Crash of a Cessna 207 Skywagon in Monterrey

Date & Time: Oct 7, 2019 at 1005 LT
Operator:
Registration:
XB-MHS
Flight Phase:
Survivors:
Yes
MSN:
207-0063
YOM:
1969
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from runway 11 at Monterrey-Del Norte Airport, while in initial climb, the single engine airplane lost height and crashed on a highway located past the runway end. Fortunately, the airplane did not struck any vehicles and eventually crashed in a field, about 15 meters below the motorway. The pilot, sole on board, was seriously injured and the aircraft was damaged beyond repair.

Crash of a Piper PA-60-602P in Kokomo: 1 killed

Date & Time: Oct 5, 2019 at 1637 LT
Operator:
Registration:
N326CW
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kokomo - Kokomo
MSN:
60-0869-8165008
YOM:
1981
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7500
Aircraft flight hours:
3002
Circumstances:
The airline transport pilot arrived at the departure airport in the reciprocating engine-powered airplane where it was fueled with Jet A jet fuel by an airport employee/line service technician. A witness stated that she saw a "low flying" airplane flying from north to south. The airplane made a "sharp left turn" to the east. The left wing "dipped low" and she then lost sight of the airplane, but when she approached the intersection near the accident site, she saw the airplane on the ground. The airplane impacted a field that had dry, level, and hard features conducive for an off-airport landing, and the airplane was destroyed. The wreckage path length and impact damage to the airplane were consistent with an accelerated stall. Postaccident examination of the airplane found Jet A jet fuel in the airplane fuel system and evidence of detonation in both engines from the use of Jet A and not the required 100 low lead fuel. Use of Jet A rather than 100 low lead fuel in an engine would result in detonation in the cylinders and lead to damage and a catastrophic engine failure. According to the Airplane Flying Handbook, the pilot should witness refueling to ensure that the correct fuel and quantity is dispensed into the airplane and that any caps and cowls are properly secured after refueling.
Probable cause:
The pilot's exceedance of the airplane’s critical angle of attack following a dual engine power loss caused by the line service technician fueling the airplane with the wrong fuel, which resulted in an aerodynamic stall and subsequent loss of control. Contributing was the pilot's inadequate supervision of the fuel servicing.
Final Report:

Crash of an Antonov AN-12BK in Lviv: 5 killed

Date & Time: Oct 4, 2019 at 0648 LT
Type of aircraft:
Operator:
Registration:
UR-CAH
Flight Type:
Survivors:
Yes
Schedule:
Vigo - Lviv - Bursa
MSN:
8345604
YOM:
1968
Flight number:
UKL4050
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
6750
Captain / Total hours on type:
6570.00
Copilot / Total flying hours:
14670
Copilot / Total hours on type:
9620
Aircraft flight hours:
12922
Aircraft flight cycles:
6616
Circumstances:
On 03.10.2019, the crew of An-12BK UR-CAH aircraft operated by PJSC «AIRLINE «UKRAINE-AIR ALLIANCE», consisting of flight crew members and two aircraft technicians, performed flight UKL4010 en-route Toronto (Canada) - Toulouse (France) and at 06:15 UTC, it landed at the Toulouse aerodrome (France). The plane delivered 1537 kg cargo to the Toulouse aerodrome (France). After the completion of post-flight procedures, the flight crew went to rest at the hotel, while the technicians remained on the aircraft to perform technical works. The next flight was scheduled from Toulouse to Birmingham airport (Great Britain). However, during the day, at the initiative of the operator, it was decided to change the route and perform the flight en-route Toulouse - Vigo (Spain) - Istanbul (Turkey). At the Toulouse aerodrome, the plane was filled with 6,000 liters of fuel. Also in Toulouse, a flight engineer was replaced. At 16:16 UTC, the plane took off from Toulouse to Vigo without cargo. Landing at the Vigo aerodrome (Spain) was performed on 03.10.2020 at 18:20 UTC. At the Vigo aerodrome, the plane was loaded with vehicle spare parts with a total weight of probably 14078 kg. From the Vigo aerodrome (Spain), the plane took off on 03.10.2019 at 22:20, flight UKL4050, with a delay of 2 h 20 minutes. On 04.10.2020, at 03:17:29 UTC, the plane approached the airspace border of the Lviv control area. The crew contacted the controller of the Lviv ACC of LVE + LVW sector and reported about the approach to waypoint MALBE at FL250. The controller informed the crew about the establishment of the radar identification of the aircraft and instructed to wait for the procedure for radar guidance to RW-31 using the ILS system. At 03:20:27, under instruction the ACC controller, the crew listened to the ATIS "Romeo" information as follows: “Lviv, ATIS “Romeo” for 03:20. The ILS approach at the aerodrome uses low visibility procedures. Runway in use is RW-31. Runway surface condition known at 19:53 - wet, clear. The measured friction coefficient is 0.55. Estimated surface friction assessed as good. Transition level - 110. Warning: large flocks of birds in the aerodrome area and on the landing final. There is no wind. Visibility - 150 meters; visibility range on the runway at the touchdown point - 550 meters, in the middle of the runway - 550 meters, at the end of the runway - 550 meters, fog. Vertical visibility - 50 meters. Temperature + 3ºС, dew point + 3ºС. Atmospheric pressure QNH - 1013 hectopascals, QFE - 974 hectopascals. Weather forecast for TREND landing: visibility sometimes is 400 meters, fog; vertical visibility - 60 meters. Attention: the frequency "Lviv-taxiing" does not work, while taxiing, get in touch with the "LvivTower" at a frequency of 128.0 MHz. Please acknowledge receipt of Romeo's information." ATIS information was transmitted in English. At 03:22:14, the crew informed the controller about the completion of listening to ATIS information and received clearance to descend to FL120. At 03:22:40, the aircraft began its descent from FL250 and at 03:28:35 switched to the frequency of the ACC controller of the LVT sector. After contacting the controller of the ACC of the LVT sector, the crew reported a descend to FL120 to KOKUP point. At 03:29:08, the ACC controller of the LVT sector instructed the crew to continue descending to an altitude of 10,000 feet at atmospheric pressure QNH-1013 hPa, reported the transition level, and instructed to wait for radar guidance for ILS approach on RW-31. The crew confirmed the instruction to descent to 10,000 feet, QNH, transition level and reported expectation for radar guidance. At 03:30:14, LVT sector ACC controller began radar guidance. At 03:32:49, the controller instructed the crew to descend to 4,000 feet. At 03:35:33, LVT sector ATC controller instructed to descend to an altitude of 3200 feet, taking into account the temperature correction. The procedure for temperature correction at determination of flight levels by an air traffic controller during the radar vectoring was published in the Aeronautical Information Publication of Ukraine, UKLL AD 2.24.7-1 dated 12.09.2019. At 03:38:33, the ATC controller of the LVT sector provided the crew with information about its location of 27 km from VOR/DME LIV, instructed by the left turn to take a 340º heading, cleared the ILS landing approach to runway 31 and gave the control instruction to inform of “the localizer beam capture.” At 03:40:01 (the height above the runway was 1170 m, descent rate: -4 ... -4.5 m/s, speed 352 km/h, distance from the runway threshold: 15.7 km), the crew reported of the localizer beam capture. At 03:40:09, ATC controller of LVT sector instructed the crew to continue the ILS approach to RWY 31. At 03:40:26, the controller informed the crew about the weather conditions at the aerodrome: RW-31 runway visual range (RVR) in the touchdown zone – 800 meters, in the middle of the runway – 800 meters, at the end of the runway – 750 meters, vertical visibility – 60 meters, fog. The crew confirmed receipt of the information. At 03:41:22, the ATC controller of LVT sector instructed to switch the communication to the ATC Lviv controller at a frequency of 128.0 MHz. There were no irregularities in air traffic servicing of the An-12 aircraft, flight UKL4050, during the flight in the area of responsibility of the TMA Lviv "LVT" sector. To enter the glide path, the PIC increased the vertical descent rate. At 03:41:47, the crew established communication with the Tower controller. The distance from the threshold was 11.3 km, the elevation over the glide path was 70 m, the vertical rate of descent was -5.5 ... -6 m/s. After communication with the air traffic controller, the crew reported an ILS approach to RW-31 and the atmospheric pressure QNH setting of 1013 hPa. At 03:41:58, the Tower controller informed the crew about the absence of wind on the surface of RW-31 and gave clearance to land. The crew confirmed the landing clearance. According to the recorders, at this time the distance to the touchdown point was 7.58 km, the plane was 11 m below the glide path, the vertical descent rate was -4.5-5.5 m/s, and the speed was 290 km/h, the flight heading – 315º. At a distance of 5.0 km to the touchdown point, the plane was 25 m below the glide path. At a distance of 3 km from the touchdown, the plane descended to an altitude of 105 meters and continued the flight with the constant descent. At an altitude of 60 meters, an audible alarm was triggered on board the aircraft, when the decision height had been reached, to which none of the crew members responded. At a distance of 1348 meters from the threshold of the RW-31, at an altitude of 5-7 meters, the aircraft collided with trees, fell to the ground and came to rest at a distance of 1117 meters from the runway threshold. All three passengers were seriously injured and all five crew members were killed.
Probable cause:
The most probable cause of the accident, collision of a serviceable aircraft with the ground during the landing approach in a dense fog, was the crew’s failure to perform the flight in the instrument conditions due to the probable physical excessive fatigue, which led to an unconscious descent of the aircraft below the glide path and ground impact (controlled flight into terrain).
Contributing Factors:
Probable exceeding the aircraft takeoff weight during departure from the Vigo Airport, which could result in increase in consumption of the fuel, the remainder of which did not allow to perform the flight to the alternate Boryspil aerodrome.
Final Report:

Crash of a Socata TBM-700 in Lansing: 5 killed

Date & Time: Oct 3, 2019 at 0858 LT
Type of aircraft:
Operator:
Registration:
N700AQ
Flight Type:
Survivors:
Yes
Schedule:
Indianapolis - Lansing
MSN:
252
YOM:
2003
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
1404
Captain / Total hours on type:
76.00
Aircraft flight hours:
3550
Circumstances:
The pilot was conducting an instrument approach at the conclusion of a cross-country flight when the airplane entered a shallow climb and left turn away from the runway heading about 0.5-mile from the intended runway. According to airspeeds calculated from automatic dependent surveillance-broadcast position data, the airplane’s calibrated airspeed was 166 knots when it crossed over the final approach fix inbound toward the runway and was about 84 knots when it was on a 0.5-mile final approach. The airplane continued to decelerate to 74 knots while it was in a shallow climb and left turn away from the runway heading. At no point during the approach did the pilot maintain the airframe manufacturer’s specified approach speed of 85 knots. The airplane impacted the ground in an open grass field located to the left of the extended runway centerline. The airplane was substantially damaged when it impacted terrain in a wings level attitude. The postaccident examination did not reveal any anomalies that would have precluded normal operation of the airplane. The altitude and airspeed trends during the final moments of the flight were consistent with the airplane entering an aerodynamic stall at a low altitude. Based on the configuration of the airplane at the accident site, the pilot likely was retracting the landing gear and flaps for a go around when the airplane entered the aerodynamic stall. The airplane was operating above the maximum landing weight, and past the aft center-of-gravity limit at the time of the accident which can render the airplane unstable and difficult to recover from an aerodynamic stall. Additionally, without a timely corrective rudder input, the airplane tends to roll left after a rapid application of thrust at airspeeds less than 70 knots, including during aerodynamic stalls. Although an increase in thrust is required for a go around, the investigation was unable to determine how rapidly the pilot increased thrust, or if a torque-roll occurred during the aerodynamic stall.
Probable cause:
The pilot’s failure to maintain airspeed during final approach, which resulted in a loss of control and an aerodynamic stall at a low altitude, and his decision to operate the airplane outside of the approved weight and balance envelope.
Final Report:

Crash of a Boeing B-17G-30-BO Flying Fortress in Windsor Locks: 7 killed

Date & Time: Oct 2, 2019 at 0953 LT
Operator:
Registration:
N93012
Flight Type:
Survivors:
Yes
Schedule:
Windsor Locks - Windsor Locks
MSN:
7023
YOM:
1942
Crew on board:
3
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
14500
Captain / Total hours on type:
7300.00
Copilot / Total flying hours:
22000
Copilot / Total hours on type:
23
Aircraft flight hours:
11388
Circumstances:
The vintage, former US military bomber airplane was on a tour that allowed members of the public to purchase an excursion aboard the airplane for an LHFE flight. The accident flight was the airplane’s first flight of the day. During the initial climb, one of the pilots retracted the landing gear, and the crew chief/flight engineer (referred to as the loadmaster) left the cockpit to inform the passengers that they could leave their seats and walk around the airplane. One of the pilots reported to air traffic control that the airplane needed to return to the airport because of a rough magneto. At that time, the airplane was at an altitude of about 600 ft above ground level (agl) on the right crosswind leg of the airport traffic pattern for runway 6. The approach controller asked the pilot if he needed any assistance, to which the pilot replied, “negative.” When the loadmaster returned to the cockpit, he realized that the airplane was no longer climbing, and the pilot, realizing the same, instructed the copilot to extend the landing gear, which he did. The loadmaster left the cockpit to instruct the passengers to return to their seats and fasten their seat belts. When the loadmaster returned again to the cockpit, the pilot stated that the No. 4 engine was losing power; the pilot then shut down that engine and feathered the propeller without any further coordination or discussion. When the airplane was at an altitude of about 400 ft agl, it was on a midfield right downwind leg for runway 6. Witness video showed that the landing gear had already been extended by that time, even though the airplane still had about 2.7 nautical miles to fly in the traffic pattern before reaching the runway 6 threshold. During final approach, the airplane struck the runway 6 approach lights in a right-wing-down attitude about 1,000 ft before the runway and then contacted the ground about 500 ft before the runway. After landing short of the runway, the airplane traveled onto the right edge of the runway threshold and continued to veer to the right. The airplane collided with vehicles and a deicing fluid tank before coming to rest upright about 940 ft to the right of the runway. A postcrash fire ensued. Both pilots and five passengers were killed and all six other occupants as well as one people on the ground were injured, five seriously.
Probable cause:
The pilot’s failure to properly manage the airplane’s configuration and airspeed after he shut down the No. 4 engine following its partial loss of power during the initial climb. Contributing to the accident was the pilot/maintenance director’s inadequate maintenance while the airplane was on tour, which resulted in the partial loss of power to the Nos. 3 and 4 engines; the Collings Foundation’s ineffective safety management system (SMS), which failed to identify and mitigate safety risks; and the Federal Aviation Administration’s inadequate oversight of the Collings Foundation’s SMS.
Final Report:

Crash of a Cessna 421A Golden Eagle I in DeLand: 3 killed

Date & Time: Sep 29, 2019 at 1600 LT
Type of aircraft:
Operator:
Registration:
N731PF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
DeLand - DeLand
MSN:
421A-0164
YOM:
1968
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
500
Captain / Total hours on type:
0.00
Aircraft flight hours:
858
Circumstances:
The owner of the airplane had purchased the airplane with the intent to resell it after repairs had been made. As part of that process, a mechanic hired by the owner had assessed the airplane’s condition, proposed the necessary repairs to the airplane’s owner, and had identified a pilot who would, once the repairs and required inspection annual inspection had been completed, fly the airplane from where it was located to where the owner resided. While the mechanic had identified a potential pilot for the relocation flight, he had not yet completed the repairs to the airplane, nor had he completed the necessary logbook entries that would have returned the airplane to service. The pilot-rated passenger onboard the airplane for the accident flight, was the pilot who had been identified by the mechanic for the relocation flight. Review of the pilot-rated passenger’s flight experience revealed that he did not possess the necessary pilot certificate rating, nor did he have the flight experience necessary to act as pilot-in-command of the complex, highperformance, pressurized, multi-engine airplane. Additionally, the owner of the airplane had not given the pilot-rated-passenger, or anyone else, permission to fly the airplane. The reason for, and the circumstances under which the pilot-rated passenger and the commercial pilot (who did hold a multi-engine rating) were flying the airplane on the accident flight could not be definitively determined, although because another passenger was onboard the airplane, it is most likely that the accident flight was personal in nature. Given the commercial pilot’s previous flight experience, it is also likely that he was acting as pilot-in-command for the flight. One witness said that he heard the airplane’s engines backfiring as it flew overhead, while another witness located about 1 mile from the accident site heard the accident airplane flying overhead. The second witness said that both engines were running, but they seemed to be running at idle and that the flaps and landing gear were retracted. The witness saw the airplane roll to the left three times before descending below the tree line. As the airplane descended toward the ground, the witness heard the engines make “two pop” sounds. The airplane impacted a wooded area about 4 miles from the departure airport, and the wreckage path through the trees was only about 75-feet long. While the witnesses described the airplane’s engines backfiring or popping before the accident, the postaccident examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Additionally, examination of both propeller blades showed evidence of low rotational energy at impact, and that neither propeller had been feathered in flight. Given the witness statement describing the airplane “rolling three times” before it descended from view toward the ground, it is most likely that the pilot lost control of the airplane and while maneuvering. It is also likely that the pilot’s lack of any documented previous training or flight experience in the accident airplane make and model contributed to his inability to maintain control of the airplane. Toxicology testing was performed on the pilot’s chest cavity blood. The results identified 6.7 ng/ml of delta-9-tetrahydracannabinol (THC, the active compound in marijuana) as well as 2.6 ng/ml of its active metabolite, 11-hydroxy-THC and 41.3 ng/ml of its inactive metabolite delta9-carboxy-THC. Because the measured THC levels were from cavity blood, it was not possible to determine when the pilot last used marijuana or whether he was impaired by it at the time of the flight. As a result, it could not be determined whether effects from the pilot’s use of marijuana contributed to the accident circumstances.
Probable cause:
The pilot’s failure to maintain control of the airplane, which resulted in a collision with terrain. Contributing was the pilot’s lack of training and experience in the accident airplane make and model.
Final Report:

Crash of a Cessna 208B Grand Caravan in San Salvador de Paúl

Date & Time: Sep 24, 2019
Type of aircraft:
Operator:
Registration:
YV0134
Flight Type:
Survivors:
Yes
Schedule:
La Paragua – San Salvador de Paúl
MSN:
208B-0905
YOM:
2001
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing at San Salvador de Paúl Airfield, the single engine airplane lost its nose gear and came to rest upside down. All seven occupants were injured and the aircraft was damaged beyond repair.

Crash of a Cessna 208B Grand Caravan in Seronera: 2 killed

Date & Time: Sep 23, 2019
Type of aircraft:
Operator:
Registration:
5H-AAM
Flight Phase:
Survivors:
No
Schedule:
Seronera - Grumeti Hills
MSN:
208B-2430
YOM:
2013
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The single engine airplane departed Seronera Airstrip in the early morning on a short flight to Grumeti Hills, about 40 km northwest, according to a statement from the operator. Shortly after takeoff, the airplane went out of control, struck a concrete wall and crashed upside down. The pilot and the sole passenger were killed.

Statement from the operator:
https://www.auricair.com/About-Us/5HAAM_Accident_23Sept2019

Crash of a Cessna 208B Grand Caravan in Manaus

Date & Time: Sep 16, 2019 at 1225 LT
Type of aircraft:
Operator:
Registration:
PT-MHC
Flight Phase:
Survivors:
Yes
Schedule:
Manaus - Maués
MSN:
208B-0543
YOM:
1996
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
22800
Captain / Total hours on type:
14150.00
Copilot / Total flying hours:
947
Copilot / Total hours on type:
791
Circumstances:
The single engine airplane departed Manaus-Eduardo Gomes Airport Runway 29 in heavy rain falls as weather conditions deteriorated shortly prior to takeoff. After liftoff, while in initial climb, the airplane lost altitude and crashed in a dense wooded area located 600 metres past the runway end. The aircraft was destroyed by impact forces and all 10 occupants were injured, among them six seriously. At the time of the accident, weather conditions were poor with heavy rain falls, turbulence and windshear.
Probable cause:
The accident was the consequence of the combination of the following factors:
- Control skills – undetermined.
While facing adverse conditions, the use of controls may have been inappropriate for the situation and may have contributed to the aircraft not being able to maintain a positive climb rate.
- Attitude – undetermined.
Familiarization with the region may have led to an attitude, on the part of the PIC, of minimizing the importance of analyzing adverse weather conditions, to the detriment of compliance with the minimum limits established by the company in its manuals.
- Training – undetermined.
It is possible that, due to possible inadequate training, the SIC did not identify the critical situation that arose shortly after the take-off in time to assist the PIC in maintaining flight control.
- Tasks characteristics – undetermined.
The characteristics present in the type of operation, compliance with schedules without the possibility of delays, due to the runway closing period, may have favored the self imposed pressure on the part of the PIC, leading him to operate with reduced safety margins.
- Adverse meteorological conditions – a contributor.
The conditions at the time of the take-off contributed to the aircraft not being able to maintain the flight with a positive climb rate. The probable occurrence of Windshear determined that the trajectory of the aircraft was modified until its collision with the ground.
- Crew Resource Management – undetermined.
On the part of the SIC, no assertive attitude was perceived in the sense of alerting the PIC that those conditions were not favorable for takeoff. Thus, the crew decided to carry out the take-off despite the company's SOP.
- Organizational culture – undetermined.
The company encouraged compliance with the legs even though, within the planning of flights, there was not an adequate margin of time to absorb any delays. This culture may have influenced the PIC's decision-making, which, despite encountering adverse conditions, chose to take off, since the short time on the ground in the intermediate locations did not allow room for delays.
- Emotional state – undetermined.
The reports indicated that the PIC felt pressured to perform the take-off even in the weather conditions found on the day of this occurrence. Also, according to the interviewees, this pressure would be related to the fulfillment of the flight schedule and the need to keep to the scheduled times. In this way, it is possible that their assessment of the performance of the flight was influenced by the stress resulting from the pressure to complete the flight within the expected time, given the closing time of the runway for works.
- Flight planning – a contributor.
The flight planning was not carried out properly, considering that the planned schedules and routes would end after the closing time of the SBEG runway for works, provided for in the NOTAM. This meant that there was little time to adjust the legs, increasing the workload and stress in the cabin.
- Decision-making process – a contributor.
There was a wrong assessment of the meteorological conditions, which contributed to the decision of performing it in an adverse situation.
- ATS publication– undetermined.
The TWR-EG did not inform, before the take-off, of the changes in the significant weather conditions that were occurring at the terminal, which could have contributed to the PIC's decision-making.
Final Report:

Crash of a Cessna 208 Caravan I in Gransee: 1 killed

Date & Time: Sep 11, 2019 at 1505 LT
Type of aircraft:
Operator:
Registration:
D-FIDI
Survivors:
No
Schedule:
Gransee - Gransee
MSN:
208-0301
YOM:
1999
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1553
Captain / Total hours on type:
288.00
Aircraft flight hours:
4066
Aircraft flight cycles:
4983
Circumstances:
At 1448 hrs, the pilot took off from Gransee Special Airfield with the Cessna 208 Caravan to a commercial flight in accordance with visual flight rules. On board were the pilot and 15 skydivers, which were dropped at flight level 130. On this day, the pilot had already conducted three flights dropping skydivers with a total flight time of 48 min. After having dropped the skydivers during the fourth flight, the airplane was last captured by the radar at 1505:49 hrs, during approach to land at the airfield, close to the accident site at about 550 ft AMSL. At the time, ground speed was 168 kt and heading 330°. The Flugleiter stated that he had observed the last phase of the approach. The airplane had been in a left-hand turn with a bank angle of up to 90° close to the ground. He assumed that the pilot might have “overshot” the extended centre line of runway 29 when he entered the final approach coming from the south. Then the airplane had vanished behind the trees. The pilot did not transmit an emergency call. The Flugleiter also stated that with the previous flight he had witnessed a similar manoeuvre. The radar recording of the third flight ended at 1417:54 hrs with a recorded altitude of about 1,400 ft AGL. At the time, ground speed was 168 kt and heading 355°. During both flights the skydivers had been dropped at flight level 130 at a heading of about 300° south of the airfield. After dropping the skydivers, at 1415:07 hrs and at 1502:52 hrs, respectively, the airplane entered a descent with a very high rate of descent and flew in a wide left-hand turn back to the airfield. During the third flight a right-left-hand turn with bank angles of about 50° to 60° occurred during descent.
Probable cause:
The air accident was due to a risky flight manoeuvre close to the ground which resulted in a controlled impact with the ground. The speed during the approach exceeded the operations limitations of the airplane. The approach was not stabilized.
Contributing Human Factors:
- Recurrent acceptance of risky flight manoeuvres close to the ground by the pilot (routine violations),
- Overconfidence and insufficient risk assessment of the pilot.
Contributing Operational Factors:
- Unsuitable wording in the operations manual in regard to approaches after dropping skydivers.
Final Report: