Crash of a Piper PA-46-350P Malibu Mirage in Worcester

Date & Time: Feb 2, 2021 at 1655 LT
Registration:
N221ST
Flight Type:
Survivors:
Yes
Schedule:
Martha’s Vineyard – Worcester
MSN:
46-36651
YOM:
2014
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot reported that, while descending through clouds and beginning the instrument approach, some ice accumulated on the wings and he actuated the deice boots twice. The pilot saw the deice boots functioning normally on the wings and could not see the tail; however, the elevator began to shake, and he lost elevator control. The pilot applied forward pressure on the yoke and had to trim nose-down to avoid a stall. There were no cockpit caution indications and the pilot had disengaged the autopilot before descent. The airplane descended through the clouds and impacted a tree before coming to rest upright in a grass area. Postaccident examination of the wreckage, including component testing of the deice system, did not reveal any preimpact mechanical malfunctions. The flap jackscrew position suggested that the flaps were likely in transit between 0° and 10° flap extension at the time of impact. Review of radar data revealed that, during the 2 minutes before the accident, the airplane’s groundspeed averaged about 82 knots; or an approximate average airspeed of 94 knots when accounting for the winds aloft. Current weather observations and forecast weather products indicated that the airplane was likely operating in an area where moderate and potentially greater structural icing conditions prevailed, and where there was the potential for the presence of supercooled liquid droplets. Review of the pilot operating handbook for the airplane revealed that the minimum speed for flight in icing conditions was 130 knots indicated airspeed. It is likely that the pilot’s failure to maintain an appropriate speed for flight in icing conditions resulted in insufficient airflow over the ice contaminated elevator and the subsequent loss of elevator control.
Probable cause:
The pilot’s failure to maintain the minimum airspeed for flight in icing conditions, which resulted in a loss of elevator control during approach due to ice accumulation.
Final Report:

Crash of a Harbin Yunsunji Y-12E in Mukinge

Date & Time: Jan 26, 2021 at 0850 LT
Type of aircraft:
Operator:
Registration:
AF-222
Flight Type:
Survivors:
Yes
Schedule:
Lusaka - Mukinge
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Lusaka Airport on a flight to Mukinge, carrying five crew members and a load of five diesel drums. After touchdown at Mukinge Airfield, the aircraft was unable to stop within the remaining distance. It overran, collided with obstacles and came to rest with its nose and cockpit severely damaged. Both pilots were injured and three other crew members escaped uninjured.

Very hard landing of a Boeing 737-4Q8 in Exeter

Date & Time: Jan 19, 2021 at 0237 LT
Type of aircraft:
Operator:
Registration:
G-JMCY
Flight Type:
Survivors:
Yes
Schedule:
East Midlands – Exeter
MSN:
25114/2666
YOM:
1994
Flight number:
NPT05L
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15218
Captain / Total hours on type:
9000.00
Circumstances:
The crew were scheduled to operate two cargo flights from Exeter Airport (EXT), Devon, to East Midlands Airport (EMA), Leicestershire, and return. The co-pilot was the PF for both sectors, and it was night. The sector from EXT to EMA was uneventful with the crew electing to landed with FLAP 40. The subsequent takeoff and climb from EMA to EXT proceeded without event. During the cruise the crew independently calculated the landing performance, using the aircraft manufacturer’s software, on their portable electronic devices. Runway 26 was forecast to be wet, so they planned to use FLAP 40 for the landing on Runway 26, with AUTOBRAKE 3. With both pilots being familiar with EXT the PF conducted a short brief of the pertinent points for the approach. However, while they did mention that the ILS had a 3.5° glideslope (GS), they did not mention that the stabilized approach criteria differed from that on a 3° GS. From the ATIS they noted that the weather seemed to be better than forecast and the surface wind was from 230° at 11 kt. The ATC provided the flight crew with radar vectors from ATC to the ILS on Runway 26 at EXT. The landing gear was lowered and FLAP 25 selected before the aircraft intercepted the GS. FLAP 40 (the landing flap) was selected on the GS just below 2,000 ft amsl. With a calculated VREF of 134 kt and a surface wind of 10 kt the PF planned to fly the approach with a VAPP of 140 kt. At about 10 nm finals, upon looking at the flight management computer, the PM noticed there was a 30 kt headwind, so a VAPP of 144 kt was selected on the Mode Control Panel (MCP). The crew became visual with the runway at about 1,000 ft aal. The PF then disconnected the Auto Pilot and Auto Throttle; the Flight Directors remained on. As the wind was now starting to decrease, the VAPP was then reduced from 142 to 140 kt at about 600 ft aal. As the wind reduced, towards the 10 kt surface wind, the PF made small adjustments to the power to maintain the IAS at or close to VAPP. At 500 ft radio altimeter (RA) the approach was declared stable by the crew, as per their standard operating procedures. At this point the aircraft had a pitch attitude of 2.5° nose down, the IAS was 143 kt, the rate of descent (ROD) was about 860 ft/min, the engines were operating at about 68% N1 and the aircraft was 0.4 dots above the GS. However, the ROD was increasing and soon thereafter was in excess of 1,150 ft/min. This was reduced to about 300 ft/min but soon increased again. At 320 ft RA, the aircraft went below the GS for about 8 seconds and, with a ROD of 1,700 ft/min, a “SINK RATE” GPWS alert was enunciated. The PF acknowledged this and corrected the flightpath to bring the aircraft back to the GS before stabilizing slightly above the GS; the PM called this deviation too. As the PF was correcting back to the GS the PM did not feel there was a need to take control. During this period the maximum recorded deviation was ¾ of a dot below the GS. At about 150 ft RA, with a ROD of 1,300 ft/min, there was a further “SINK RATE” GPWS alert, to which the PM said, “WATCH THAT SINK RATE”, followed by another “SINK RATE” alert, which the PF responded by saying “AND BACK…”. The commander recalled that as the aircraft crossed the threshold, at about 100 ft, the PF retarded the throttles, pitched the aircraft nose down, from about 5° nose up to 4° nose down, and then applied some power in the last few feet. During these final moments before the landing, there was another “SINK RATE” alert. The result was a hard landing. A “PULL UP” warning was also triggered by the GPWS, but it was not audible on the CVR. The last surface wind transmitted by ATC, just before the landing, was from 230° at 10 kt. During the rollout the commander took control, selected the thrust reversers and slowed down to taxi speed. After the aircraft had vacated the runway at Taxiway Bravo it became apparent the aircraft was listing to the left. During the After Landing checks the co-pilot tried to select FLAPS UP, but they would not move. There was then a HYDRAULIC LP caution. As there was still brake accumulator pressure the crew were content to taxi the aircraft slowly the short distance onto Stand 10. Once on stand the listing became more obvious. It was then that the crew realized there was something “seriously wrong” with the aircraft. After they had shut the aircraft down, the flight crew requested that the wheels were chocked, and the aircraft be connected to ground power before going outside to inspect the aircraft. Once outside a hydraulic leak was found and the airport RFFS, who were present to unload the aircraft, were informed.
Probable cause:
The aircraft suffered a hard landing as a result of the approach being continued after it became unstable after the aircraft had past the point where the crew had declared the approach stable and continued. Despite high rates of descent being observed beyond the stable point, together with associated alerts the crew elected to continue to land. Had the approach been discontinued and a GA flown, even at a low height, while the aircraft may have touched down the damage sustained may have been lessened. While the OM did not specifically state that an approach was to remain stable beyond the gate on the approach, the FCTM was specific that, if it did not remain stable, a GA should be initiated. The commander may have given the co-pilot the benefit of doubt and believed she had the ability to correct an approach that became unstable in the final few hundred feet of the approach. However, had there been any doubt, a GA should be executed.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Old Bethpage

Date & Time: Jan 10, 2021 at 1302 LT
Registration:
N421DP
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Farmingdale – Bridgeport
MSN:
421B-0353
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1893
Captain / Total hours on type:
12.00
Aircraft flight hours:
5331
Circumstances:
The pilot reported that, during the initial climbout, about 1,000 ft above ground level, one of the engines stopped producing power. He confirmed that all engine controls were full forward and the main fuel tanks were selected. Immediately thereafter, the remaining engine began to surge, then stopped producing power. He established best glide speed and looked for an area to perform a forced landing. The airplane crashed into a solid waste disposal facility, about 2.3 nautical miles northwest of the departure airport. First responders arrived immediately after the accident and found only a trace amount of fuel within the confines of the accident site or in the fuel tanks. The only postaccident fire was centered on a small, localized area near the right engine turbocharger. Both main fuel tanks were empty, and the auxiliary bladder tanks were ruptured by impact forces. Examination of both engines revealed no evidence of a pre accident malfunction or anomaly. A surveillance video showed no evidence of smoke or mist training the airplane seconds prior to impact. The pilot reported that he departed the airport with 112 gallons of fuel on board. The pilot did not provide evidence of the latest refueling when requested by investigators. The available evidence is consistent with a total loss of engine power to both engines due to fuel exhaustion.
Probable cause:
The pilot’s inadequate preflight fuel planning, which resulted in a total loss of engine power due to fuel exhaustion and a forced landing.
Final Report:

Crash of a Learjet 31A in Diamantina

Date & Time: Jan 2, 2021 at 0851 LT
Type of aircraft:
Operator:
Registration:
PP-BBV
Flight Type:
Survivors:
Yes
Schedule:
São Paulo – Diamantina
MSN:
31-113
YOM:
1995
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4606
Captain / Total hours on type:
1138.00
Copilot / Total flying hours:
1475
Copilot / Total hours on type:
680
Circumstances:
The airplane departed São Paulo-Congonhas Airport on an ambulance flight to Diamantina-Juscelino Kubitschek Airport, carrying two doctors and two pilots. Following an unstabilized approach, the airplane landed too far down the runway 03 and was unable to stop within the remaining distance. It overran, went down a ravine and came to rest. All four occupants evacuated with minor injuries while the aircraft was damaged beyond repair.
Probable cause:
Following a wrong approach configuration on part of the crew, it was determined that the airplane landed about 600 metres from the runway end. In such conditions, the airplane could not be stopped within the remaining distance.
The following contributing factors were identified:
- Both pilots knew each other well and often flew together, thus it is possible that they over-relied on each other during the final phase of the flight,
- This over-confidence led the crew to neglect certain parameters related to the approach manoeuvre,
- Lack of crew coordination,
- Post-accident medical examinations revealed that the pilot-in-commands' (PF) lack of reaction to the pilot monitoring's (PM) warnings, and his impaired alertness, could indicate that he was suffering from the effects of alcohol and fatigue, reducing his performances,
- The pilots' decision to continue with the landing procedure despite an unstabilized approach characterized by inadequate situational awareness,
- Poor judgment on the part of the crew who failed to take the correct decision to initiate a go-around procedure.
Final Report:

Crash of a Hawker 800XP in Farmingdale

Date & Time: Dec 20, 2020 at 2035 LT
Type of aircraft:
Operator:
Registration:
N412JA
Flight Type:
Survivors:
Yes
Schedule:
Miami - Farmingdale
MSN:
258516
YOM:
2001
Flight number:
TFF941
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4188
Captain / Total hours on type:
2060.00
Copilot / Total flying hours:
10000
Copilot / Total hours on type:
4100
Aircraft flight hours:
12731
Circumstances:
The flight crew were conducting an instrument landing system (ILS) approach in night instrument meteorological conditions when they were advised by the tower controller that the weather had deteriorated below minimums. The captain was the pilot monitoring, and the first officer was the pilot flying during the approach. Since the airplane was inside the final approach fix and stabilized, both pilots agreed to continue with the approach. Both pilots stated that they had visual contact with the runway approach lighting system at the 200 ft above ground level (agl) decision altitude, and they decided to continue the approach. The first officer said he then returned to flying the airplane via instruments. As the first officer continued the approach, the captain told him the airplane was drifting right of the runway centerline. The first officer said that he looked outside, saw that the weather had deteriorated, and was no longer comfortable with the approach. The first officer said he pressed the takeoff and go-around switch, while at the same time, the captain called for a go-around. The captain said that he called for the go-around because the airplane was not aligned with the runway. Although both pilots stated that the go-around was initiated when the airplane was about 50 to 100 ft agl, the cockpit voice recorder (CVR) recording revealed that the first officer flew an autopilot-coupled approach to 50 ft agl (per the approach procedure, a coupled approach was not authorized below 240 ft agl). As the airplane descended from 30 to 20 ft agl, the captain told the first officer three times to “flare” then informed him that the airplane was drifting to right and he needed to make a left correction to get realigned with the runway centerline. Three seconds passed before the first officer reacted by trying to initiate transfer control of the airplane to the captain. The captain did not take control of the airplane and called for a go-around. The first officer then added full power and called for the flaps to be retracted to 15º; however, the airplane impacted the ground about 5 seconds later, resulting in substantial damage to the fuselage. Data downloaded from both engines’ digital electronic engine control units revealed no anomalies. No mechanical issues with the airplane or engines were reported by either crew member or the operator. The sequence of events identified in the CVR recording revealed that the approach most likely became unstabilized after the autopilot was disconnected and when the first officer lost visual contact with the runway environment. The captain, who had the runway in sight, delayed calling for a go-around after the approach became unstabilized, and the airplane was too low to recover.
Probable cause:
The flight crew’s delayed decision to initiate a go-around after the approach had become unstabilized, which resulted in a hard landing.
Final Report:

Crash of an Eclipse EA500 in Leadville

Date & Time: Dec 13, 2020 at 2000 LT
Type of aircraft:
Operator:
Registration:
N686TM
Flight Type:
Survivors:
Yes
Schedule:
San Diego – Leadville
MSN:
221
YOM:
2008
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5300
Captain / Total hours on type:
31.00
Aircraft flight hours:
1740
Circumstances:
The pilot reported that, while conducting a night landing on a runway contaminated with ice and patchy packed snow, the airplane overshot the touchdown zone. The pilot tried to fly the airplane onto the runway to avoid floating. The airplane touched down firm and the pilot applied moderate braking, but the airplane did not decelerate normally. The airplane went off the end of the runway and collided with several Runway End Identifier Lights (REILs) and a tree. The airplane sustained substantial damage to the left and right wings. The pilot reported that he did not feel modulation in the anti-lock braking system (ABS) and felt that might have contributed to the accident. An examination of fault codes from the airplane’s diagnostic storage unit indicated no ABS malfunctions or failures. An airport employee reported that he saw the airplane unusually high on the final approach and during the landing the airplane floated or stayed in ground effect before it touched down beyond the midpoint of the runway. The airplane’s long touchdown was captured by an airport surveillance video, which is included in the report docket.
Probable cause:
The pilot’s failure to maintain proper control of the airplane, which led to an unstabilized approach and a long landing on a runway contaminated with ice and patchy packed snow resulting in a runway excursion.
Final Report:

Crash of a Cessna T303 Crusader in Annecy

Date & Time: Dec 4, 2020 at 1550 LT
Type of aircraft:
Operator:
Registration:
HB-LUV
Flight Type:
Survivors:
Yes
Schedule:
Marseille - Annecy
MSN:
303-00058
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1077
Circumstances:
The twin engine airplane departed Marseille-Provence Airport on a private flight to Annecy. En route, while cruising at FL110, the pilot was informed about the weather conditions at destination with a braking coefficient considered as medium due to a wet runway. After being cleared to land on runway 04, the pilot continued the approach but landed half way down the runway at a speed of 119 knots. After touchdown, he initiated the braking procedure but the airplane suffered an aquaplaning and was unable to stop within the remaining distance. It overran, impacted an embankment, went trough a fence and came to rest on a road. While both passengers aged 26 and 28 were slightly injured, the pilot aged 70 was seriously injured. The aircraft was destroyed.
Probable cause:
The accident was the result of the combination of the following factors:
- The pilot initiated the descent too late, causing the aircraft to approach well above the glide,
- The pilot continued the approach with an unstabilized airplane nor in speed nor on the glide,
- The airplane landed halfway down the runway, reducing the landing distance available,
- The speed upon touchdown was recorded at 119 knots, 30 knots above the recommended speed in the flight manual,
- The braking coefficient was considered as medium because of a wet runway surface,
- The airplane suffered an aquaplaning effect when the pilot initiated the braking procedure.
Final Report:

Crash of a Boeing 737-529 in Garowe

Date & Time: Dec 2, 2020 at 0930 LT
Type of aircraft:
Operator:
Registration:
EY-560
Survivors:
Yes
Schedule:
Djibouti – Hargeisa – Garowe – Mogadishu
MSN:
26538/2298
YOM:
1992
Flight number:
IV206
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
31
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6050
Captain / Total hours on type:
5170.00
Copilot / Total flying hours:
900
Circumstances:
The aircraft departed Djibouti on a regular schedule service to Mogadishu with intermediate stops in Hargeisa and Garowe. There were 31 passengers and 8 crew members on board. On short final approach to Garowe Airport Runway 06, the aircraft was too low, causing the right main gear to struck the ground just short of runway threshold (concrete). The right main gear collapsed and the airplane slid on the runway until it turned to the right and came to rest on the runway with the right engine cowling contacting the runway surface. All 39 occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of a Cessna 551 Citation II/SP in Lufkin

Date & Time: Dec 2, 2020 at 0842 LT
Type of aircraft:
Registration:
N48DK
Survivors:
Yes
Schedule:
Austin - Lufkin
MSN:
551-0095
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17772
Captain / Total hours on type:
2000.00
Aircraft flight hours:
9395
Circumstances:
After a 30-minute uneventful instrument flight rules (IFR) flight, the business jet landed in the rain on the 4,311ft-long runway. The pilot reported, and runway skid marks corroborated, that the airplane touched down about 1,000 ft from the approach end of the runway. The pilot reported braking action was initially normal and the anti-skid system cycled twice before it stopped working and he was unable to slow the airplane using the emergency brakes. The airplane continued off the departure end of the runway where it traveled through wet grass and a fence before coming to rest with the landing gear collapsed. A video of the airplane during the landing roll indicated there was a significant amount of water on the runway. No mechanical anomalies were found with the brake/antiskid systems during the postaccident examination of the airplane. Marks on the runway indicated functionality of the antiskid system. Stopping performance calculations estimated the distance required to stop the airplane on the runway was about 4,127 ft. The runway length remaining after the airplane touched down was about 3,311 ft. The pilot was aware of the runway length and weather conditions prior to departure and reported that he should have not accepted the trip.
Probable cause:
The pilot’s decision to land on a runway that did not provide enough length to stop the airplane given the wet surface conditions, resulting in a runway excursion.
Final Report: