Crash of a Cessna 402C in Bahía Solano

Date & Time: Dec 20, 2017 at 0955 LT
Type of aircraft:
Operator:
Registration:
HK-4417
Flight Phase:
Survivors:
Yes
Schedule:
Bahía Solano – Quibdó
MSN:
402C-0020
YOM:
1979
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2901
Captain / Total hours on type:
1050.00
Copilot / Total flying hours:
675
Copilot / Total hours on type:
430
Aircraft flight hours:
9711
Circumstances:
The twin engine aircraft was departing Bahía Solano-José Celestino Mutis Airport on a flight to Quibdó, carrying seven passengers and two pilots. During the takeoff roll on runway 36, the airplane deviated to the right and veered off runway. While contacting soft ground, the right main gear collapsed. The aircraft rotated and came to rest in a grassy area about 5 metres to the right of the runway. All 9 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
A loss of control during the takeoff roll as a result of inappropriate techniques on the part of the pilot-in-command who suffered a loss of situational awareness by not detecting the deviation in a timely manner.
The following contributing factors were identified:
- Inadequate crew decisions to apply appropriate corrective actions,
- Inadequate crew training program,
- Poor operational supervision on part of the operator.
Final Report:

Crash of a PZL-Mielec AN-2MS in Naryan-Mar: 4 killed

Date & Time: Dec 19, 2017 at 1027 LT
Type of aircraft:
Operator:
Registration:
RA-01460
Flight Phase:
Survivors:
Yes
Schedule:
Narian-Mar – Kharuta
MSN:
1G231-51
YOM:
1988
Flight number:
NYA9280
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2342
Captain / Total hours on type:
25.00
Copilot / Total flying hours:
6146
Copilot / Total hours on type:
434
Aircraft flight hours:
14767
Circumstances:
The single engine aircraft (an Antonov An-2TP that was converted in 2014 with a TPE331 turbine engine) departed Naryan-Mar Airport on a schedule service (flight NYA9280) to Kharuta, Republic of Komi, carrying 11 passengers and two pilots. Shortly after takeoff, while climbing to a height of 30-40 metres, the aircraft entered an excessive nose-up attitude then rolled to the right, stalled and crashed in a snow covered field. A passengers was killed and 12 other occupants were injured. In the evening, two other passengers died and a fourth passed away on 10 January 2018.
Probable cause:
Loss of control during initial climb due to the combination of an excessive weight (the total weight of the aircraft was 42 kilos above MTOW) and a CofG that was too far aft, well above the permissible limit (32%). Poor flight preparation.
Final Report:

Crash of an ATR42-320 in Fond-du-Lac: 1 killed

Date & Time: Dec 13, 2017 at 1812 LT
Type of aircraft:
Operator:
Registration:
C-GWEA
Flight Phase:
Survivors:
Yes
Schedule:
Saskatoon – Prince Albert – Fond-du-Lac – Stony Rapids
MSN:
240
YOM:
1991
Flight number:
WEW280
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
22
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5990
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
15769
Copilot / Total hours on type:
7930
Aircraft flight hours:
26481
Aircraft flight cycles:
32051
Circumstances:
On 13 December 2017, an Avions de Transport Régional ATR 42-320 aircraft (registration C-GWEA, serial number 240), operated by West Wind Aviation L.P. (West Wind), was scheduled for a series of instrument flight rules flights from Saskatoon through northern Saskatchewan as flight WEW282. When the flight crew and dispatcher held a briefing for the day’s flights, they became aware of forecast icing along the route of flight. Although both the flight crew and the dispatcher were aware of the forecast ground icing, the decision was made to continue with the day’s planned route to several remote airports that had insufficient de-icing facilities. The aircraft flew from Saskatoon/John G. Diefenbaker International (CYXE) to Prince Albert (Glass Field) Airport (CYPA) without difficulty, and, after a stop of about 1 hour, proceeded on toward Fond-du-Lac Airport (CZFD). On approach to Fond-du-Lac Airport, the aircraft encountered some in-flight icing, and the crew activated the aircraft’s anti-icing and de-icing systems. Although the aircraft’s ice protection systems were activated, the aircraft’s de-icing boots were not designed to shed all of the ice that can accumulate, and the anti-icing systems did not prevent ice accumulation on unprotected surfaces. As a result, some residual ice began to accumulate on the aircraft. The flight crew were aware of the ice; however, there were no handling anomalies noted during the approach. Consequently, they likely did not assess that the residual ice was severe enough to have a significant effect on aircraft performance. The crew continued the approach and landed at Fond-du-Lac Airport at 1724 Central Standard Time. According to post-accident analysis of the data from the flight data recorder, the aircraft’s drag and lift performance was degraded by 28% and 10%, respectively, shortly before landing at Fond-du-Lac Airport. This indicated that the aircraft had significant residual ice adhering to its structure upon arrival. However, this data was not available to the flight crew at the time of landing. The aircraft was on the ground at Fond-du-Lac Airport for approximately 48 minutes. The next flight was destined for Stony Rapids Airport (CYSF), Saskatchewan, with 3 crew members (2 pilots and 1 flight attendant) and 22 passengers on board. Although there was no observable precipitation or fog while the aircraft was on the ground, weather conditions were conducive to ice or frost formation. This, combined with the residual mixed ice on the aircraft, which acted as nucleation sites that allowed the formation of ice crystals, resulted in the formation of additional ice or frost on the aircraft’s critical surfaces. Once the passengers had boarded the aircraft, the first officer completed an external inspection of the aircraft. However, because the available inspection equipment was inadequate, the first officer’s ice inspection consisted only of walking around the aircraft and looking at the left wing from the top of the stairs at the left rear door, without the use of a flashlight on the dimly lit apron. Although he was unaware of the full extent of the ice and the ongoing accretion, the first officer did inform the captain that there was some ice on the aircraft. The captain did not inspect the aircraft himself, nor did he attempt to have it de-iced; rather, he and the first officer continued with departure preparations. Company departures from remote airports, such as Fond-du-Lac, with some amount of surface contamination on the aircraft’s critical surfaces had become common practice, in part due to the inadequacy of de-icing equipment or services at these locations. The past success of these adaptations resulted in this unsafe practice becoming normalized and this normalization influenced the flight crew’s decision to depart. Although the flight crew were aware of icing on the aircraft’s critical surfaces, they decided that the occurrence departure could be accomplished safely. Their decision to continue with the original plan to depart was influenced by continuation bias, as they perceived the initial and sustained cues that supported their plan as more compelling than the later cues that suggested another course of action. At 1812 Central Standard Time, in the hours of darkness, the aircraft began its take-off roll on Runway 28, and, 30 seconds later, it was airborne. As a result of the ice that remained on the aircraft following the approach and the additional ice that had accreted during the ground stop, the aircraft’s drag was increased by 58% and its lift was decreased by 25% during the takeoff. Despite this degraded performance, the aircraft initially climbed; however, immediately after liftoff, the aircraft began to roll to the left without any pilot input. This roll was as a result of asymmetric lift distribution due to uneven ice contamination on the aircraft. Following the uncommanded roll, the captain reacted as if the aircraft was an uncontaminated ATR 42, with the expectation of normal handling qualities and dynamic response characteristics; however, due to the contamination, the aircraft had diminished roll damping resulting in unexpected handling qualities and dynamic response. Although the investigation determined that the ailerons had sufficient roll control authority to counteract the asymmetric lift, due to the unexpected handling qualities and dynamic response, the roll disturbance developed into an oscillation with growing magnitude and control in the roll axis was lost. This loss of control in the roll axis, which corresponds with the known risks associated with taking off with ice contamination, ultimately led to the aircraft colliding with terrain 17 seconds after takeoff. The aircraft collided with the ground in a relatively level pitch, with a bank angle of 30° left. As a result of the sudden vertical deceleration upon contact with the ground, the aircraft suffered significant damage, which varied in severity at different locations on the aircraft due to impact angle and variability in structural design. The design standards for transport category aircraft in effect at the time the ATR 42 was certified did not specify minimum loads that a fuselage structure must be able to tolerate and remain survivable, or minimum loads for fuselage impact energy absorption. As a result, the ATR 42 was not designed with these crashworthy principles in mind. The main landing gear at the bottom of the centre fuselage section was rigid, and, on impact, did not absorb or attenuate much of the load. The impact-induced acceleration was not attenuated because the landing gear housing did not deform. This unattenuated acceleration resulted in a large inertial load from the wing, causing the wing support structure to fail and the wing to collapse into the cabin. The reduced survivable space between the floor above the main landing gear and the collapsed upper fuselage caused crushing injuries, such as major head, body, and leg trauma, to passengers in the middle-forward left section of the aircraft. Of the 3 passengers in this area, 2 experienced, serious life-changing injuries, and 1 passenger subsequently died. The collapse of part of the floor structure compromised the restraint systems, limiting the protection afforded to the aircraft occupants when they were experiencing vertical, longitudinal, and lateral forces. This resulted in serious velocity-related injuries and impeded their ability to take post-crash survival actions in a timely manner. Unaware of the danger, most passengers in this occurrence did not brace for impact. Because their torsos were unrestrained, they received injuries consistent with jackknifing and flailing, such as hitting the seat in front of them. As a result of unapproved repairs, the flight attendant seat failed on impact, resulting in injuries that impeded her ability to perform evacuation and survival actions in a timely manner. Although the TSB has previously recommended the development and use of child restraints aboard commercial aircraft, planned regulations have yet to be implemented by Transport Canada. As a result, the occurrence aircraft was not equipped with these devices, and an infant passenger who was unrestrained received flailing and crushing injuries during the accident sequence. By the time the aircraft came to a rest, all occupants had received injuries. Passengers began to call for help within minutes of the impact, using their cell phones. Numerous people from the nearby community received the messages and quickly set out to help. The passengers and crew began to evacuate, but they experienced significant difficulties as a result of the aircraft damage. It took approximately 20 minutes for the first 17 passengers to evacuate, and the remaining passengers much longer; it took as long as 3 hours to extricate 1 passenger, who required rescuer assistance. As a result of the accident, 9 passengers and 1 crew member received serious injuries, and the remaining 13 passengers and 2 crew members received minor injuries. One of the passengers who had received serious injuries died 12 days after the accident. There was no post-impact fire, and the emergency locator activated on impact.
Probable cause:
Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. When West Wind commenced operations into Fond-du-Lac Airport (CZFD) in 2014, no effective risk controls were in place to mitigate the potential hazard of ground icing at CZFD.
2. Although both the flight crew and the dispatcher were aware of the forecast ground icing, the decision was made to continue with the day’s planned route to several remote airports that had insufficient de-icing facilities.
3. Although the aircraft’s ice-protection systems were activated on the approach to CZFD, the aircraft’s de-icing boots were not designed to shed all of the ice that can accumulate, and the anti-icing systems did not prevent ice accumulation on unprotected surfaces. As a result, some residual ice began to accumulate on the aircraft.
4. Although the flight crew were aware of the ice, there were no handling anomalies noted on the approach. Consequently, the crew likely did not assess that the residual ice was severe enough to have a significant effect on aircraft performance. Subsequently, without any further discussion about the icing, the crew continued the approach and landed at CZFD.
5. Weather conditions on the ground were conducive to ice or frost formation, and this, combined with the nucleation sites provided by the residual mixed ice on the aircraft, resulted in the formation of additional ice or frost on the aircraft’s critical surfaces.
6. Because the available inspection equipment was inadequate, the first officer’s ice inspection consisted only of walking around the aircraft on a dimly lit apron, without a flashlight, and looking at the left wing from the top of the stairs at the left rear entry door (L2). As a result, the full extent of the residual ice and ongoing accretion was unknown to the flight crew.
7. Departing from remote airports, such as CZFD, with some amount of surface contamination on the aircraft’s critical surfaces, had become common practice, in part due to the inadequacy of de-icing equipment or services at these locations. The past success of these adaptations resulted in the unsafe practice becoming normalized and this normalization influenced the flight crew’s decision to depart.
8. Although the flight crew were aware of icing on the aircraft’s critical surfaces, they decided that the occurrence departure could be accomplished safely. Their decision to continue with the original plan to depart was influenced by continuation bias, as they perceived the initial and sustained cues that supported their plan as more compelling than the later cues that suggested another course of action.
9. As a result of the ice that remained on the aircraft following the approach and the additional ice that had accreted during the ground stop, the aircraft’s drag was
increased by 58% and its lift was decreased by 25% during the takeoff.
10. During the takeoff, despite the degraded performance, the aircraft initially climbed; however, immediately after lift off, the aircraft began to roll to the left without any pilot input. This roll was as a result of asymmetric lift distribution due to uneven ice contamination on the aircraft.
11. Following the uncommanded roll, the captain reacted as if the aircraft was an uncontaminated ATR 42, with the expectation of normal handling qualities and dynamic response characteristics; however, due to the contamination, the aircraft had diminished roll damping resulting in unexpected handling qualities and dynamic response.
12. Although the investigation determined the ailerons had sufficient roll control authority to counteract the asymmetric lift, due to the unexpected handling qualities and dynamic response, the roll disturbance developed into an oscillation with growing magnitude and control in the roll axis was lost.
13. This loss of control in the roll axis, which corresponds with the known risks associated with taking off with ice contamination, ultimately led to the aircraft colliding with terrain.
14. The aircraft collided with the ground in relatively level pitch, with a bank angle of 30° left. As a result of the sudden vertical deceleration upon contact with the ground, the aircraft suffered significant damage, which varied in severity at different locations on the aircraft because of the impact angle and the variability in structural design.
15. The design standards for transport category aircraft in effect at the time the ATR 42 was certified did not specify minimum loads that a fuselage structure must be able to tolerate and remain survivable, or minimum loads for fuselage impact energy absorption. As a result, the ATR 42 was not designed with these crashworthy principles in mind.
16. On impact, the induced acceleration was not attenuated because the landing gear housing did not deform. This unattenuated acceleration resulted in a large inertial load from the wing, causing the wing support structure to fail and the wing to collapse into the cabin.
17. The reduced survivable space between the floor above the main landing gear and the collapsed upper fuselage caused crushing injuries, such as major head, body, and leg trauma, to passengers in the middle-forward left section of the aircraft. Of the 3 passengers in this area, 2 experienced serious life-changing injuries, and 1 passenger died.
18. The collapse of part of the floor structure compromised the restraint systems, limiting the protection afforded to the occupants when they were experiencing vertical, longitudinal, and lateral forces. This resulted in serious velocity-related injuries and impeded their ability to take post-impact survival actions in a timely manner.
19. Most passengers in this occurrence did not brace before impact. Because their torsos were unrestrained, they received injuries consistent with jackknifing and flailing, such as hitting the seat in front of them.
20. Given that regulations requiring the use of child-restraint systems have yet to be implemented, the aircraft was not equipped with these devices. As a result, the infant passenger was unrestrained and received flail and crushing injuries. 21. As a result of unapproved repairs, the flight attendant seat failed on impact, resulting in injuries that impeded her ability to perform evacuation and survival actions in a timely manner.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Miami: 1 killed

Date & Time: Dec 10, 2017 at 1450 LT
Registration:
N7529S
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Miami - Miami
MSN:
61-0161-082
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1000
Aircraft flight hours:
3576
Circumstances:
Before departing on the flight, the private pilot, who did not hold a current medical certificate, fueled the multiengine airplane and was seen shortly thereafter attempting to repair a fuel leak of unknown origin. The pilot did not hold a mechanic certificate and review of the maintenance logbooks revealed that the most recent annual inspection was completed 2 years before the accident. After performing undetermined maintenance to the airplane, the pilot reported to a witness that he had fixed the fuel leak. The pilot then taxied to the runway for takeoff. Witnesses reported that a large fuel stain was present on the ramp where the airplane had been parked; however, the amount of fuel that leaked from the airplane could not be determined. The pilot aborted the first takeoff shortly after becoming airborne. Although he did not state why he aborted the takeoff, he told the tower controller that he did not need assistance; shortly thereafter, he requested and was cleared for a second takeoff. During the initial climb, the pilot declared an emergency and was cleared to land on any runway. Witnesses reported that the airplane was between 400 ft and 800 ft above the ground in a left bank and appeared to be turning back to land on an intersecting runway. They thought the airplane was going to make it back to the runway, but the airplane's bank angle increased past 90° and the nose suddenly dropped; the airplane subsequently impacted terrain. One of the pilots likened the maneuver to a stall/spin, Vmc roll, or snap roll. Examination of the flight controls and engines did not reveal any anomalies that would have prevented normal operation. The position of the fuel valves was consistent with the fuel being shut off to the left engine. The fuel valves, with the exception of the left main valve, functioned when power was applied. The left main valve was intact, but the motor was found to operate intermittently. The amount of fuel found in the left engine injection servo was less than that in the right engine; however, the cylinder head temperatures and exhaust gas temperatures were consistent between both engines for the duration of the flight, and whether or to what extent the left engine may have experienced a loss of power could not be determined. The available evidence was insufficient to determine why the pilot declared an emergency and elected to return to the airport; however, the airplane's increased left bank and nose-down attitude just before impact is consistent with a loss of control.
Probable cause:
The pilot's loss of control while returning to the airport after takeoff for reasons that could not be determined based on the available information.
Final Report:

Crash of a Beechcraft C90 King Air in Rockford

Date & Time: Dec 5, 2017 at 1802 LT
Type of aircraft:
Registration:
N500KR
Flight Type:
Survivors:
Yes
Schedule:
Kissimmee - Rockford
MSN:
LJ-708
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2500
Aircraft flight hours:
9856
Circumstances:
The private pilot departed on a cross-country flight in his high-performance, turbine-powered airplane with full tanks of fuel. He landed and had the airplane serviced with 150 gallons of fuel. He subsequently departed on the return flight. As the airplane approached the destination airport, the pilot asked for priority handling and reported that the airplane "lost a transfer pump and had a little less fuel than he thought," and he did not want to come in with a single engine. When asked if he needed assistance, he replied "negative." The pilot was cleared to perform a visual approach to runway 19 during night conditions. As the airplane approached the airport, the pilot requested the runway lights for runway 25 be turned on and reported that the airplane lost engine power in one engine. The controller advised that the lights on runway 25 were being turned on and issued a landing clearance. The airplane impacted terrain before the threshold for runway 25. During examination of the recovered wreckage, flight control continuity was established. No useable amount of fuel was found in any of the airplane's fuel tanks; however, fuel was observed in the fuel lines. All transfer pumps and boost pumps were operational. The engine-driven fuel pumps on both engines contained fuel in their respective fuel filter bowls. Both pumps were able to rotate when their input shafts were manipulated by hand. Disassembly of both pumps revealed that their inlet filters were free of obstructions. Bearing surfaces in both pumps exhibited pitting consistent with pump operation with inadequate fuel lubrication and fuel not reaching the pump. The examination revealed no evidence of airframe or engine preimpact malfunctions or failures that would have precluded normal operation of the airplane. Performance calculations using a flight planning method described in the airplane flight manual indicated that the airplane could have made the return flight with about 18 gallons (119 lbs) of fuel remaining. However, performance calculations using a fuel burn simulation method developed from the fuel burn and data from the airplane flight manual indicated that the airplane would have run out of fuel on approach. Regulations require that a flight depart with enough fuel to fly to the first point of intended landing and, assuming normal cruising speed, at night, to fly after that for at least 45 minutes. The calculated 45-minute night reserves required about 56 gallons (366 lbs) of fuel using a maximum recommended cruise power setting or about 37.8 gallons (246 lbs) of fuel using a maximum range power setting. Regardless of the flight planning method he could have used, the pilot did not depart on the accident flight with the required fuel reserves and exhausted all useable fuel while on approach to the destination. The airplane was owned by Edward B. Noakes III.
Probable cause:
The pilot's inadequate preflight planning and his decision to depart without the required fuel reserve, which resulted in fuel exhaustion during a night approach and subsequent loss of engine power.
Final Report:

Crash of a Piper PA-46-500TP Malibu Meridian in Saint Petersburg

Date & Time: Nov 25, 2017 at 1315 LT
Operator:
Registration:
N863RB
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Saint Petersburg – Pensacola
MSN:
46-97213
YOM:
2005
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15000
Captain / Total hours on type:
25.00
Aircraft flight hours:
1341
Circumstances:
The pilot performed a preflight inspection of the turboprop airplane and an engine run-up with no anomalies noted. The takeoff roll and lift off from the runway were normal; however, when the pilot initiated a landing gear retraction, the engine torque decreased, but the rpm did not change. The torque then surged back to full power and continued to surge as the pilot attempted to return to the runway. The left wing of the airplane struck the ground, and the airplane came to rest in the grass on the side of the runway. Examination of the engine, engine accessories, and propeller revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation before the accident. The reason for the partial loss of engine power could not be determined based on the available
information.
Probable cause:
A partial loss of engine power for reasons that could not be determined based on the available information.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Presque Isle

Date & Time: Nov 22, 2017 at 1845 LT
Operator:
Registration:
N421RX
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Presque Isle – Bangor
MSN:
421C-0264
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4482
Captain / Total hours on type:
3620.00
Aircraft flight hours:
7473
Circumstances:
After takeoff, the commercial pilot saw flames coming from the left engine nacelle area. He retarded the throttle and turned off the fuel boost pump; however, the fire continued. He then feathered the propeller, shut down the engine, and maneuvered the airplane below the clouds to remain in the local traffic pattern. He attempted to keep the runway environment in sight while drifting in and out of clouds. He was unable to align the airplane for landing on the departure runway, so he attempted to land on another runway. When he realized that the airspeed was decreasing and that the airplane would not reach the runway, he landed it on an adjacent grass field. After touchdown, the landing gear separated, and the airplane came to a stop. The airframe sustained substantial damage to the wings and lower fuselage. Examination of the left engine revealed evidence of a fuel leak where the fuel mixture control shaft inserted into the fuel injector body, which likely resulted in fuel leaking onto the hot turbocharger in flight and the in-flight fire. A review of recent maintenance records did not reveal any entries regarding maintenance or repair of the fuel injection system. The pilot reported clouds as low as 500 ft with rain, snow, and reduced visibility at the time of the accident, which likely reduced his ability to see the runway and maneuver the airplane to land on it.
Probable cause:
The in-flight leakage of fuel from the fuel injection system's mixture shaft onto the hot turbocharger, which resulted in an in-flight fire, and the pilot's inability to see the runway due to reduced visibility conditions and conduct a successful landing.
Final Report:

Crash of a Raytheon 390 Premier I in Johannesburg

Date & Time: Nov 22, 2017 at 1623 LT
Type of aircraft:
Registration:
ZS-CBI
Flight Type:
Survivors:
Yes
Schedule:
Cape Town - Johannesburg
MSN:
RB-214
YOM:
2007
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3048
Captain / Total hours on type:
649.00
Copilot / Total flying hours:
4718
Copilot / Total hours on type:
305
Aircraft flight hours:
963
Circumstances:
On 22 November 2017, the pilot-in-command (PIC) accompanied by the first officer (FO) took off from the Cape Town International Airport (FACT) on a private flight to the Rand Airport (FAGM). The flight was conducted under instrument flight rules (IFR) by day and the approach was conducted under visual flight rules (VFR). The PIC was the pilot flying (PF) and was seated on the left seat and the FO was occupying the right seat. The air traffic controller (ATC) on duty at FAGM tower stated that the FO reported in-bound for a fullstop landing at FAGM. The last wind direction data for Runway 29 was transmitted to the FO as 230°/11 knots (kts) and Query Nautical Height (QNH): 1021. The FO acknowledged the transmission and the crew elected to land on Runway 11. The PIC stated that the approach for landing was stable and that the touchdown was near the first taxiway exit point. According to the FO, the aircraft floated for a while before touchdown. This was confirmed during the investigation. During the landing rollout, the PIC applied the brakes and the brakes responded for a short while, however, the aircraft continued to roll without slowing down. At approximately 300 metres (m) beyond the intersection of Runway 35 and Runway 11, the PIC requested the FO to apply emergency brakes. The FO applied the emergency brakes gradually and the aircraft continued to roll before the brakes locked and the tyres burst. The aircraft skidded on the main wheels and continued for approximately 180m until it overshot the runway. The undercarriage went over a ditch of approximately 200 millimetres in depth at the end of the runway into the soft ground and the aircraft came to a stop approximately 10m from the threshold facing slightly left off the extended centre line Runway 11. The aircraft was substantially damaged during the impact sequence and none of the occupants sustained injuries. The crash alarm was activated by the tower and the fire services responded to the scene.
Probable cause:
The investigation revealed that the aircraft was unstable on approach (hot and high), resulting in deep landing, probably near the second exit point, leading to a runway excursion. Contributing factors were attributed to the lift dumps not being deployed and the incorrect application of the emergency brakes.
Final Report:

Crash of a Let L-410UVP-E20 in Nelkan: 6 killed

Date & Time: Nov 15, 2017 at 1309 LT
Type of aircraft:
Operator:
Registration:
RA-67047
Survivors:
Yes
Schedule:
Khabarovsk - Chumikan - Nelkan
MSN:
15 30 10
YOM:
2015
Flight number:
RNI463
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
12076
Captain / Total hours on type:
1243.00
Copilot / Total flying hours:
1220
Copilot / Total hours on type:
837
Aircraft flight hours:
1693
Aircraft flight cycles:
1071
Circumstances:
On 14.11.2017, Khabarovsk Airlines' representative submitted the flight request for L-410UVP-E20 RA-67047 A/C flight to Joint ATM System Khabarovsk regional unit; the flight (NI 463) was planned along the route Khabarovsk – Nikolayevsk-on-Amur – Nelkan. On 14.11.2017 at 22:00 (local time: on 15.11.2017 at 08:00) at Khabarovsk airport, the preflight preparation was started including the medical examination. While the preflight preparation was being performed, new information was received that Nikolayevsk-on-Amur airport was closed due to the RWY snow removal. In coordination with ATC of Nikolayevsk-on-Amur airport, it was decided to change the route as follows: Khabarovsk – Chyumican – Nelkan. Before coming onboard the crew passed all mandatory preflight procedures as required by the normative documentation. On 15.11.2017, before the departure, Khabarovsk Airlines' technicians provided the line maintenance check in accordance with the F-A Form (Maintenance Job Card #687). No findings in relation to the aircraft and/or systems' operation were reported. The total amount of fuel on board was 1250 kg. The flight crew obtained all the necessary weather information (actual and forecast) during of the preflight weather briefing. The actual weather and the weather forecast for the departure aerodrome, on route weather, the weather forecast for the destination and alternate aerodromes – all met the FAP-128 (Russian FAR) requirements stated in items 5.30 and 5.38, and did not preclude the PIC's decision for departure. There were 2 crew members, 5 passengers and 410 kg of cargo (personal luggage and mail) onboard. The A/C takeoff mass was 6368 kg and the A/C center of gravity was at 25.5% MAC, which was within the AFM limits for the flight. The takeoff from Khabarovsk airport was performed at 23:33. 50 minutes before the approach to Chyumikan aerodrome, the flight crew checked the remaining fuel and requested the Khabarovsk ATC controller for the route change (AFIL): after passing of the OGUMI waypoint to follow the B226 airway to Nelkan destination airport without a stop at Chyumikan. According the initial flight plan, the stop at Chyumikan was intended only for refueling. On 15.11.2017 at 01:47 the Khabarovsk ATC approved the AFIL. At 02:35 the crew contacted the Nelkan Tower controller and received the approach conditions and the actual weather at the landing site. During the approach, at the true height of about 100 m and IAS of about 100 knots, developing the aggressive right roll and losing its altitude, the aircraft left the descending glidepath, collided with the ground and was destroyed. The crew and 4 passengers were killed. A 3-and-half year old child was taken to hospital with serious injuries. Nobody was killed on ground and there was no on-ground damage. The accident area is mountainous, marshy, with broad-leaved and needle-leaved trees. In winter, the area is covered with snow which is about 50-100 cm deep. The accident place ASL elevation is 304 m, the magnetic dip is minus 15°.
Probable cause:
The direct cause of the L410UVP-E20 RA-67047 A/C accident was the uncommanded inflight RH engine propeller blades setting to the angle of minus 1.8° which is significantly below the
minimum inflight pitch angle (13.5°) with TCLs set to forward thrust. It caused the significant rolling and turning moments, the A/C loss of speed and controllability, and the subsequent with the ground collision. The propeller blades' setting to the negative angles was caused by the failures of two systems: the BETA Feedback system and the Pitch Lock system. As the Propeller Pitch Lock system components that are to be tested during the PITCH LOCK TEST most probably did not contribute to the system malfunction, then it is unlikely that the crews' deviation of the PITCH LOCK TEST procedure could have make any difference in the detection of the said system malfunction before the flight. The said situation had been classified as extremely improbable during the aircraft type certification, so, there was no required crew actions in AFM for such situations, and the respective crew training was not required.
Final Report:

Crash of a Quest Kodiak 100 in Goiás

Date & Time: Nov 10, 2017 at 1327 LT
Type of aircraft:
Operator:
Registration:
N154KQ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lucas do Rio Verde – Anápolis
MSN:
100-0154
YOM:
2015
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3000
Captain / Total hours on type:
8.00
Circumstances:
The aircraft took off from the Bom Futuro Municipal Aerodrome (SILC), Lucas do Rio Verde - MT, to the Anápolis Aerodrome (SWNS) - GO, in order to carry out a transfer flight, with a pilot and three passengers on board. During the flight, the pilot identified conflicting information related to the amount of fuel remaining and chose to make an intermediate landing on an unapproved runway, located in the city of Goiás Velho - GO, in order to check the data visually. After the conference, the N154KQ took off from that location and, reaching approximately 300ft height, the aircraft lost power, colliding with vegetation 1.86 km from the runway used for takeoff. The aircraft was destroyed by the fire. The pilot suffered serious injuries and the three passengers suffered minor injuries.
Probable cause:
Contributing factors:
- Attitude – a contributor
The pilot's failure to monitor the fueling showed a complacent attitude regarding the verification of conditions that could affect flight safety. Therefore, the lack of knowledge about the real fuel levels implied the insertion of wrong data and an intermediate landing to check the situation, after its identification.
- Training – undetermined
It is possible that the pilot's little familiarization with the aircraft emergency procedures delayed the identification of the situation and limited his possibilities of action.
- Insufficient pilot’s experience – undetermined
The pilot's little experience on the aircraft may have slowed his ability to recognize the emergency and to perform the actions described in the checklist efficiently.
Final Report: