Crash of an Embraer ERJ-190AR in Durango

Date & Time: Jul 31, 2018 at 1523 LT
Type of aircraft:
Operator:
Registration:
XA-GAL
Flight Phase:
Survivors:
Yes
Schedule:
Durango – Mexico City
MSN:
190-00173
YOM:
2008
Flight number:
AM2431
Location:
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
98
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3700
Captain / Total hours on type:
1064.00
Copilot / Total flying hours:
1973
Copilot / Total hours on type:
460
Aircraft flight hours:
27257
Aircraft flight cycles:
18200
Circumstances:
The takeoff from Durango-Guadalupe Victoria Airport was initiated in poor weather conditions as a thunderstorm just passed over the airport five minutes prior to the accident. The takeoff from runway 03 was completed with a wind from 047° at 33 knots. Eight seconds after liftoff, the aircraft climbed to a height of 8 feet with a speed of 145 knots. At this time, the wind came from 103° at 11 knots. The aircraft continued to climb to 30 feet when the wind changed with a tailwind component of 22 knots from 030°. The aircraft started to descend and impacted ground, causing both engines to be torn off. The aircraft continued, overran and slid for 380 metres before coming to rest, bursting into flames. All 103 occupants were evacuated and 39 were injured, 14 seriously. The aircraft was totally destroyed by a post crash fire. At the time of the accident, weather conditions were poor with thunderstorm activity, heavy rain falls and strong winds. Notable variations in wind components were noticed at the time of the accident.
Probable cause:
Impact against the runway caused by loss of control of the aircraft in the final phase of the take-off run by low altitude windshear that caused a loss of speed and lift. The following contributing factors were reported:
- Decrease in situational awareness of the flight crew when the commander was performing unauthorized instructional tasks without being qualified to provide flight instruction and to assign copilot and Pilot Flying duties to a an uncertified and unlicensed pilot,
- Failure to detect variations in the indicator displayed by the airspeed indicator on the PFD during the take-off run,
- Lack of adherence to sterile cabin procedures and operational procedures (TVC; Changes of runway and/or take off conditions after door closings; Take off in adverse windshear conditions) established in the Flight Operations Manual, the Dispatch Manual and the Standard Operating Procedures,
- Lack of adherence to published procedure,
- Lack of adherence to Aerodrome and meteorological information procedures,
- Lack of supervision on part of Tower personnel at Durango Airport.
Final Report:

Crash of a Piper PA-60-602P Aerostar (Ted Smith 600) in Greenville: 3 killed

Date & Time: Jul 30, 2018 at 1044 LT
Operator:
Registration:
C-GRRS
Flight Type:
Survivors:
No
Schedule:
Pembroke – Charlottetown
MSN:
60-8265-026
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
590
Captain / Total hours on type:
136.00
Aircraft flight hours:
4856
Circumstances:
The private pilot of the multiengine airplane was in cruise flight at 23,000 ft mean sea level (msl) in day visual meteorological conditions when he reported to air traffic control that the airplane was losing altitude due to a loss of engine power. The controller provided vectors to a nearby airport; about 7 minutes later, the pilot reported the airport in sight and stated that he would enter a downwind leg for runway 14. By this time, the airplane had descended to about 3,200 ft above ground level. Radar data indicated that the airplane proceeded toward the runway but that it was about 400 ft above ground level on short final. The airplane flew directly over the airport at a low altitude before entering a left turn to a close downwind for runway 21. Witnesses stated that the airplane's propellers were turning, but they could not estimate engine power. When the airplane reached the approach end of runway 21, it entered a steep left turn and was flying slowly before the left wing suddenly "stalled" and the airplane pitched nose-down toward the ground. Postaccident examination of the airplane and engines revealed no mechanical deficiencies that would have precluded normal operation at the time of impact. Examination of both propeller systems indicated power symmetry at the time of impact, with damage to both assemblies consistent with low or idle engine power. The onboard engine monitor recorded battery voltage, engine exhaust gas temperature, and cylinder head temperature for both engines. A review of the recorded data revealed that about 14 minutes before the accident, there was a jump followed by a decrease in exhaust gas temperature (EGT) and cylinder head temperature (CHT) for both engines. The temperatures decreased for about 9 minutes, during which time the right engine EGT data spiked twice. Both engines' EGT and CHT values then returned to normal, consistent with both engines producing power, for the remaining 5 minutes of data. It is possible that a fuel interruption may have caused the momentary increase in both engines' EGT and CHT values and prompted the pilot to report the engine power loss; however, the engine monitor did not record fuel pressure or fuel flow, and examination of the airplane's fuel system and engines did not reveal any mechanical anomalies. Therefore, the reason for the reported loss of engine power could not be determined. It is likely that the pilot's initial approach for landing was too high, and he attempted to circle over the airport to lose altitude. While doing so, he exceeded the airplane's critical angle of attack while in a left turn and the airplane entered an aerodynamic stall at an altitude too low for recovery.
Probable cause:
The pilot's exceedance of the airplane's critical angle of attack while maneuvering to land, which resulted in an aerodynamic stall.
Final Report:

Crash of a Beechcraft C90GTi King Air in Campo de Marte: 1 killed

Date & Time: Jul 29, 2018 at 1810 LT
Type of aircraft:
Operator:
Registration:
PP-SZN
Survivors:
Yes
Schedule:
Videira – Campo de Marte
MSN:
LJ-1910
YOM:
2008
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
While approaching Campo de Marte Airport by night following an uneventful flight from Videira, the crew encountered technical problems with the landing gear and was cleared to complete two low passes over the runway to confirm visually the problem. While performing a third approach, the twin engine airplane rolled to the left then overturned and crashed inverted about 100 metres to the left of runway 30, bursting into flames. Six occupants were injured and one pilot was killed.

Crash of a PZL-Mielec AN-2R in Kamako: 5 killed

Date & Time: Jul 27, 2018 at 1000 LT
Type of aircraft:
Operator:
Registration:
9S-GFS
Flight Phase:
Survivors:
Yes
Schedule:
Kamako – Nsumbula – Diboko – Tshikapa
MSN:
1G201-29
YOM:
1983
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Aircraft flight hours:
4371
Aircraft flight cycles:
2585
Circumstances:
The single engine airplane departed Kamako Airport on a flight to Tshikapa with intermediate stops in Nsumbula and Diboko, carrying five passengers and two pilots. After takeoff, while climbint to a height of about 3,500 feet, the crew spotted birds in the vicinity when the engine lost power. The captain decided to return to Kamako but as he was unable to maintain a safe altitude, he attempted an emergency landing when the aircraft crashed in a marshy field located 3 km from the airport, bursting into flames. The captain and a passenger survived while five other occupants were killed.
Probable cause:
It is believed that the engine lost power following a collision with a flock of birds, but the extent of damages could not be determined.
Final Report:

Crash of a Douglas C-47B in Burnet

Date & Time: Jul 21, 2018 at 0915 LT
Operator:
Registration:
N47HL
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Burnet – Sedalia – Oshkosh
MSN:
15758/27203
YOM:
1945
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12500
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
8000
Copilot / Total hours on type:
17
Circumstances:
According to the copilot, before takeoff, he and the pilot had briefed that the copilot would conduct the takeoff for the planned cross-country flight and be the pilot flying and that the pilot would be the pilot monitoring. The accident flight was the copilot's first takeoff in the accident airplane with it at or near its maximum gross weight. The pilot reported that he taxied the airplane onto the runway and locked the tailwheel in place and that the copilot then took over the controls. About 13 seconds after the start of the takeoff roll, the airplane veered slightly right, and the copilot counteracted with left rudder input. The airplane then swerved left, and shortly after the pilot took control of the airplane. The airplane briefly became airborne; the pilot stated that he knew the airplane was slow as he tried to ease it back over to the runway and set it back down. Subsequently, he felt the shudder “of a stall,” and the airplane rolled left and impacted the ground, the right main landing gear collapsed, and the left wing struck the ground. After the airplane came to a stop, a postimpact fire ensued. All the airplane occupants egressed through the aft left door. Postaccident examination of the airplane revealed no evidence of any mechanical malfunctions or failures with the flight controls or tailwheel. Both outboard portions of the of the aluminum shear pin within the tailwheel strut assembly were sheared off, consistent with side load forces on the tailwheel during the impact sequence. The copilot obtained his pilot-in-command type rating and his checkout for the accident airplane about 2 months and 2 weeks before the accident, respectively. The copilot had conducted two flights in the accident airplane with a unit instructor before the accident. The instructor reported that, during these flights, he noted that the copilot had directional control issues; made "lazy inputs, similar to those for small airplanes"; tended to go to the right first; and seemed to overcorrect to the left by leaving control inputs in for too long. He added that, after the checkout was completed, the copilot could take off and land without assistance; however, he had some concern about the his reaction time to a divergence of heading on the ground. Given the evidence, it is likely the copilot failed to maintain directional control during the initial takeoff roll. It is also likely that, if the pilot, who had more experience in the airplane, had monitored the copilot's takeoff more closely and taken remedial action sooner, he may have been able to correct the loss of directional control before the airplane became briefly airborne and subsequently experienced an aerodynamic stall.
Probable cause:
The copilot's failure to maintain directional control during the initial takeoff roll and the pilot's failure to adequately monitor the copilot during the takeoff and his delayed remedial action, which resulted in the airplane briefly becoming airborne and subsequently experiencing an aerodynamic stall.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Baton Rouge

Date & Time: Jul 20, 2018 at 1430 LT
Registration:
N327BK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Baton Rouge - Baton Rouge
MSN:
61-0145-076
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
28829
Captain / Total hours on type:
600.00
Aircraft flight hours:
1912
Circumstances:
The mechanic who maintained the airplane reported that, on the morning of the accident, the right engine would not start due to water contamination in the fuel system. The commercial pilot and mechanic purged the fuel tanks, flushed the fuel system, and cleaned the left engine fuel injector nozzles. After the maintenance work, they completed engine ground runs for each engine with no anomalies noted. Subsequently, the pilot ordered new fuel from the local fixed-based operator to complete a maintenance test flight. The pilot stated that he completed a preflight inspection, followed by engine run-ups for each engine with no anomalies noted and then departed with one passenger onboard. Immediately after takeoff, the right engine stopped producing full power, and the airplane would not maintain altitude. No remaining runway was left to land, so the pilot conducted a forced landing to a field about 1 mile from the runway; the airplane landed hard and came to rest upright. Postaccident examination revealed no water contamination in the engines. Examination of the airplane revealed numerous instances of improper and inadequate maintenance of the engines and fuel system. The fuel system contained corrosion debris, and minimal fuel was found in the lines to the fuel servo. Although maintenance was conducted on the airplane on the morning of the accident, the right engine fuel injectors nozzles were not removed during the maintenance procedures; therefore, it is likely that the fuel flow volume was not measured. It is likely that the corrosion debris in the fuel system resulted when the water was recently purged from the fuel system. The contaminants were likely knocked loose during the subsequent engine runs and attempted takeoff, which subsequently blocked the fuel lines and starved the right engine of available fuel.
Probable cause:
The loss of right engine power due to fuel starvation, which resulted from corrosion debris in the fuel lines. Contributing to the accident was the mechanic's and pilot's inadequate maintenance of the airplane before the flight.
Final Report:

Crash of a Curtiss C-46F-1-CU Commando in Manley Hot Springs

Date & Time: Jul 16, 2018 at 0925 LT
Type of aircraft:
Operator:
Registration:
N1822M
Flight Type:
Survivors:
Yes
Schedule:
Fairbanks – Kenai
MSN:
22521
YOM:
1945
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6500
Captain / Total hours on type:
3500.00
Copilot / Total flying hours:
300
Copilot / Total hours on type:
135
Aircraft flight hours:
37049
Circumstances:
The pilot reported that, following a precautionary shutdown of the No. 2 engine, he diverted to an alternate airport that was closer than the original destination. During the landing in tailwind conditions, the airplane touched down "a little fast." The pilot added that, as the brakes faded from continuous use, the airplane was unable to stop, and it overran the end of the runway, which resulted in substantial damage to the fuselage. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause:
The pilot's failure to attain the proper touchdown speed and his decision to land with a tailwind without ensuring that there was adequate runway length for the touchdown.
Final Report:

Crash of a Douglas DC-3C in San Felipe

Date & Time: Jul 11, 2018 at 1220 LT
Type of aircraft:
Operator:
Registration:
HK-3293
Flight Type:
Survivors:
Yes
Schedule:
Inírida – San Felipe
MSN:
9186
YOM:
1943
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18000
Captain / Total hours on type:
16000.00
Copilot / Total flying hours:
7784
Copilot / Total hours on type:
1715
Aircraft flight hours:
29170
Circumstances:
The aircraft departed Inírida on a humanitarian flight to San Felipe, carrying nine passengers, three crew members and various goods and equipment dedicated to the victims of the recent floods. Following an uneventful flight, the crew landed on runway 18. After touchdown, the aircraft deviated to the left. It pivoted to the left, lost its left main gear and the left propeller and came to a halt on the runway edge. All 12 occupants were rescued, among them one passenger was slightly injured. The aircraft was damaged beyond repair.
Probable cause:
The accident was the consequence of a lateral runway excursion as a result of a loss of control on the ground caused by the loss of air pressure in the left main gear tire, as a result of the penetration of a FOD (metallic object) into the tire during the landing run. Poor risk management by the San Felipe Aerodrome operator (SKFP) and a lack of a runway FOD control program (SKFP) by the operator of the aerodrome was considered as contributing factors.
Final Report:

Crash of a Convair CV-340 in Pretoria: 1 killed

Date & Time: Jul 10, 2018 at 1639 LT
Type of aircraft:
Operator:
Registration:
ZS-BRV
Flight Type:
Survivors:
Yes
Schedule:
Pretoria - Sun City
MSN:
215
YOM:
1954
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
18240
Captain / Total hours on type:
63.00
Copilot / Total flying hours:
19616
Aircraft flight hours:
18115
Circumstances:
On Tuesday 10 July 2018, at approximately 1439Z, two crew members and 17 passengers took off on a ZS-BRV aircraft for a scenic flight from Wonderboom Aerodrome (FAWB) destined for Pilanesberg Aerodrome (FAPN) when the accident occurred. During take-off, the left engine caught fire, however, the crew continued with the flight. They declared an emergency by broadcasting ‘MAYDAY’ and requesting to return to the departure aerodrome. The crew turned to the right with the intention of returning to the aerodrome. However, the left engine fire intensified, causing severe damage to the left wing rear spar and left aileron system, resulting in the aircraft losing height and the crew losing control of the aircraft and colliding with power lines, prior to crashing into a factory building. The footage taken by one of the passengers using their cellphone showed flames coming from the front top side of the left engine cowling and exhaust area after take-off. The air traffic control (ATC) on duty at the time of the accident confirmed that the left engine had caught fire during take-off and that the crew had requested clearance to return to the aerodrome. The ATC then activated the crash alarm and the aircraft was prioritized for landing. During the accident sequence that followed, one passenger (engineer) occupying the jump seat in the cockpit was fatally injured and 18 others sustained injuries. The investigation revealed that during take-off, the left engine had caught fire and the crew had continued with the flight without securing the left engine as prescribed in the aircraft flight manual (AFM). The crew had then declared an emergency and attempted to return to the aerodrome, however, they lost control of the aircraft and collided with power lines prior to crashing into a factory building. Owned by Rovos Air (part of the South African Rovos Rail Group), the aircraft was donated to the Dutch Museum Aviodrome based in Lelystad and has to be transferred to Europe with a delivery date on 23 July 2018. For this occasion, the aircraft was repaint with full Martin's Air Charter colorscheme. Part of the convoy program to Europe, the airplane was subject to several test flights, carrying engineers, technicians, pilots and also members of the Aviodrome Museum.
Probable cause:
During take-off, the left engine caught fire and the crew continued with the flight without securing the left engine as prescribed in the aircraft flight manual (AFM). The crew declared an emergency and attempted to return to the aerodrome, however, they lost control of the aircraft and collided with power lines prior to crashing into a factory building. The following contributing factors were reported:
- Pre-existing damage to the cylinder No 13 piston and ring pack deformation and, most probably, the cylinder No 7’s fractured exhaust valve head that were not detected during maintenance of the aircraft,
- Substandard maintenance for failing to conduct compression tests on all cylinders during the scheduled maintenance prior to the accident,
- Misdiagnosis of the left engine manifold pressure defect as it was reported twice prior to the accident,
- The crew not aborting take-off at 50 knots prior to reaching V1; manifold pressure fluctuation was observed by the crew at 50 knots and that should have resulted in an aborted take-off,
- Lack of crew resource management; this was evident as the crew ignored using the emergency checklist to respond to the in-flight left engine fire,
- Lack of recency training for both the PF and PM, as well as the LAME,
- Non-compliance to Civil Aviation Regulations by both the crew and the maintenance organisation.
Final Report:

Crash of a PZL-Mielec AN-2R in Nizhneudinsk

Date & Time: Jun 27, 2018 at 1507 LT
Type of aircraft:
Operator:
Registration:
RA-62524
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nizhneudinsk - Nizhneudinsk
MSN:
1G175-47
YOM:
1977
Flight number:
FU9350
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5689
Captain / Total hours on type:
5474.00
Copilot / Total flying hours:
2252
Aircraft flight hours:
14683
Circumstances:
The single engine airplane departed Nizhneudinsk Airport on a forest fire survey mission, carrying two observers and two pilots. Shortly after takeoff, while climbing to a height of about 150-170 metres, the engine started to vibrate. The captain attempted an emergency landing when the aircraft crash landed in a marshy field located 4,9 km from the airport, coming to rest upside down. All four occupants escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
The accident was the consequence of a total engine failure during initial climb for reasons that could not be determined. The fact that the field was waterlogged and did not permit a safe landing was considered as a contributing factor.
Final Report: