Crash of a Beechcraft B200 Super King Air in Matsieng: 1 killed

Date & Time: Mar 23, 2019 at 2020 LT
Operator:
Registration:
A2-MBM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Gaborone - Matsieng
MSN:
BB-1489
YOM:
1994
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Earlier in the afternoon the pilot was an uninvited guest at a private function that was held at the Matsieng Flying Club facility at Matsieng Aerodrome. In a statement, the Matsieng Flying Club reported that it was rumored that the pilot was involved in a domestic dispute earlier in the afternoon. At 2015LT the aircraft approached Matsieng Aerodrome from the direction of Sir Seretse Khama Airport and made a number of low level fly passes from different directions past the Club facilities next to the Air Traffic Control tower. An immediate evacuation of the club premises was ordered. The final extreme low level run by the aircraft along runway 36 resulted in an impact with the Matsieng Flying Club facility at ground level. The Club facility and Matsieng ATC tower was destroyed on impact. The post impact fire destroyed 13 parked vehicles. The emergency services of the Kgatleng District Council were on the scene within minutes to attend to the post-impact fire and distress. These response actions are to be commended. It is believed that the pilot had no permission to fly the aircraft involved. Sole on board, he was killed.
Probable cause:
Pilot suicide suspected.

Crash of an IAI 1124 Westwind in Sundance: 2 killed

Date & Time: Mar 18, 2019 at 1531 LT
Type of aircraft:
Registration:
N4MH
Flight Type:
Survivors:
No
Schedule:
Panama City - Sundance
MSN:
232
YOM:
1978
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5872
Copilot / Total flying hours:
5259
Aircraft flight hours:
11030
Circumstances:
The two commercial pilots were conducting a personal, cross-country flight. A video surveillance camera at the airport captured their airplane’s approach. Review of the video revealed that, as the airplane approached the approach end of the landing runway, it began to climb, rolled left, became inverted, and then impacted terrain. The left thrust reverser (T/R) was found open and unlatched at the accident site. An asymmetric deployment of the left T/R would have resulted in a left roll/yaw. The lack of an airworthy and operable cockpit voice recorder, which was required for the flight, precluded identifying which pilot was performing pilot flying duties, as well as other crew actions and background noises, that would have facilitated the investigation. Postaccident examination of the airplane revealed that it was not equipped, nor was required to be equipped, with a nose landing gear (NLG) ground contact switch intended to preclude inflight operation of the thrust reverser (T/R). The left T/R door was found unlatched and open, and the right T/R door was found closed and latched. Further, electrical testing of the T/R left and right stow microswitches within the cockpit throttle quadrant revealed that the left stow microswitch did not operate within design specifications. Disassembly of the left and right stow microswitches revealed evidence of arc wear due to aging. Based on this information, it is likely that the airplane’s lack of an NLG ground contact switch and the age-related failure of the stow microswitches resulted in an asymmetric T/R deployment while on approach and a subsequent loss of airplane control. Also, there were additional T/R system components that were found to unairworthy that would have affected the control of the T/R system. Operational testing of the T/R system could not be performed due to the damage the airplane incurred during the accident. Toxicology testing results of the pilot’s specimens indicated that the pilot had taken diazepam, which is considered impairing at certain levels. However, the detected amounts of both diazepam and its metabolite nordiazepam were at subtherapeutic levels, and given the long half-life of these compounds, it appears that the medication was taken several days before the accident; therefore, it is unlikely that the pilot was impaired at the time of the accident and thus that his use of diazepam was a not factor in the accident.
Probable cause:
The airplane’s unairworthy thrust reverser (T/R) system due to inadequate maintenance that resulted in an asymmetric T/R deployment during an approach to the airport and the subsequent loss of airplane control.
Final Report:

Crash of a Learjet 35A in Buenos Aires

Date & Time: Mar 7, 2019 at 1930 LT
Type of aircraft:
Operator:
Registration:
LV-BNR
Survivors:
Yes
Schedule:
Rosario – Buenos Aires
MSN:
35-373
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Rosario-Islas Malvinas Airport at 1900LT on a charter flight to Buenos Aires, carrying two passengers and two pilots. On approach to Buenos Aires-Aeroparque-Jorge Newbury Airport by night, the crew encountered poor weather conditions with thunderstorm activity, heavy rain falls and strong winds. The aircraft landed 200 metres past the runway 13 threshold and the crew stated the braking procedure. After a course of about 500 metres, the aircraft deviated to the left and veered off runway. It rolled on a grassy area then contacted the concrete taxiway, causing both main landing gear to be torn off. The aircraft came to rest 860 metres from the runway threshold and was damaged beyond repair. All four occupants evacuated safely.
Probable cause:
Conclusions regarding factors related to the accident:
- At the time of the event, meteorological conditions were poor with a strong storm, rain and gusts of wind.
- Visual cues may have been reduced due to heavy rain falls.
- The aircraft was displaced from the runway center line when it made contact with the ground.
- The aircraft made contact with the left landing gear off the runway due to strong gusts of wind.
- The lateral excursion to the grassy area occurred due to the impossibility of recovering the trajectory of the aircraft, once it was displaced by the action of the wind.
Final Report:

Crash of an Embraer ERJ-145XR in Presque Isle

Date & Time: Mar 4, 2019 at 1129 LT
Type of aircraft:
Operator:
Registration:
N14171
Survivors:
Yes
Schedule:
Newark - Presque Isle
MSN:
145-859
YOM:
2004
Flight number:
UA4933
Crew on board:
3
Crew fatalities:
Pax on board:
28
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5655
Captain / Total hours on type:
1044.00
Copilot / Total flying hours:
4909
Copilot / Total hours on type:
470
Circumstances:
The first instrument landing system (ILS) approach to runway 1 appeared to be proceeding normally until the first officer (the pilot flying) transitioned from instrument references inside the flight deck to outside references. During a postaccident interview, the first officer stated that he expected to see the runway at that time but instead saw “white on white” and a structure with an antenna that was part of the runway environment but not the runway itself. The captain (the pilot monitoring) stated that she saw a tower and called for a go-around. (Both flight crewmembers were most likely seeing the automated weather observing system wind sensor pole, which was located about 325 ft to the right of the runway 1 centerline and about 870 ft beyond the runway threshold, and the damage to the lightning arrester at the top of the wind sensor pole was likely due to contact with the accident airplane as it flew over the pole.) According to the cockpit voice recorder (CVR), after the go-around, the first officer asked the captain if she saw the runway lights during the approach. The captain responded that she saw the lights but that “it’s really white down there that’s the problem.” Airport personnel stated that snow plowing operations on the runway had finished about 10 minutes before the first approach. The CVR recorded the flight crew’s discussion about turning on the pilot-controlled runway lights and sounds similar to microphone clicks before and after the discussion. However, the PQI maintenance foreman stated that, after the first approach, the runway lights were not on. Thus, the investigation could not determine, based on the available evidence, whether the flight crew had turned on the runway lights during the first approach. The captain thought that the airplane had drifted off course when the first officer transitioned from flight instruments to the outside, so she instructed the first officer to remain on the instruments during the second approach until the decision altitude (200 ft above ground level [agl]). The second approach proceeded normally with no problems capturing or maintaining the localizer and glideslope. During this approach, the captain asked airport maintenance personnel to ensure that the runway lighting was on, and the PQI maintenance foreman replied that the lights were on “bright”(the high-intensity setting). Thus, the flight crew had a means to identify the runway surface even with the reported snow cover at the time. As the airplane approached the decision altitude, the captain instructed the first officer to disconnect the autopilot, which he did. About nine seconds later, the airplane reached the decision altitude, and the captain called, “runway in sight twelve o’clock.” This callout was followed by the first officer’s statement, “I’m stayin’ on the flight director ‘cause I don’t see it yet.” A few seconds later, while the airplane was below 100 ft agl, the captain and the first officer expressed confusion, stating “what the [expletive]” and “I don’t know what I'm see in’,” respectively, but neither called for a go-around. The airplane subsequently impacted the snow-covered grassy area between runway 1 and a parallel taxiway. During a postaccident interview, the first officer stated that, when he transitioned from flight instruments to the outside during the second approach, he again saw “white on white” as well as blowing snow and that the airplane touched down before he could determine what he was seeing. The maintenance foreman estimated that, at the time of the accident, the runway had about 1/8 inch of snow with about 20% to 25% of the runway visible.
Probable cause:
The flight crew’s decision, due to confirmation bias, to continue the descent below the decision altitude when the runway had not been positively identified. Contributing to the accident were:
1) the first officer’s fatigue, which exacerbated his confirmation bias, and
2) the failure of CommutAir pilots who had observed the localizer misalignment to report it to the company and air traffic before the accident.
Final Report:

Crash of a Gulfstream G200 in Moscow

Date & Time: Feb 26, 2019 at 1244 LT
Type of aircraft:
Operator:
Registration:
4K-AZ88
Survivors:
Yes
Schedule:
Baku - Moscow
MSN:
189
YOM:
2008
Flight number:
EWS88
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7608
Captain / Total hours on type:
2356.00
Copilot / Total flying hours:
2554
Copilot / Total hours on type:
609
Aircraft flight hours:
4174
Aircraft flight cycles:
1787
Circumstances:
The airplane departed Baku-Bina Airport on a charter flight to Moscow, carrying three passengers and three crew members. Following an uneventful flight, the crew was cleared for an approach to Moscow-Sheremetyevo Airport runway 24C. The aircraft landed at a speed of 150 knots some 250 metres past the runway threshold. After touchdown, the crew started the braking procedure and activated the thrust reversers. After a course of several hundred metres, the aircraft deviated to the left, made an almost 180 turn and veered off runway to the left. While contacting soft ground, the right main gear was torn off and the aircraft came to rest in a snow covered area. All six occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The reason for the accident with the Gulfstream G200 4K-AZ88 was the stowing of the right-engine reverser by the pilot KVS from maximum thrust reversal while maintaining maximum thrust reversal on the left engine, which led to the appearance of a significant turning moment to the left. The aircraft turning to the left in the presence of a cross wind to the right, as well as turbulence of the airflow near the rudder due to the open thrust reversal mechanism of the left engine and possible ice deposition on the outer surfaces of the aircraft, which led to the development of a significant swing moment on the rudder. The development of a significant articulated moment on the rudder, in the absence of power steering in the rudder control system, led to its deviation to the leftmost position despite significant (up to 82 kg or 180 pounds) forces exerted by the crew on the pedals. The deviation of the rudder (pedals) to the left also led to the deviation of the nose wheel to the left. The total moment from the running reverse of the left engine, from the right engine in direct draft mode, and from the rudder and nose wheel deflection to the left, led to the aircraft rolling out of the runway and its damage. Separate braking applied by the crew could not prevent the aircraft from rolling out.

The following contributing factors were identified:
- The crew did not take into account the provisions of the AOM about the possible "destabilizing" effect of the thrust reverse when landing with a cross wind on the runway with a reduced braking coefficient;
- Increased psycho-emotional tension of the crew members due to long dissatisfaction and emotional discussion of instructions and actions of ATC controllers. At the same time, the instructions and actions of the ATC service controllers were in line with established procedures.
Final Report:

Crash of a De Havilland EO-5C (Dash-7-102) at Pyongtaek-Desiderio AAF

Date & Time: Feb 25, 2019
Operator:
Registration:
N89068
Flight Type:
Survivors:
Yes
Schedule:
Pyongtaek - Pyongtaek
MSN:
88
YOM:
1982
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was complering a survey mission on behalf of the US Ministry of Defense. For unknown reasons, the four engine airplane landed hard at Pyongtaek-Desiderio AAF (Camp Humphreys), causing the right main gear to collapse. The right wing fell on the ground and the aircraft slid for few dozen metres before coming to rest. All occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of an Embraer EMB-120 Brasília in Somalia

Date & Time: Feb 14, 2019
Type of aircraft:
Operator:
Registration:
5Y-FAU
Survivors:
Yes
MSN:
120-194
YOM:
1990
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The left main gear collapsed after the airplane landed on a gravel airstrip located somewhere in Somalia. There were no injuries among the occupants and the airplane was damaged beyond repair.
Probable cause:
Failure of the left main gear upon landing on a gravel airstrip.

Crash of a Learjet 35A in Toluca

Date & Time: Feb 7, 2019 at 0714 LT
Type of aircraft:
Operator:
Registration:
XA-DOC
Flight Type:
Survivors:
Yes
MSN:
35A-447
YOM:
1981
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight, the crew configured the aircraft for landing when he realized that the right main landing gear was stuck in its wheel well. The crew continued the approach and landed on runway 15. The airplane fell on its belly, causing the right wing to struck the ground. The airplane slid for few hundred metres then veered off runway to the left and came to rest in a grassy area. All nine occupants were rescued and the aircraft was damaged beyond repair.

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

Date & Time: Feb 6, 2019 at 1530 LT
Operator:
Registration:
N997MA
Flight Type:
Survivors:
Yes
Schedule:
Aurora - Aurora
MSN:
46-36126
YOM:
1997
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
970
Captain / Total hours on type:
23.00
Aircraft flight hours:
2670
Circumstances:
On February 6, 2019, about 1530 Pacific standard time, a Piper PA 46-350P, N997MA, was substantially damaged when it was involved in an accident near Aurora, Oregon. The private pilot and flight instructor were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The pilot reported that the purpose of the flight was to practice commercial pilot maneuvers. After practicing slow flight, chandelles, lazy eights, and eights on pylons, they returned to the airport and discussed how to conduct a practice a power-off 180° landing as they entered the traffic pattern. When the airplane was abeam the 1,000-foot runway markings, the pilot reduced the power to idle and started a left turn toward the runway. He stated that he realized that the airplane was “probably not going to make the runway” and that the airplane was “not on final course.” He recalled the airplane turning sharply to the left as he was pulled up on the control yoke and added right rudder. He could not recall whether he applied power. The pilot did not report any mechanical malfunctions or anomalies with the airplane. A video of the event showed the airplane in a left turn as it descended toward the runway. The airplane’s left bank decreased to a wings-level attitude before the airplane entered a steeper left bank, followed immediately by a right bank as the airplane descended into the ground short of the runway. The airplane’s right wing and fuselage sustained substantial damage.

Crash of a Cessna 207 Stationair 7 in Cayenne

Date & Time: Jan 25, 2019 at 1435 LT
Operator:
Registration:
F-OSIA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cayenne – Maripasoula
MSN:
207-0042
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3620
Circumstances:
The single engine airplane departed Cayenne-Rochambeau-Félix Eboué Airport on a cargo flight to Maripasoula, carrying a load of foods on behalf of a restaurant. The pilot was sole on board. Shortly after takeoff, while in initial climb, the engine lost power. The pilot reduced his altitude and attempted an emergency landing on a known open area located near the airport. But on short final, the aircraft struck a embankment and came to rest upside down. The pilot was seriously injured and the aircraft was destroyed.
Probable cause:
The flight was undertaken with an airplane whose center of gravity was beyond the rear center of gravity limits and a mass greater than the maximum take-off mass. The load was not secured. As a result, the performance of the aircraft was degraded and piloting made more difficult. The BEA investigation did not reveal any major failure that could explain a loss of power. Engine performance may have been lower than the manufacturer's standards, due in particular to improper adjustment of the mechanical fuel pump, probably resulting from unsuitable maintenance. This defect was most likely already present on previous flights. It is likely that the power required for the initial climb was greater than what the engine could deliver. This brought the aircraft into a situation where the speed gradually decreased. When the pilot turned, the stall warning sounded and the pilot sensed the engine was losing power.
Final Report: