Crash of a Piper PA-46-500TP Malibu Meridian in Marshfield: 3 killed

Date & Time: Nov 22, 2008 at 2309 LT
Operator:
Registration:
N67TE
Flight Type:
Survivors:
No
Schedule:
Green Bay – Marshfield
MSN:
46-97364
YOM:
2008
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
749
Captain / Total hours on type:
60.00
Aircraft flight hours:
153
Circumstances:
Witnesses reported that the airplane appeared to be making a normal approach for landing when it suddenly rolled to the left, descended, and impacted the terrain about one-half mile from the runway. On arrival at the scene, the witnesses saw the airplane fully engulfed in flames. The flight was operating in night visual meteorological conditions and the runway lights were illuminated at the time of the accident. The pilot communicated no problems or difficulties while in contact with air traffic control (ATC) during the accident flight. A postaccident examination of the airframe and engine did not reveal any anomalies associated with a pre-impact failure or malfunction. Radar track data and weather observations indicated that the pilot climbed through an overcast cloud layer without the required ATC clearance, en route to his intended destination. The pilot previously had been issued a private pilot certificate with single and multi-engine airplane ratings upon successful completion of the prescribed practical tests. He was subsequently issued a commercial pilot certificate, which included the addition of an instrument airplane rating, based on military flight experience. However, a review of military records and statements from his family indicated that the pilot had never served in the military. The pilot's medical history and toxicology testing showed he had a history of back pain and was taking medication for that condition that commonly causes impairment. However, the time proximity for the pilot having taken the medication prior to the accident flight and any possible impairment, could not be determined.
Probable cause:
The pilot's failure to maintain control of the airplane during final approach for landing in night, visual meteorological conditions for undetermined reasons.
Final Report:

Crash of a Beechcraft A100 King Air in Gods Lake Narrows

Date & Time: Nov 22, 2008 at 2140 LT
Type of aircraft:
Operator:
Registration:
C-FSNA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Gods Lake Narrows – Thompson
MSN:
B-227
YOM:
1976
Flight number:
SNA683
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3200
Captain / Total hours on type:
1850.00
Copilot / Total flying hours:
1000
Copilot / Total hours on type:
500
Circumstances:
The Sky North Air Ltd. Beechcraft A100 (registration C-FSNA, serial number B-227) operating as SN683 departed Runway 32 at Gods Lake Narrows, Manitoba, for Thompson, Manitoba with two pilots, a flight nurse, and two patients on board. Shortly after takeoff, while in a climbing left turn, smoke and then fire emanated from the pedestal area in the cockpit. The crew continued the turn, intending to return to Runway 14 at Gods Lake Narrows. The aircraft contacted trees and came to rest in a wooded area about one-half nautical mile northwest of the airport. The accident occurred at 2140 central standard time. All five persons onboard evacuated the aircraft; two received minor injuries. At approximately 0250, the accident site was located and the occupants were evacuated. The aircraft was destroyed by impact forces and a post-crash fire. The emergency locator transmitter was consumed by the fire and whether or not it transmitted a signal is unknown.
Probable cause:
Findings as to Causes and Contributing Factors:
1. An electrical short circuit in the cockpit pedestal area produced flames and smoke, which induced the crew to take emergency action.
2. The detrimental effects of aging on the wires involved may have been a factor in this electrical arc event.
3. The crew elected to return to the airport at low level in an environment with inadequate visual references. As a result, control of the aircraft was lost at an altitude from which a recovery was not possible.
Findings as to Risk:
1. The actions specified in the standard operating procedures (SOP) do not include procedures for an electrical fire encountered at low altitude at night, which could lead to a loss of control.
2. Visual inspection procedures in accordance with normal phase inspection requirements may be inadequate to detect defects progressing within wiring bundles, increasing the risk of electrical fires.
3. In the event of an in-flight cockpit pedestal fire, the first officer does not have ready access to available fire extinguishers, reducing the likelihood of successfully fighting a fire of this nature.
4. Sealed in plastic containers and stored behind each pilot seat, the oxygen masks and goggles are time consuming to access and cumbersome to apply and activate. This could increase the probability of injury or incapacitation through extended exposure to smoke or fumes, or could deter crews from using them, especially during periods of high cockpit workload.
Other Finding:
1. A failure of the hot-mic recording function of the cockpit voice recorder (CVR) had gone undetected and information that would have been helpful to the investigation was not available.
Final Report:

Crash of a Beechcraft 100 King Air in Stony Rapids

Date & Time: Nov 11, 2008 at 1817 LT
Type of aircraft:
Registration:
C-GWWQ
Flight Type:
Survivors:
Yes
Schedule:
Uranium City – Stony Rapids
MSN:
B-76
YOM:
1971
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
For unknown reasons, the aircraft made a wheels up landing and skidded on runway at Stony Rapids Airport before coming to rest. Both pilots were uninjured while the aircraft was damaged beyond repair.
Probable cause:
Gear up landing for undetermined reason.

Crash of a Boeing 737-8AS in Rome

Date & Time: Nov 10, 2008 at 0756 LT
Type of aircraft:
Operator:
Registration:
EI-DYG
Survivors:
Yes
Schedule:
Hahn - Rome
MSN:
33639/2557
YOM:
2008
Flight number:
FR4102
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
164
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9883
Captain / Total hours on type:
6045.00
Copilot / Total flying hours:
600
Copilot / Total hours on type:
400
Aircraft flight hours:
2419
Aircraft flight cycles:
1498
Circumstances:
The airplane departed Hahn Airport at 0630LT on a flight to Rome-Ciampino Airport, carrying 14 passengers and a crew of 8. The first officer was the Pilot Flying on the leg whilst the captain was the Pilot Monitoring. The flight was uneventful until the approach phase at the destination airport. The aircraft established the first radio contact with Ciampino Tower, communicating that it was 9 NM from the runway and stabilised on the ILS for runway 15. The aircraft, authorized and configured for the approach, was proceeding for landing, when, at a height of 136 ft and a distance of about 300 m from the runway, the captain noticed birds on the flight trajectory. He stated "Ahi", repeated in rapid sequence. At a distance of about 100 m from the runway, the TO/GA pushbutton was activated. The first officer acknowledged: "Go around, flaps 15", setting the go around attitude. At the same time as the TO/GA was activated, the aircraft collided with a thick flock of some 90 starlings. A loud bang was heard and both engines stalled. The aircraft climbed to 173 feet and then continued to lose height, despite the nose-up command. There was a progressive speed reduction and an increase of the angle of attack until the activation of the stick shaker, which was recorded at 21 feet. The aircraft hit the ground in aerodynamic stall conditions, near taxiway AC, about half way along the total length of the runway at a vertical acceleration of 2.66g. First contact with the runway occurred with the main landing gear properly extended and with the lower part of the fuselage tail section. The left main landing gear detached from its attachment during the landing run and the lower part of the left engine nacelle came into contact with the runway. The aircraft stopped near the threshold of runway 33. The fire brigade sprayed extinguishing foam around the area where the engine nacelle had come into contact with the runway. The captain then arranged for the disembarkation of the passengers and crew using a ladder truck from the right front door, with the addition of the right rear slide, later activated and used.
Probable cause:
The accident has been caused by an unexpected loss of both engines thrust as a consequence of a massive bird strike, during the go-around manoeuvre. The loss of thrust has prevented the aircrew from performing a successful go around and has led the aircraft to an unstabilized runway contact. The following factors have contributed to the event:
- The inadequate effectiveness of bird control and dispersal measures put in place by the airport operator at the time of the accident,
- The captain decision to perform a go around, when the aircraft was at approximately 7 seconds from touchdown. The above decision was significantly influenced by:
- The lack of instructions to flight crew concerning the most suitable procedures to adopt in the case of single or multiple bird strikes in the landing phase,
- The absence of specific training in the management, by the flight crew, of the "surprise" and "startle" effects in critical phases of the flight.
Final Report:

Crash of an Antonov AN-12B in Pointe-Noire

Date & Time: Nov 10, 2008
Type of aircraft:
Registration:
UR-PLV
Flight Type:
Survivors:
Yes
MSN:
4 3 423 08
YOM:
1964
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Few minutes after takeoff from Pointe-Noire Airport, while flying 80 km away, the crew contacted ATC and declared an emergency after a fire erupted in the cargo compartment. The crew was able to return and after landing, the aircraft stopped on the main runway, bursting into flames. All six occupants escaped uninjured while the aircraft was destroyed by fire.
Probable cause:
It is believed that the fire started in the cargo bay near a generator.

Crash of a Piper PA-31-350 Navajo Chieftain in Bathurst: 4 killed

Date & Time: Nov 7, 2008 at 2024 LT
Registration:
VH-OPC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Melbourne – Bathurst – Port Macquarie
MSN:
31-7952082
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2061
Aircraft flight hours:
11000
Circumstances:
On 7 November 2008, a Piper Aircraft Corp. PA-31-350 Chieftain, registered VH-OPC, was being operated on a private flight under the instrument flight rules (IFR) from Moorabbin Airport, Vic. to Port Macquarie via Bathurst, NSW. On board the aircraft were the owner-pilot and three passengers. The aircraft departed Moorabbin Airport at about 1725 Eastern Daylight-saving Time and arrived at Bathurst Airport at about 1930. The pilot added 355 L of aviation gasoline (Avgas) to the aircraft from a self-service bowser and spent some time with the passengers in the airport terminal. Recorded information at Bathurst Airport indicated that, at about 2012 (12 minutes after civil twilight), the engines were started and at 2016 the aircraft was taxied for the holding point of runway 35. The aircraft was at the holding point for about 3 minutes, reportedly at high engine power. At 2020, the pilot broadcast that he was entering and backtracking runway 35 and at 2022:08 the pilot broadcast on the common traffic advisory frequency that he was departing (airborne) runway 35. At 2023:30, the pilot transmitted to air traffic control that he was airborne at Bathurst and to standby for departure details. There was no record or reports of any further radio transmissions from the pilot. At about 2024, a number of residents of Forest Grove, a settlement to the north of Bathurst Airport, heard a sudden loud noise from an aircraft at a relatively low height overhead, followed shortly after by the sound of an explosion and the glow of a fire. A witness located about 550 m to the south-west of the accident site, reported seeing two bright lights that were shining in a constant direction and ‘wobbling’. There was engine noise that was described by one witness as getting very loud and ‘rattling’ or ‘grinding’ abnormally before the aircraft crashed. At 2024:51, the first 000 telephone call was received from witnesses and shortly after, emergency services were notified. The aircraft was seriously damaged by impact forces and fire, and the four occupants were fatally injured.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain involving Piper Aircraft Corp. PA-31-35 Chieftain, registered VH-OPC, 3 km north of Bathurst Airport on 7 November 2008 and should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing safety factors:
• The aircraft descended at a steep angle before impacting the ground at high speed, consistent with uncontrolled flight into terrain.
Other key findings:
• Based on analysis of the available information, an airworthiness issue was considered unlikely to be a contributing factor to this accident.
• The investigation was unable to establish why the aircraft collided with terrain; however, pilot spatial disorientation or pilot incapacitation could not be discounted.
Final Report:

Crash of a Partenavia P.68C in Gainesville: 3 killed

Date & Time: Nov 7, 2008 at 0246 LT
Type of aircraft:
Operator:
Registration:
N681KW
Flight Type:
Survivors:
No
Schedule:
Key West - Gainesville
MSN:
273
YOM:
1983
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
8300
Captain / Total hours on type:
1500.00
Aircraft flight hours:
6971
Circumstances:
The pilot of the multiengine airplane was flying two passengers at night on an instrument-flight-rules flight plan. One of the passengers had been on an organ recipient waiting list and his wife was accompanying him. A viable matched organ was available at a distant hospital and the passenger had to arrive on short notice for surgery the following morning. All radio communications during the flight between the pilot and air traffic control (ATC), a flight service station (FSS), and a fixed-based operator (FBO) were routine. The pilot was aware of the weather at the destination airport, and had commented to ATC about 75 miles from the destination that the weather was "going up and down…like a real thin fog layer.” Additionally, better weather conditions prevailed at nearby suitable airports. The pilot mentioned one of those airports to ATC in the event he decided to divert. According to an employee at an FBO located at the destination airport, the pilot contacted him via radio and asked about the current weather conditions. The employee replied that the visibility was low due to fog and that he could not see the terminal lights from the FBO. The pilot then asked which of the two alternate airports was closer and the employee stated that he did not know. The employee then heard the pilot “click” the runway lights and contact the local FSS. about 5 miles from runway 29, just prior to the initial approach fix, the pilot radioed on the common traffic advisory frequency and reported a 5-mile final leg for runway 29. The FSS reported that the current weather was automated showing an indefinite ceiling of 100 feet vertical visibility and 1/4 mile visibility in fog. The pilota cknowledged the weather information. The weather was below the minimum published requirements for the instrument-landing-system (ILS) approach at the destination airport. Radar data showed that the flight intercepted and tracked the localizer, then intercepted the glideslope about 1 minute later. There were a few radar targets without altitude data due to intermittent Mode C transponder returns. The last recorded radar target with altitude indicated the airplane was at 600 feet, on glideslope and heading for the approach; however, the three subsequent and final targets did not show altitude information. The last recorded radar target was about 1.4 miles from the runway threshold. The airplane flew below glideslope and impacted 100-foot-tall trees about 4,150 feet from the runway 29 threshold. On-ground facility checks and a postaccident flight check of the ILS runway 29 approach conducted by the Federal Aviation Administration did not reveal malfunctions with the ILS. The cabin and cockpit area, including the NAV/COMM/APP, equipment were consumed by a postimpact fire which precluded viable component testing. Detailed examination of the wreckage that was not consumed by fire did not reveal preimpact mechanical malfunctions that may have contributed to the accident. Given that the pilot was aware of the weather conditions before and during the approach, it is possible that the pilot’s goal of expeditiously transporting a patient to a hospital for an organ transplant may have affected his decision to initiate and continue an instrument approach while the weather conditions were below the published minimum requirements for the approach.
Probable cause:
The pilot's failure to maintain the proper glidepath during an instrument-landing-system (ILS) approach. Contributing to the accident were the pilot's decision to initiate the ILS approach with weather below the published minimums, and the pilot's self-induced pressure to expeditiously transport an organ recipient to a hospital.
Final Report:

Crash of a Dornier DO328-100TP in Fakfak

Date & Time: Nov 6, 2008 at 1033 LT
Type of aircraft:
Operator:
Registration:
PK-TXL
Survivors:
Yes
Schedule:
Sorong - Fakfak
MSN:
3037
YOM:
1995
Flight number:
XAR9000
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10190
Captain / Total hours on type:
2365.00
Copilot / Total flying hours:
4673
Copilot / Total hours on type:
15
Aircraft flight hours:
24404
Aircraft flight cycles:
21916
Circumstances:
The aircraft touched down heavily approximately 5 meters before the touch-down area of runway 10 at Torea Airport, Fak-Fak at 01:33. The investigation found that the left main landing gear touched the ground first (5 meters before the end of the runway), and the right main landing gear touched the ground (4.5 meters from the end of the runway). It stopped on the runway, approximately 700 meters from the touch-down area. The left main landing gear fractured in two places; at the front pivot point, and the aft pivot point. The left fuselage contacted the runway surface 200 meters from the touch-down point and the aircraft slid with the left fuselage on the ground for a further 500 meters, before it stopped at the right edge of the runway. The wing tip and left propeller blade tips also touched the runway and were damaged. The passengers and crew disembarked normally; there were no injuries. Following an inspection of the landing gear and temporary replacement of the damaged left main landing gear, the aircraft was moved to the apron on 8 November 2008 at 04:00. The runway was closed for 5 days.
Probable cause:
The Digital Flight Data Recorder data showed evidence that the aircraft descended suddenly and rapidly when it was on short final approach before the aircraft was above the touchdown area. Propeller RPM was reduced suddenly and rapidly to 70% less than 10 seconds before ground contact. Given that the propellers are constant speed units, the sudden and rapid changes could not be explained other than the probability that a crew member had made the control inputs. The PIC (pilot monitoring/flight instructor) did not monitor the operation of the aircraft sufficiently to ensure timely and effective response to the pilot induced excessive sink rate.
Other Factors:
The airport did not meet the ICAO Annex 14 Standard with respect to the requirement to have runway end safety areas.
Final Report:

Crash of a Beechcraft 200 Super King Air in Punta Chivato: 1 killed

Date & Time: Nov 3, 2008 at 1330 LT
Operator:
Registration:
N200JL
Flight Phase:
Flight Type:
Survivors:
No
MSN:
BB-127
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The twin engine aircraft was completing a flight from South Pacific to the US with an intermediate stop in Punta Chivato, Baja California Sur, where a passenger was dropped off. Shortly after takeoff from Punta Chivato Airfield, the aircraft lost speed and height, stalled and crashed near the Hotel Posada de la Flores. The aircraft was destroyed by a post crash fire and the pilot was killed.

Crash of a Cessna 208B Grand Caravan in Nyala Lodge

Date & Time: Nov 1, 2008 at 1100 LT
Type of aircraft:
Registration:
ZS-PCM
Flight Phase:
Survivors:
Yes
Schedule:
Pretoria - Nyala Lodge
MSN:
208B-0851
YOM:
2000
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1371
Captain / Total hours on type:
390.00
Aircraft flight hours:
2659
Circumstances:
On 1 November 2008 the pilot, accompanied by 5 passengers, departed from Wonderboom aerodrome to Njala Lodge in the Limpopo Province on a chartered flight. The coordinates used by the pilot were insufficient for the purpose and resulted in him landing on an incorrect aerodrome. During the take-off from the incorrect runway, the pilot apparently failed to do a proper assessment of the wind conditions and the result was an aborted take-off as the aircraft failed to gain height. During the landing following the aborted take-off, the aircraft collided with a huge rock, a telephone pole and the associated telephone wires and a 4 ft wire fence. The aircraft sustained substantial damage during the accident sequence and stopped a mere 5 metres from high tension wires across the dirt road.
Probable cause:
The pilot failed to carry out a proper assessment of the wind conditions. The aircraft failed to gain height as a result of a possible down draft and collided with obstacles on the ground after landing. The pilot failed to maintain directional control after take-off, resulting in a landing on the left side of the runway after aborting the take-off.
Final Report: