Crash of a Beechcraft E18S in Eden Prairie: 2 killed

Date & Time: Aug 12, 2009 at 1145 LT
Type of aircraft:
Registration:
N3038C
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Eden Prairie - Osceola
MSN:
BA-374
YOM:
1958
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1150
Captain / Total hours on type:
0.00
Aircraft flight hours:
10626
Circumstances:
The pilot purchased the airplane approximately one year prior to the accident with the intention of restoring it for flight. The airplane had not been flown for approximately five years and had been used for spare parts. The pilot was flying the airplane to another airport to pick up passengers prior to returning. The pilot was cleared for takeoff and to circle the airport at 2,500 feet prior to departing the area. Witnesses reported that after taking off the airplane seemed to “wobble” at a slow airspeed in a nose-high attitude and that it never got higher than 500 feet. Some witnesses reported the engine(s) sputtering, and another stated that the airplane was loud and "didn't sound good," although other witnesses reported that the engines sounded normal. One witness reported seeing white smoke coming from the left engine and hearing the engine "popping" as the airplane took off. The airplane made three left turns and it appeared as if the pilot was attempting to return to land. Witnesses described the left wing rising prior to the airplane banking hard to the left and the nose dropping straight down. The airplane impacted the ground just northeast of the airport property and a postimpact fire ensued. Flight control continuity was established. The right side of the elevator/tailcone structure exhibited black rub marks and scrapes. Grass and nesting material was found inside the left wing. The left fuel valve was found in the OFF position and the right fuel valve was positioned to the rear auxiliary tank. Neither the fuel crossfeed valve nor the fuel boost pump switch was located. The left engine sustained substantial fire and impact damage. The right engine sustained heavy impact damage. The airplane was last fueled one month prior to the accident with 120 gallons of fuel. About 20 engine test runs in addition to high-speed taxi tests had been conducted since then. A Special Flight Permit had been obtained but had not been signed by the mechanic, who did not know that the pilot was going to fly the airplane on the day of the accident. The pilot reportedly did not have any Beech 18 flight experience.
Probable cause:
The pilot’s lack of experience flying the accident make and model of airplane, which led to a loss of control while maneuvering to return to the airport. Contributing to the accident was a partial loss of engine power for undetermined reasons.
Final Report:

Crash of an ATR72-212A in Koh Samui: 1 killed

Date & Time: Aug 4, 2009 at 1430 LT
Type of aircraft:
Operator:
Registration:
HS-PGL
Survivors:
Yes
Schedule:
Krabi – Koh Samui
MSN:
670
YOM:
2001
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
68
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Following an uneventful flight from Krabi, the crew started the approach to Koh Samui Airport. Conditions at destination were marginal with stormy weather, winds and turbulences. Upon landing on runway 35, the aircraft bounced then landed a second time. It deviated from the centerline to the left, veered off runway, rolled through a grassy area and eventually collided with the concrete structure of the airport tower. The captain was killed and the copilot was seriously injured as the cockpit area was destroyed upon impact. 26 other people were injured.

Incident with a Boeing 707-3J9C in Ahwaz

Date & Time: Aug 3, 2009 at 1000 LT
Type of aircraft:
Operator:
Registration:
EP-SHK
Flight Phase:
Survivors:
Yes
Schedule:
Ahwaz - Tehran
MSN:
21128/917
YOM:
1976
Flight number:
IRZ124
Location:
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
162
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after take off from Ahwaz Airport, while in initial climb, the engine n°2 suffered an uncontained failure. The crew informed ATC about the situation and was cleared for an immediate return. The aircraft landed safely 10 minutes later and was stopped on the main runway. All 174 occupants were rescued, among them two passengers were slightly injured. The aircraft was considered as damaged beyond repair as n°1 engine and the left wing were also damaged due to debris from the n°2 engine's compressor.
Probable cause:
It appears that a stage of the high pressure compressor in the n°2 engine disintegrated during initial climb. Elements punctured the nacelle and hit the left wing and the n°1 engine. After the n°2 engine failed, the n°1 engine lost power.

Crash of an Ilyushin II-62M in Mashhad: 16 killed

Date & Time: Jul 25, 2009 at 1805 LT
Type of aircraft:
Operator:
Registration:
UP-I6208
Survivors:
Yes
Schedule:
Tehran - Mashhad
MSN:
19 51 5 2 5
YOM:
1989
Flight number:
IRX1525
Country:
Region:
Crew on board:
17
Crew fatalities:
Pax on board:
156
Pax fatalities:
Other fatalities:
Total fatalities:
16
Captain / Total flying hours:
14200
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
8294
Copilot / Total hours on type:
1319
Aircraft flight hours:
13573
Aircraft flight cycles:
3987
Circumstances:
At July 24, 2009, Ilyushin aircraft, model IL-62M of DETA Airline with registration, UP-I6208 and flight IRX1525 of Aria Airline flight with 169 passengers from Mehrabad International Airport/ Tehran, and it has landed at 18:05 local time on RWY 13 L in Mashhad International Airport; then it has run off from end of the runway, without considerable reduction in aircraft speed and it collided with wall of the airport and it was stopped after approximately 185 m. The mentioned aircraft has been leased by Aria Airline as ACMI, according to contract No. 002/IL-62M/ACMI. Subsequently, the ground safety unit of the airport has attended in place of occurring accident, by breaking protective fences and barbed wires of the airport, and then they evacuated passengers and extinguished fire outside of aircraft by carrying out necessary actions. 16 people were killed, 11 crew members and five passengers. All other occupants were rescued, among them 30 were injured. Accident site inspection revealed that the aircraft position had coordinates N 36,218º E 59,666º, at a road in the vicinity of the aerodrome, 1km away from the RWY-31R threshold (130º MH or 133, 5º TH) of the Mashhad airport with the azimuth of 125º (true). Power line along the road was destroyed by the right aircraft wing. Wing fuel tanks of the right wing were damaged evidenced by fuel leaking. Main and emergency exits were open. An inflatable slide was dropped down from the port side. No evidences of fire on board and at the accident site were found. First tracks of intensive braking (black tire tracks) were found at the concrete at a distance of 550 m from the departure threshold of RWY31R. The track of the main gear wheels was going along the RWY in its left part, and diverging further to the right beyond the departure threshold. At about 100m away from the threshold at the end portion of the braking way, a net barrier was found (textile aerodrome emergency braking unit).The aircraft ran over the RWY when moving along the right side of the stop way, 300m long. Beyond the end of the RWY landing gear wheels track could be clearly seen passing over a rough partly grassed surface, and crossing a dirt road. At a distance of 100m from the RWY end, where the right gear crossed the road, a destroyed tire tube was found, which presumably belonged to the right gear front wheel. At a distance of 160m from the RWY end smashed approach lights were found, and after that point the gear wheel track started to diverge to the left from the RWY centerline. The front gear wheel track further merged with the left gear wheel track and extended joining the forward airframe track. At a distance of 320 m from the RWY end another line of broken approach lights were found. Airframe structures were found before the approach lights (along the aircraft way). From that point small aircraft structure pieces were found along the whole aircraft path. 40m past the destroyed approach lights line a ditch of 0,5…1m in depth was found (with an underground pipeline) which was crossing this area from the south to the north. The south-eastern part of the aerodrome was fenced with a brick wall of 2,5m high and 0,4m thick with a concrete strip foundation. It went along the RWY there. The aircraft collided with the fence at a distance of 820m from the departure threshold (520m past the stop way end) with a heading of 105 degrees. The fence was destroyed throughout 70m. Debris of the nose part of the airframe, cockpit, passenger seats, aircraft cabin parts were found behind the fence. Earlier aerodrome employees, police and medical services found at the site and evacuated crew bodies, as well as killed and injured passengers. After the collision with the fence the aircraft kept moving for 160 m with a heading of 105 degrees and came to a stop at the road.
Probable cause:
The following findings were identified:
- The crew was not trained &acquainted with flight conditions in the Iran territory with an Iranian instructor pilot and the operation unit of Aria Airline has acted so weak regarding those mentioned subjects.
- The approach speed of aircraft was higher than recommended available airport charts & aircraft weight, however it was controllable if the crew could proceed to land correctively.
- The crew had not done correct procedure according to the aircraft Standard Operation Procedure (SOP) to use related check lists. (Descend-Approach-Landing)
- There was lack of precise coordination between flight crew on their self responsibility during the approach and landing.
- The flight crew did not pay attention to EGPWS warning, and did not take corrective action.
- The crew did not use engine reverser and spoiler systems correctly to reduce aircraft speed during the landing and consequently it caused to loose long Runway distance.
- The flight crew had not good English language proficiency. And they were poor in England language conversation.
- The Capitan of the aircraft as the pilot in command had not sufficient force and efficient management in the cockpit. (lack of Cockpit Resource Management).
- There were unauthorized actions of flight engineer for shifting engine reversers as well as lack of mutual oversight by crew members in checklist accomplishment during approach and landing.
- The crew has had disagreement about “Go around” due to unsuitable landing situations.
- Presence of General Director of airline in the cockpit had adverse psychological effect on crew efficiency behaviors.
- The DETA airline did not use correct procedure to extend engines No; 1-2-4 life time from Ukrainian company (Aerotechservice co.) and the technical manager of ARIA airline did not control and
supervise the matter accordingly.

Main Cause :
Considering those items in factual information and analysis, the main cause of this accident is “weak Cockpit management between the crew” to use correct landing techniques same as releasing Engine trust reversers – Engine shut down in unsuitable time - ….

Contributive Factors :
Some of contributive factors for this accident occurrence are noted as:
- The copilot and the flight engineer had self activity& decision without the (PIC) coordination.
- The cockpit crew was careless and not paying proper attention toward EGPWS warning.
- Psychological adverse effect on cockpit crew because of presence of General Director of Aria airline

Violation & other deficiencies:
The accident investigation team encountered some violations and deficiencies with ICAO Standards and Iran Local Authority regulation (CAO) which are descript as:
- Poor and in-sufficient supervision controlled of operation &technical manger of Aria Airline.
- The DETA airline has not used proper procedure to receive life time extension of engine and has not passed necessary information to Iranian and Kazakhstan Authorities.
- It has not been designed a headset for flight engineer to make more coordination between the crew, by the aircraft design bureau.
- The crew was not familiar with Iranian AIP completely.
- The total on board persons was not according to written load sheet.
Final Report:

Crash of a Piper PA-46-310P Malibu in Kamsack: 2 killed

Date & Time: Jul 19, 2009 at 2124 LT
Registration:
C-GUZZ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Kamsack – Saskatoon
MSN:
46-8508108
YOM:
1985
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1000
Captain / Total hours on type:
300.00
Circumstances:
The aircraft departed Kamsack, on an instrument flight rules flight to Saskatoon, Saskatchewan. The pilot and three passengers were on board. At takeoff from runway 34, the aircraft began rolling to the left. The aircraft initially climbed, then descended in a steep left bank and collided with terrain 200 feet to the left of the runway. A post-impact fire ignited immediately. Two passengers survived the impact with serious injuries and evacuated from the burning wreckage. The pilot and third passenger were fatally injured. The aircraft was destroyed by impact forces and the post-impact fire. The accident occurred during evening civil twilight at 2124 Central Standard Time.
Probable cause:
Finding as to Causes and Contributing Factors:
1. The pilot was unable to maintain aircraft control after takeoff for undetermined reasons and the aircraft rolled to the left and collided with terrain.
Finding as to Risk:
1. The manufacturer issued a service bulletin to regularly inspect and lubricate the stainless steel cables. Due to the fact that the bulletin was not part of an airworthiness directive and was not considered mandatory, it was not carried out on an ongoing basis. It is likely that the recommended maintenance action has not been carried out on other affected aircraft at the 100-hour or annual frequency recommended in FAA SAIB CE-01-30.
Other Findings:
1. Due to the complete destruction of the surrounding structure, restriction to aileron cable movement prior to impact could not be determined.
2. The use of the available three-point restraint systems likely prevented the two survivors from being incapacitated, enabling them to evacuate from the burning wreckage.
Final Report:

Crash of a Noorduyn Norseman IV in Akiachak

Date & Time: Jul 11, 2009 at 1300 LT
Type of aircraft:
Operator:
Registration:
N225BL
Survivors:
Yes
Schedule:
Bethel – Tuluksak
MSN:
542
YOM:
1944
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8500
Captain / Total hours on type:
100.00
Aircraft flight hours:
15729
Circumstances:
The airline transport pilot was on a Title 14, CFR Part 135 passenger flight. The pilot said during cruise flight he heard a loud bang, and the engine started running rough. He said he diverted to the nearest airport, but the engine quit completely, and he was unable to reach the runway. The airplane subsequently collided with terrain, sustaining substantial damage to both wings and the fuselage. An examination of the engine revealed that a locking screw had backed out of one of the anti-vibration counterweights on the crankshaft, scoring the interior back surface of the engine case. The unsecured counterweight then moved from its position in the crankshaft, and was likely struck by the engine's master rod, which shattered the weight, and liberated it from its normal location. The liberated counterweight was struck by internal moving parts, creating several component failures, and ultimately an engine seizure.
Probable cause:
The loss of engine power due to the failure of a crankshaft component, resulting in an off airport landing.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Vancouver: 2 killed

Date & Time: Jul 9, 2009 at 2208 LT
Operator:
Registration:
C-GNAF
Flight Type:
Survivors:
No
Schedule:
Vancouver – Nanaimo – Victoria – Vancouver
MSN:
31-8052130
YOM:
1980
Flight number:
APEX511
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2300
Copilot / Total flying hours:
400
Circumstances:
The Canadian Air Charters Piper PA-31-350 Chieftain (registration C-GNAF, serial number 31-8052130) was operating under visual flight rules as APEX 511 on the final leg of a multi-leg cargo flight from Vancouver to Nanaimo and Victoria, British Columbia, with a return to Vancouver. The weather was visual meteorological conditions and the last 9 minutes of the flight took place during official darkness. The flight was third for landing and turned onto the final approach course 1.5 nautical miles behind and 700 feet below the flight path of a heavier Airbus A321, approaching Runway 26 Right at the Vancouver International Airport. At 2208, Pacific Daylight Time, the target for APEX 511 disappeared from tower radar. The aircraft impacted the ground in an industrial area of Richmond, British Columbia, 3 nautical miles short of the runway. There was a post-impact explosion and fire. The 2 crew members on board were fatally injured. There was property damage, but no injuries on the ground. The onboard emergency locator transmitter was destroyed in the accident and no signal was detected.
Probable cause:
Findings as to Causes and Contributing Factors:
1. APEX 511 turned onto the final approach course within the wake turbulence area behind and below the heavier aircraft and encountered its wake, resulting in an upset and loss of control at an altitude that precluded recovery.
2. The proximity of the faster trailing traffic limited the space available for APEX 511 to join the final approach course, requiring APEX 511 not to lag too far behind the preceding aircraft.
Findings as to Risk:
1. The current wake turbulence separation standards may be inadequate. As air traffic volume continues to grow, there is a risk that wake turbulence encounters will increase.
2. Visual separation may not be an adequate defence to ensure that appropriate spacing for wake turbulence can be established or maintained, particularly in darkness.
3. Neither the pilots nor Canadian Air Charters (CAC) were required by regulation to account for employee duty time acquired at other non-aviation related places of employment. As a result, there was increased risk that pilots were operating while fatigued.
4. Not maintaining engine accessories in accordance with manufacturers’ recommendations can lead to failure of systems critical to safety.
Other Finding:
1. APEX 511 was not equipped with any type of cockpit recording devices, nor was it required to be. As a result, the level of collaboration and decision making discussion between the 2 pilots remains unknown.
Final Report:

Crash of a PZL-Mielec AN-28 in Sarif-Umra

Date & Time: Jul 6, 2009 at 0950 LT
Type of aircraft:
Operator:
Registration:
ST-TYB
Flight Type:
Survivors:
Yes
Schedule:
Al Fashir - Sarif-Umra
MSN:
1AJ006-02
YOM:
1988
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10144
Captain / Total hours on type:
1269.00
Copilot / Total flying hours:
5500
Copilot / Total hours on type:
950
Aircraft flight hours:
2180
Aircraft flight cycles:
2113
Circumstances:
The flight progress strip at Al Fashir aerodrome control tower illustrate that on the 6th of July 2009 – ST-TYB, AN-28 departed Al Fashir at time 0601 UTC, estimated time to arrive destination Sarif-Umra was 0650 UTC, persons on board were two (crew only), intended flight level was 085 (VFR) re-cleared later FL105, fuel endurance was 3,5 hours, load on board as indicated on the cargo manifest was 1511 k.gm (food stuff) destined for the UNAMID forces. Aircraft center of gravity was organized. Calculated actual take off weight was 6335 k.gm and the actual landing weight was 6035 k.gm as reported by the pilot. The aircraft proceeded normally to destination at FL 105, when it reached the airfield, the pilot stated that, they started descend gradually at a speed of 250 km/h willing to check the strip serviceability and to specify the direction of landing from the located wind sock. They detected that, the strip was clear, dry and the wind was favorable to the direction of 23 (strip 23/05). As the crew established a speed of 210 km/h at an altitude of 60 meters on final approach, they saw a dust devil storm on their right crossing the air strip, to avoid this phenomena, they decided to go around for another approach. Eye witnesses confirmed the occurrence of the storm at the time the aircraft commenced the final approach. The crew reported that, they started a right turn and applied full power to gain height, but they felt that there was no response from the engines and the aircraft was influenced by a wind shear and began to sink. The crew managed to control the aircraft, but in few minutes its altitude decreased rapidly. At time 0650 UTC the aircraft impacted with the ground and rolled, there after struck a small rock and bounced, finally the aircraft impacted the ground by the left main gear and nose, and stopped at a distance of 1,850 meters from the beginning of strip 05 coordinates N 13 29.527 ـــــــ E 023 16.794. Crews (2) were safe and the aircraft sustained substantial damage.
Probable cause:
The unexpected weather phenomena at destination, and environmental conditions, wind shear and CB down drafts caused the accident.
Final Report:

Crash of a Britten Norman BN-2A Trislander III-1 on Great Barrier Island

Date & Time: Jul 5, 2009 at 1305 LT
Type of aircraft:
Operator:
Registration:
ZK-LOU
Flight Phase:
Survivors:
Yes
Schedule:
Great Barrier Island - Auckland
MSN:
322
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
868
Captain / Total hours on type:
28.00
Circumstances:
At about 1300 on Sunday 5 July 2009, ZK-LOU, a 3-engined Britten Norman BN2A Mk III Trislander operated by Great Barrier Airlines (the company), took off from Great Barrier Aerodrome at Claris on Great Barrier Island on a regular service to Auckland International Airport. On board were 10 passengers and a pilot, all of whom were wearing their seat belts. That morning the pilot had flown a different Trislander from Auckland International Airport to Claris and swapped it for ZK-LOU for the return flight because it was needed for pilot training back in Auckland. Another company pilot had that morning flown ZK-LOU to Claris from North Shore Aerodrome. He had completed a full engine run-up for the first departure of the day, as was usual, and said he noticed nothing unusual with the aeroplane during the approximate 30-minute flight. For the return flight the pilot said he completed the normal after-start checks in ZK-LOU and noticed nothing abnormal. He did not do another full engine run-up because it was not required. He taxied the aeroplane to the start of sealed runway 28, applied full power while holding the aeroplane on brakes and rechecked that the engine gauges were indicating normally before starting the take-off roll. The aeroplane took off without incident, but the pilot said when it was climbing through about 500 feet he heard an unusual “pattering” sound. He also heard the propellers going out of synchronisation, so he attempted to resynchronise them with the propeller controls. He checked the engine’s gauges and noticed that the right engine manifold pressure and engine rotation speed had dropped, so he adjusted the engine and propeller controls to increase engine power. At that time there was a loud bang and he heard a passenger scream. Looking back to his right the pilot saw that the entire propeller assembly for the right engine was missing and that there was a lot of oil spray around the engine cowling. The pilot turned the aeroplane left and completed the engine failure and shutdown checks. He transmitted a distress call on the local area frequency and asked the other company pilot, who was airborne behind him, to alert the local company office that he was returning to Claris. The company office manager and other company pilot noticed nothing unusual with ZK-LOU as it taxied and took off. The other pilot was not concerned until he saw what looked like white smoke and debris emanate from the aeroplane as though it had struck a flock of birds. Despite the failure, ZK-LOU continued to climb, so the pilot said he levelled at about 800 feet and reduced power on the 2 serviceable engines, completed a left turn and crossed over the aerodrome and positioned right downwind for runway 28. There was quite a strong headwind for the landing, so the pilot elected to do a flapless landing and keep the power and speed up a little because of the possibility of some wind shear. The pilot and other personnel said that the cloud was scattered at about 2500 feet, that there were a few showers in the area and that the wind was about 15 to 20 knots along runway 28. The visibility was reported as good. After landing, the pilot stopped the aeroplane on the runway and checked on the passengers before taxiing to the apron. At the apron he shut down the other engines and helped the passengers to the terminal, where they were offered drinks. The company chief executive, who lived locally, and a local doctor attended to the passengers. Three of the passengers received some minor abrasions and scrapes from shattered Perspex and broken interior lining when the propeller struck the side of the fuselage.
Probable cause:
Findings are listed in order of development and not in order of priority.
- The engine propeller assembly separated from the right engine of ZK-LOU in flight and struck the fuselage when the crankshaft failed at the flange that connected it to the propeller hub.
- High-cycle fatigue cracking on the flange that had developed during normal operations from undetected corrosion had reached a critical stage and allowed the flange to fail in overload.
- The crankshaft had inadvertently passed its overhaul service life by around 11% when the failure occurred, but the company had not realized this because of an anomaly in the recorded overseas service hours prior to importation of the engine to New Zealand. Ordinarily, the crankshaft would have been retired before a failure was likely.
- The crankshaft was an older design that has since been progressively superseded by those with flanges less prone to cracking.
- There was no requirement for a specific periodic crack check of the older-design crankshaft flanges, but this has been addressed by the CAA issuing a Continuing Airworthiness Notice on the issue.
- The CAA audit of the company had examined whether its engine overhaul periods were correct, but the audit could not have been expected to discover the anomaly in the overseas-recorded engine hours.
- This failure highlighted the need by potential purchasers of overseas components to follow the guidelines outlined in CAA Advisory Circular 00-1 to scrutinize overseas component records to ensure that the reported in-service hours are accurate.
Final Report:

Crash of a BAe 3201 Jetstream 31 at Salerno AFB

Date & Time: Jun 27, 2009
Type of aircraft:
Operator:
Registration:
N485UE
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
901
YOM:
1990
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Salerno AFB, the pilot-in-command decided to abandon the takeoff procedure for unknown reasons. The aircraft went out of control, veered off runway and came to rest. There were no injuries and the aircraft was damaged beyond repair.