also discussed traffic in the area and were maneuvering around clouds, which may have increased the pilots' workload. As the approach continued, the airplane crossed a ridgeline at 710 ft above ground level (agl), which triggered a terrain awareness and warning system (TAWS) alert. Further, the flight crew made several comments about the airplane flying too fast and allowed the airspeed to increase well above the reference speed (Vref) for the approach. At 1535:57 (about 1 minute 52 seconds before landing), the pilot pulled back the throttles to idle, where they stayed for the remainder of the approach. In an attempt to slow the airplane for landing, the pilot partially extended the speedbrakes when the airplane was below 500 ft agl, which is prohibited in the airplane flight manual (AFM). Five seconds before touchdown, the airplane's descent rate was 1,500 ft per minute (fpm), which exceeded the maximum allowed for landing per the AFM of 600 fpm. When the airplane first touched down, it was traveling about 18 knots above Vref. The pilot did not extend the speedbrakes upon touchdown, which the landing checklist required, but instead attempted to deploy the thrust reversers immediately after touchdown, which was a later item on the landing checklist. However, the thrust reversers did not unlock because the airplane bounced and was airborne again before the command could be executed, which was consistent with system design and logic: the thrust reversers will not unlock until all three landing gear are on the ground. The airplane touched down four times total; on the third touchdown (after the second bounce), when all three landing gear contacted the runway, the thrust reversers unlocked as previously commanded during the first touchdown. Although the pilot subsequently advanced the throttles to idle, which would normally stow the thrust reversers, the airplane had bounced a third time and had already become airborne again before the thrust reversers could stow. When the airplane became airborne, the system logic cut hydraulic power to the thrust reverser actuators; thus the reversers would not stow. The thrust reversers were subsequently pulled open due to the aerodynamic forces. The pilot attempted to go around by advancing the throttles when the airplane was airborne. However, the electronic engine controls prevented the increase in engine power because the thrust reversers were not stowed. When the airplane touched down the fourth and final time, the pilot attempted to land straight ahead on the runway; the airplane touched down hard and the right main landing gear then collapsed under the wing. The airplane departed the paved surface and came to rest about 600 ft beyond the runway threshold. The passengers and crew eventually evacuated the airplane through the main cabin door, and the airplane was destroyed in a postaccident fire. A postaccident examination of the airplane systems, structure, powerplants, and landing gear revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation. The airplane's approach was unstabilized: its airspeed during the approach and landing well exceeded Vref and its descent rate exceeded the maximum allowed for landing just seconds before touchdown. Both the pilot and copilot commented on the airplane's high speed several times during the approach. During short final, the pilot asked the copilot if he should go around, and the copilot responded, "no." Although the copilot was the director of operations for the flight department and the direct supervisor of the pilot, the pilot stated that the copilot's position did not influence his decisions as pilot-in-command nor did it diminish his command authority. Neither the pilot nor copilot called for a go-around before landing despite awareness that the approach was unstabilized. As the airplane touched down, the pilot failed to follow the AFM guidance and used the thrust reversers before the speedbrakes. According to the airplane manufacturer's calculations, the airplane could have stopped within the length of runway available if the airplane had not bounced and the speedbrakes and wheel brakes were used at the point of the first touchdown. After the third touchdown, when the airplane became airborne again, the pilot attempted a go-around; the AFM prohibits touch-and-go landings after the thrust reversers are deployed. It is critical for pilots to know the point at which they should not attempt a go-around; a committed-to-stop (CTS) point is the point at which a go-around or rejected landing procedure will not be initiated and the only option will be bringing the aircraft to a stop. Establishing a CTS point eliminates the ambiguity for pilots making decisions during time-critical events. The FAA issued Information for Operators 17009, "Committed-toStop Point on Landings," to inform operators and pilots about the importance of establishing a CTS point; however, the director of operations was not aware of the concept of a CTS point during landing.
Probable cause:
The pilot's continuation of an unstabilized approach despite recognizing associated cues and the flight crew's decision not to initiate a go-around before touchdown, which resulted in a bounced landing, a loss of airplane control, a landing gear collapse, and a runway excursion. Contributing to the accident was the pilot's failure to deploy the speedbrakes during the initial touchdown, which may have prevented the runway excursion, and the pilot's attempt to go around after deployment of the thrust reversers.
Final Report:

Crash of a Cessna 208B Grand Caravan near Mayo: 2 killed

Date & Time: Aug 6, 2019 at 1113 LT
Type of aircraft:
Operator:
Registration:
C-FSKF
Flight Phase:
Survivors:
No
Site:
Schedule:
Rackla - Mayo
MSN:
208B-0673
YOM:
1998
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1694
Captain / Total hours on type:
212.00
Aircraft flight hours:
19060
Circumstances:
At 1101 Pacific Daylight Time on 06 August 2019, the Alkan Air Ltd. Cessna 208B Grand Caravan aircraft (registration C‐FSKF, serial number 208B0673) departed Rau Strip, Yukon, on a visual flight rules company flight itinerary to Mayo Airport, Yukon. The aircraft had 1 pilot, 1 passenger, and cargo on board. At 1113, the aircraft entered instrument meteorological conditions and struck rising terrain in a box canyon shortly after. The crash occurred approximately 25 nautical miles east‐northeast of Mayo Airport, at an elevation of 5500 feet above sea level. The Canadian Mission Control Centre did not receive a signal from the aircraft’s 406 MHz emergency locator transmitter. Eyewitnesses from a nearby exploration camp arrived at the site after approximately 1 hour. Royal Canadian Mounted Police and emergency medical services arrived on site approximately 90 minutes after the accident. The pilot and passenger received fatal injuries. The aircraft was destroyed; there was a brief post‐impact fire.
Probable cause:
Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. The pilot’s decision making was influenced by several biases and, as a result, the flight departed and subsequently continued into poor weather conditions in mountainous terrain.
2. The high speed at low altitude and low forward visibility reduced the opportunities for the pilot to take alternative action to avoid terrain.
3. Within the box canyon, the canyon floor elevation increased abruptly within less than 1 NM and the low visibility prevented the pilot from detecting this and taking sufficient actions to prevent collision with terrain.
4. When the pilot turned into the box canyon, the terrain awareness and warning system aural alerts were ineffective in warning the pilot about the rising terrain either because he had already heard multiple similar alerts in the preceding minutes, or because he had silenced the alerts.

Findings as to risk:
These are conditions, unsafe acts, or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
1. If administrative safety defences are not used as intended, it increases the risk that the hazards associated with the flight will not be identified and mitigated.

Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
1. The pilot held a valid instrument rating and the aircraft was equipped to fly in instrument meteorological conditions. However, there were no scenarios in the pilot’s flying history on the Cessna 208B Grand Caravan or in his training where a transition from visual flight rules to a flight under instrument flight rules in an emergency was performed.
Final Report:

Crash of a Douglas C-118A Liftmaster in Candle

Date & Time: Aug 1, 2019 at 1400 LT
Type of aircraft:
Operator:
Registration:
N451CE
Flight Type:
Survivors:
Yes
Schedule:
Fairbanks – Candle
MSN:
43712/358
YOM:
1953
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9910
Captain / Total hours on type:
147.00
Copilot / Total flying hours:
8316
Copilot / Total hours on type:
69
Aircraft flight hours:
42037
Circumstances:
The flight crew was landing the transport-category airplane at a remote, gravel-covered runway. According to the captain, the terrain on the approach to the runway sloped down toward the approach end, which positioned the airplane close to terrain during the final stages of the approach. A video recorded by a bystander showed that while the airplane was on short final approach, it flew low on the glidepath and dragged its landing gear through vegetation near the approach end of the runway. The video showed that, just before the main landing gear wheels reached the runway threshold, the right main landing wheel impacted a dirt and rock berm. The captain said that to keep the airplane from veering to the right, he placed the No. 1 and No. 2 engine propellers in reverse pitch. The flight engineer applied asymmetric reverse thrust to help correct for the right turning tendency, and the airplane tracked straight for about 2,000 ft. The video then showed that the right main landing gear assembly separated, and the airplane continued straight down the runway before veering to the right, exiting the runway, and spinning about 180°, resulting in substantial damage to the fuselage. On-site examination of the runway revealed several 4-ft piles of rocks and dirt at the runway threshold, which is likely what the right main landing wheel impacted. Given that the airplane landing gear struck vegetation and rocks on the approach to the runway, it is likely that they were below the proper glidepath for the approach. The crew stated there were no preaccident mechanical malfunctions or anomalies that would have precluded normal operation.
Probable cause:
The pilot's failure to maintain an adequate glidepath during the approach, which resulted in the airplane impacting rocks and dirt at the runway threshold, a separation of the right main landing gear, and a loss of directional control.
Final Report:

Crash of a De Havilland DHC-2 Beaver off Sechelt

Date & Time: Jul 30, 2019 at 1248 LT
Type of aircraft:
Registration:
C-GPZP
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Vancouver - Pender Harbour
MSN:
722
YOM:
1954
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
En route from Vancouver to Pender Harbour, the pilot encountered engine problems and elected to ditch the aircraft about three miles off Sechelt. All three occupants were able to evacuate the cabin before the aircraft sank and was lost. All three occupants were rescued.

Crash of a Cessna 208 Caravan 675 on Addenbroke Island: 4 killed

Date & Time: Jul 26, 2019 at 1104 LT
Type of aircraft:
Operator:
Registration:
C-GURL
Flight Phase:
Survivors:
Yes
Site:
MSN:
208-0501
YOM:
2008
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
8500
Captain / Total hours on type:
504.00
Aircraft flight hours:
4576
Circumstances:
Seair Seaplanes (Seair) was contracted by a remote fishing lodge on the central coast of British Columbia (BC) (Figure 1) to provide seasonal transport of guests and supplies between Vancouver International Water Aerodrome (CAM9), BC, and the lodge, which is located about 66 nautical miles (NM) north-northwest of Port Hardy Airport (CYZT), BC, and about 29 NM southeast of Bella Bella (Campbell Island) Airport (CBBC), BC. On 26 July 2019, the occurrence pilot arrived at Seair’s CAM9 base at approximately 0630. Over the next hour, the pilot completed a daily inspection of the Cessna 208 Caravan aircraft (registration C-GURL, serial number 20800501), added 300 L of fuel to the aircraft, and began flight planning activities, which included gathering and interpreting weather information. On the morning of the occurrence, 4 Seair visual flight rules (VFR) flights were scheduled to fly to the central coast of BC, all on Caravan aircraft: C-GURL (the occurrence aircraft) was to depart CAM9 at 0730, C-GSAS at 0745, C-FLAC at 0800, and C-GUUS at 0900. The first 3 flights were direct flights to the fishing lodge, while the 4th flight had an intermediate stop at the Campbell River Water Aerodrome (CAE3), BC, to pick up passengers before heading to a research institute located approximately 4 NM southwest of the fishing lodge. Because of poor weather conditions in the central coast region, however, all of the flights were delayed. After the crews referred to weather cameras along the central coast region, the flights began to depart, but in a different order than originally scheduled. It is not uncommon for the order of departure to change when groups of aircraft are going to the same general location. One of Seair’s senior operational staff (operations manager) departed CAM9 at 0850 aboard C-FLAC. C-GUUS, bound for the research institute, departed CAM9 next at 0906, and then the occurrence aircraft departed at 0932 (Table 1). The pilot originally scheduled to fly C-GSAS declined the flight. This pilot had recently upgraded to the Caravan, had never flown to this destination before, and was concerned about the weather at the destination. When Seair’s chief pilot returned to CAM9 at 0953 after a series of scheduled flights on a different type of aircraft, he assumed the last remaining flight to the lodge and C-GSAS departed CAM9 at 1024.After departing the Vancouver terminal control area, the occurrence aircraft climbed to 4500 feet above sea level (ASL) and remained at this altitude until 1023, when a slow descent was initiated. The aircraft levelled off at approximately 1300 feet ASL at 1044, when it was approximately 18 NM northeast of Port Hardy Airport (CYZT), BC, and 57 NM southeast of the destination. At 1050, the occurrence aircraft slowly descended again as the flight continued northbound. During this descent, the aircraft’s flaps were extended to the 10° position. At this point, the occurrence aircraft was 37 NM south-southeast of the fishing lodge. The aircraft continued to descend until it reached an altitude of approximately 330 feet ASL, at 1056. By this point, the occurrence aircraft was being operated along the coastline, but over the ocean. C-FLAC departed from the fishing lodge at 1056 on the return flight to CAM9. C-FLAC flew into the Fitz Hugh Sound and proceeded southbound along the western shoreline. At approximately 1100, it flew through an area of heavy rain where visibility was reduced to about 1 statute mile (SM). C-FLAC descended to about 170 feet ASL and maintained this altitude for the next 5 minutes before climbing to about 300 feet ASL. As the southbound C-FLAC entered Fitz Hugh Sound from the north at Hecate Island, the occurrence aircraft entered Fitz Hugh Sound from the south, near the southern tip of Calvert Island. The occurrence aircraft then changed course from the western to the eastern shoreline, and descended again to about 230 feet ASL (Figure 2), while maintaining an airspeed of approximately 125 knots. The 2 aircraft established 2-way radio contact. The pilot of C-FLAC indicated that Addenbroke Island was visible when he flew past it, and described the weather conditions in the Fitz Hugh Sound to the occurrence pilot as heavy rain showers and visibility of approximately 1 SM around Kelpie Point. The occurrence pilot then indicated that he would maintain a course along the eastern shoreline of the sound. At 1103, the 2 aircraft were separated by 2 NM and passed each other on reciprocal tracks, approximately 4 NM south of the accident site. The occurrence aircraft maintained a consistent track and altitude for the next 54 seconds, then slowly began a 25° change in track to the west (0.35 NM from the Addenbroke Island shoreline). Seven seconds after the turn started (0.12 NM from the island’s shoreline), the aircraft entered a shallow climb averaging 665 fpm. At 1104:55, the occurrence aircraft struck trees on Addenbroke Island at an altitude of approximately 490 feet ASL, at an airspeed of 114 knots, and in a relatively straight and level attitude. The aircraft then continued through the heavily forested hillside for approximately 450 feet, coming to rest at an elevation of 425 feet ASL, 9.7 NM east-southeast of the destination fishing lodge. The pilot and three passengers were killed and five other occupants were injured, four seriously.
Probable cause:
Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. The flight departed Vancouver International Water Aerodrome even though the reported and forecast weather conditions in the vicinity of the destination were below visual flight rules minima; the decision to depart may have been influenced by the group dynamics of Seair pilots and senior staff at the flight planning stage.
2. The pilot continued flight in reduced visibility, without recognizing the proximity to terrain, and subsequently impacted the rising terrain of Addenbroke Island.
3. The configuration of the visual and aural alerting systems and the colouration ambiguity in the primary flight display of the Garmin G1000 was ineffective at alerting the occurrence pilot to the rising terrain ahead.
4. The occurrence pilot’s attention, vigilance, and general cognitive function were most likely influenced to some degree by fatigue.

Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
1. If pilots do not receive specialized training that addresses the hazards of their flying environment, there is a risk that they will not be proficient in the specific skills necessary to maintain safety margins.
2. If aircraft are operated in excess of the maximum allowable take-off weight, there is a risk of performance degradation and adverse flight characteristics, which could jeopardize the safety of the flight.
3. If cargo is stowed in front of emergency exits, there is a risk that egress may be impeded in an emergency situation, potentially increasing evacuation time and risk of injuries.
4. If air operators do not employ a methodology to accurately assess threats inherent to daily operations, then there is a risk that unsafe practices will become routine and operators will be unaware of the increased risk.
5. If air operators that have flight data monitoring capabilities do not actively monitor their flight operations, they may not be able to identify drift toward unsafe practices that increase the risk to flight crew and passengers.
6. If Transport Canada’s oversight of operators is insufficient, there is a risk that air operators will be non-compliant with regulations or drift toward unsafe practices, thereby reducing safety margins.
7. If Transport Canada does not make safety management systems mandatory, and does not assess and monitor these systems, there is an increased risk that companies will be unable to effectively identify and mitigate the hazards associated within their operations.

Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
1. The pilot was actively using a cellphone throughout the flight; the operator provided no guidance or limitations on approved cellphone use in flight.
Final Report: