Crash of a Socata TBM-910 in Westlock

Date & Time: Oct 10, 2021 at 1102 LT
Type of aircraft:
Registration:
C-FFYM
Flight Type:
Survivors:
Yes
Schedule:
Vernon – Calgary – Westlock
MSN:
1190
YOM:
2017
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
235.00
Aircraft flight hours:
449
Circumstances:
The airplane was conducting an instrument flight rules flight from Vernon Airport, British Columbia, to Westlock Aerodrome, Alberta, with a stop at Calgary/Springbank Airport, Alberta, to pick up passengers, after which 1 pilot and 3 passengers were on board. At 1102:26 Mountain Daylight Time, while the aircraft was landing on Runway 28 at Westlock Aerodrome, the aircraft bounced and the pilot initiated a go-around. During the application of engine power for the go-around, the aircraft rolled to the left, struck the runway inverted, and came to rest on the runway’s south side. The 3 passengers exited the aircraft through the main cabin door with the assistance of persons nearby. One passenger received serious injuries, and the other 2 had minor injuries. The pilot, who was seriously injured, was trapped in the cockpit for approximately 2 hours before first responders could safely rescue him from the wreckage. An emergency locator transmitter signal was received by the search and rescue satellite system. The aircraft was significantly damaged and there was no post-impact fire.
Probable cause:
Findings as to causes and contributing factors:
1. The aircraft joined the final approach well above the optimal 3° descent path and, during the steep approach that followed, the aircraft’s airspeed continually decelerated and resulted in an unstabilized approach.
2. On short final, the pilot reduced the rate of descent by increasing pitch rather than by adding power. As a result, the airspeed continued to decrease and the aircraft entered a stall, resulting in a hard landing and a subsequent bounce.
3. During the attempted rejected landing, the aircraft entered a 25° nose-high attitude and approached a stall condition. This low-speed condition combined with the high power setting resulted in the aircraft entering a rapid roll to the left and striking the runway in an inverted attitude.
4. The passengers did not receive a safety briefing before departure or before landing, and multiple items in the cabin were not secured. As a result, 1 passenger sustained serious injuries due to the deceleration forces and the loose items that were thrown around in the cabin during the accident.
5. The pilot was not wearing the available shoulder harness, and his torso was unrestrained during the impact. As a result, he sustained serious injuries.

Findings as to risk:
1. If pilots do not declare all health issues to Transport Canada Civil Aviation Medical Examiners and pilots’ family physicians do not declare issues assessed to be a risk to aviation safety to Transport Canada, there is an increased risk that pilots will operate with diagnosed medical conditions or medical side effects that could affect flight safety.
2. If an aircraft propeller is rotating and passengers are not supervised during boarding operations, there is a risk that passengers may inadvertently contact the propeller, potentially causing fatal injuries.

Other findings:
1. Following a review of the pilot’s medical history and prescription medication use, the investigation determined that the medication did not contribute to the accident.
Final Report:

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 Dassault Falcon 20CC in Thomson: 2 killed

Date & Time: Oct 5, 2021 at 0544 LT
Type of aircraft:
Registration:
N283SA
Flight Type:
Survivors:
No
Schedule:
Lubbock - Thomson
MSN:
83
YOM:
1967
Flight number:
PKW887
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
11955
Captain / Total hours on type:
1665.00
Copilot / Total flying hours:
10908
Copilot / Total hours on type:
1248
Aircraft flight hours:
18798
Circumstances:
The captain and first officer were assigned a two-leg overnight on-demand cargo flight. The flight crew were accustomed to flying night cargo flights, had regularly flown together, and were experienced pilots. The first leg of the trip was uneventful and was flown by the captain; however, their trip was delayed 2 hours and 20 minutes at the intermediate stop due to a delay in the freight arriving. The flight subsequently departed with the first officer as the pilot flying. While enroute, about forty minutes from the destination, the flight crew asked the air traffic controller about the NOTAMs for the instrument landing system (ILS) instrument approach procedure at the destination. The controller informed the flight crew of two NOTAMs: the first pertained to the ILS glidepath being unserviceable and the second applied to the localizer being unserviceable. When the controller read the first NOTAM, he stated he did not know what “GP” meant, which was the abbreviation for the glideslope/glidepath on the approach. The controller also informed the flight crew that the localizer NOTAM was not in effect until later in the morning after their expected arrival, which was consistent with the published NOTAM. The flight crew subsequently requested the ILS approach and when the flight was about 15 miles from the final approach fix, the controller cleared the flight for the ILS or localizer approach, to which the captain read back that they were cleared for the ILS approach. As the flight neared the final approach fix, the captain reported that they had the airport in sight; he cancelled the instrument flight rules flight plan, and the flight continued flying towards the runway. The airplane crossed the final approach fix off course, high, and fast. The cockpit voice recorder (CVR) transcript revealed that the captain repeatedly instructed the first officer to correct for the approach path deviations. Furthermore, the majority of the approach was conducted with a flight-idle power setting and no standard altitude callouts were made during the final approach. Instead of performing a go-around and acknowledging the unstable approach conditions, the captain instructed the first officer to use the air brakes on final approach to reduce the altitude and airspeed. Shortly after this comment was made, the captain announced that they were low on the approach and a few seconds later the captain announced that trees were observed in their flight path. The CVR captured sounds consistent with power increasing; however, the audible stall warning tone was also heard. Subsequently, the airplane continued its descent and impacted terrain about .70 nautical mile from the runway. The airplane was destroyed by impact forces and both occupants were killed.
Probable cause:
The flight crew’s continuation of an unstable dark night visual approach and the captain’s instruction to use air brakes during the approach contrary to airplane operating limitations, which resulted in a descent below the glide path, and a collision with terrain. Contributing to the accident was the captain’s poor crew resource management and failure to take over pilot flying responsibilities after the first officer repeatedly demonstrated deficiencies in flying the airplane, and the operator’s lack of safety management system and flight data monitoring program to proactively identify procedural non-compliance and unstable approaches.
Final Report:

Crash of a Britten Norman BN-2B-26 Islander in Montserrat

Date & Time: Sep 29, 2021 at 1733 LT
Type of aircraft:
Operator:
Registration:
J8-VBI
Survivors:
Yes
Schedule:
Saint John’s – Montserrat
MSN:
2025
YOM:
1981
Flight number:
SVD207
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2650
Captain / Total hours on type:
712.00
Circumstances:
After an uneventful return flight to Barbuda, the aircraft departed Antigua at 2114 hrs (1714 hrs local) for John A Osborne Airport, Montserrat, with the pilot and six passengers on board. The aircraft cruised at 2,000 ft enroute and the pilot recalled there were good visual meteorological conditions throughout the 19 minute flight. On arriving at Montserrat there were no other aircraft operating in the vicinity of the airport and the pilot positioned the aircraft visually on a downwind leg for Runway 10. The pilot reported he commenced the approach, flying an approach speed of 65 kt, reducing to 60 kt as the aircraft touched down. The runway surface was dry and the pilot described the landing as “smooth”. After the main landing gear touched down, but prior to the nosewheel contacting the runway, the pilot applied the brakes. He reported that the left brake felt “spongy” and did not seem to act, but that the right brake felt normal. The pilot was unable to maintain directional control of the aircraft which veered to the right two seconds after touchdown, departing the runway a further three seconds later. The aircraft continued across the adjacent grassed area before impacting an embankment close to the runway. After the aircraft had come to a stop, the pilot shut down the engines using the normal shut down procedure. The left main gear had collapsed and rendered the left cabin exit unusable. The pilot evacuated through the flight deck door which was on the left of the aircraft. The six passengers were able to evacuate through the right cabin exit. The airport fire service then arrived at the aircraft, less than one minute after the accident.
Probable cause:
On landing at John A. Osborne Airport, Montserrat, the pilot was unable to maintain directional control of the aircraft, later reporting the left brake felt “spongy”. The aircraft veered off the right side of the runway and came to rest in an adjacent drainage ditch. An inspection of the aircraft’s braking system revealed a slight brake fluid leak from one of the pistons in the left outboard brake calliper. This would have prevented full brake pressure being achieved on the left brakes, resulting in an asymmetric braking effect. Difficulty in maintaining directional control was compounded by the use of an incorrect braking technique on landing. The investigation identified shortcomings with the operator’s manuals, procedures and regulatory oversight.
Final Report:

Crash of a Beechcraft 3NMT Expeditor in Bastia

Date & Time: Sep 14, 2021 at 1025 LT
Type of aircraft:
Registration:
G-BKGL
Flight Type:
Survivors:
Yes
Schedule:
Bastia - Bastia
MSN:
A-764
YOM:
1952
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4000
Captain / Total hours on type:
15.00
Circumstances:
On August 19, 2021, the airplane was acquired by a British citizen in Saudi Arabia and repatriated to UK via Egypt, Crete, Greece, Croatia and France. On August 25, en route from Croatia to France, the right engine suffered a loss of hydraulic pressure after the cylinder n°5 failed. The crew diverted to Bastia-Poretta Airport where he landed safely. On September 13, the cylinder n°5 was replaced by a qualified technician and a post maintenance control flight was scheduled for September 14, despite the pilot was slightly ill. The airplane departed Bastia-Poretta Airport at 1010LT and six minutes later, the pilot informed ATC that the control was completed and that he wanted to return to the airport. Due to departure traffic, the pilot was asked to fly along the mountain for a left hand circuit to land on runway 34. Seven minutes later, the right engine failed, followed 20 seconds later by a loss of power on the left engine. With a rate of descent between 900 and 1,500 feet per minute, the pilot was unable to reach the airport and attempted an emergency landing when the airplane impacted trees and crashed in an orchard, bursting into flames. All three occupants escaped the airplane by their own and were injured. The airplane was totally destroyed by a post crash fire.
Probable cause:
Most likely, the fuel selectors were in the 'Nose' position at start-up. The pilot thought that the main tanks were selected. He probably took off and flew on the 'Nose' tank, common to both engines, without realizing it. At the end of the downwind leg, having probably consumed all the fuel available in the 'Nose' tank, the right engine stopped. In this hypothesis, the left engine would also have suffered the effects of a fuel supply failure. This hypothesis is consistent with the observation of the position of the left and right fuel selectors on 'Nose' in the wreckage, and the pilot's initial testimony that the selectors had not been manipulated. The pilot, who was no longer able to hold the landing and was too far from the runway to reach it, was unable to avoid colliding with trees during the forced landing. His attention was focused on the aircraft's path, and he didn't think to switch off the battery, magnetos or the fuel supply system. During the collision with trees, the right engine and wing were torn off, and a fire broke out.
It is considered that the following factors may have contributed to the probable selection of fuel selectors on the 'Nose' instead of the main tanks:
- The pilot's lack of experience on type, which could have exposed him to a selection error and which was not conducive to his detection during the pre-start-up and pre-takeoff checks;
- The ergonomics of the fuel tank selector levers, which could have led him to think that they were positioned on 'Front';
- The pilot's state of health and fatigue at the time he undertook the flight, which was likely to have impaired his cognitive abilities.
- A form of objective-destination linked to the accumulated delay in repairing the cylinder may have contributed to the pilot's decision not to postpone the flight, despite his altered general state;
- A misrepresentation of the position of the fuel selectors may have led the pilot not to change their position when the engine problem occurred.
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 Let L-410UVP-E20 in Kazashinskoye: 4 killed

Date & Time: Sep 12, 2021 at 2251 LT
Type of aircraft:
Operator:
Registration:
RA-67042
Survivors:
Yes
Schedule:
Irkutsk – Kazashinskoye
MSN:
14 29 16
YOM:
2014
Flight number:
SL51
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
5623
Captain / Total hours on type:
4625.00
Copilot / Total flying hours:
1385
Copilot / Total hours on type:
693
Aircraft flight hours:
5481
Aircraft flight cycles:
3632
Circumstances:
The twin engine airplane was supposed to depart Irkust at 1435LT but the flight had been delayed for several hours. On approach to Kazashinskoye Airport, the crew encountered poor visibility due to the night and fog. On final approach to runway 04, at an altitude of 130 metres, the crew initiated a go-around procedure as he was unable to establish a visual contact with the ground. Few minutes later, during a second attempt to land, the crew descended to the height of 10 metres when he initiated a second go-around procedure, again for the same reason. The airplane climbed to an altitude of 400 metres then the crew made a 180 turn in an attempt to land on runway 22. In below minima weather conditions, the airplane deviated 1,100 metres to the right of the runway 22 extended path, descended into trees and crashed in a wooded area located about 3 km from the airport. Three passengers and a pilot were killed while 12 others occupants were injured. The aircraft was totally destroyed by impact forces.
Probable cause:
The accident was the consequence of the crew's non-compliance with the rules for visual flights at night, which was expressed in making an approach to land with visibility below the established minimum values, leading to a collision with natural obstacles and resulting in a controlled flight into terrain (CFIT).
The following contributing factors were identified:
- The discrepancy between the coordinates of the runway thresholds at Kazachinskoe in the GPS receivers of the aircraft commander and the co-pilot and their actual values, which led to an incorrect calculation for landing ;
- The failure of the aircraft commander to make a timely decision to divert to an alternate airport despite having information about the meteorological conditions not meeting the established minimum values. The individual psychological characteristics of the aircraft commander allowed him to make leadership decisions, but in the case of their erroneousness, he did not possess the ability to correct them and was inclined to unjustifiably risky, dangerous decisions ;
- The crew's use of the autopilot in the final stage of flight, which did not comply with the Flight Operations Manual. The autopilot modes selected significantly reduced the crew's situational awareness. In fact, the descent was carried out significantly to the right of the extended runway centerline over an area that lacked light landmarks ;
- The lack of proper interaction within the crew and insufficient monitoring of flight parameters.
Final Report:

Crash of a Cessna 402C in Provincetown

Date & Time: Sep 9, 2021 at 1600 LT
Type of aircraft:
Operator:
Registration:
N88833
Survivors:
Yes
Schedule:
Boston – Provincetown
MSN:
402C-0265
YOM:
1979
Flight number:
9K2072
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17617
Captain / Total hours on type:
10000.00
Aircraft flight hours:
36722
Circumstances:
The pilot was transporting six passengers on a scheduled revenue flight in instrument meteorological conditions. The pilot familiarized himself with the weather conditions before departure and surmised that he would be executing the instrument landing system (ILS) instrument approach for the landing runway at the destination airport. The operator prohibited approaches to runways less than 4,000 ft long if the tailwind component was 5 knots or more. The landing runway was 498 ft shorter than the operator-specified length. The pilot said he obtained the automated weather observing system (AWOS) data at least twice during the flight since he was required to obtain it before starting the instrument approach and then once again before he crossed the approach’s final-approach-fix (FAF). Though the pilot could not recall when he checked the AWOS, he said the conditions were within the airplane and company performance limits and he continued with the approach. A review of the wind data at the time he accepted the approach revealed the tailwind component was within limitations. As the airplane approached the FAF, wind speed increased, and the tailwind component ranged between 1 and 7 knots. Since the exact time the pilot checked the AWOS is unknown, it is possible that he obtained an observation when the tailwind component was within operator limits; however, between the time that the airplane crossed over the FAF and the time it landed, the tailwind component increased above 5 knots. The pilot said the approach was normal until he encountered a strong downdraft when the airplane was about 50 to 100 ft above the ground. He said that the approach became unstabilized and that he immediately executed a go-around; the airplane touched down briefly before becoming airborne again. The pilot said he was unable to establish a positive rate of climb and the airplane impacted trees off the end of the runway. The accident was captured on three airport surveillance cameras. A study of the video data revealed the airplane made a normal landing and touched down about 500 ft from the beginning of the runway. It was raining heavily at the time. The airplane rolled down the runway for about 21 seconds, and then took off again. The airplane entered a shallow climb, collided with trees, and caught on fire. All seven occupants were seriously injured and the airplane was destroyed.
Probable cause:
The pilot’s delayed decision to perform an aborted landing late in the landing roll with insufficient runway remaining. Contributing to the accident was the pilot’s failure to execute a go-around once the approach became unstabilized, per the operator’s procedures.
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 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: