Crash of a PZL-Mielec AN-2 in Ekimchan: 1 killed

Date & Time: Nov 7, 2017 at 0825 LT
Type of aircraft:
Operator:
Registration:
RA-02305
Flight Type:
Survivors:
Yes
Schedule:
Ekimchan - Udskoye
MSN:
1G240-07
YOM:
1990
Flight number:
SHA9001
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5253
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
13550
Copilot / Total hours on type:
10000
Aircraft flight hours:
2483
Aircraft flight cycles:
8807
Circumstances:
The single engine airplane depart Ekimchan Airport at 0834LT on a cargo flight to Udskoye, carrying two pilots and a load of 1,199 kilos of various goods. Six minutes after takeoff, while climbing to an altitude of 1,600 metres, the crew noticed a strong smell of fuel in the cockpit and decided to return. During the descent, flames came out from the engine that started to rough and eventually stopped on short final. The airplane stalled, impacted a birch tree and crashed in a wooded area located 132 metres short of runway 06, bursting into flames. The copilot was killed and the captain was seriously injured. The aircraft was totally destroyed by a post crash fire.
Probable cause:
The crash of An-2 RA-02305 aircraft occurred during the forced landing. The necessity of the forced landing was caused by the engine stopping in flight due to the destruction of the cylinder head No.1 of the ASH62-IR engine No.K16509153. The destruction of cylinder head No. 1 is of fatigue nature and occurred due to exhaustion of fatigue life of the cylinder head material and reaching its limit state. Most likely, during the last repair of the engine the crack in the cylinder head was present, but was not through and was not revealed during the inspection. The most likely contributing factor to stopping the engine in flight was the impoverishment of the fuel-air mixture due to icing of the BAC filter mesh and the presence of a rubber plug on the filter flange of the corrector.
Final Report:

Crash of a Socata TBM-850 in Las Vegas

Date & Time: Nov 5, 2017 at 1145 LT
Type of aircraft:
Operator:
Registration:
N893CA
Flight Type:
Survivors:
Yes
Schedule:
Tomball – Las Vegas
MSN:
393
YOM:
2007
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3000
Captain / Total hours on type:
1850.00
Aircraft flight hours:
2304
Circumstances:
The pilot of the turbine-powered airplane reported that, while landing in a gusting crosswind, it was "obvious" the wind had changed directions. He performed a go-around, but "the wind slammed [the airplane] to the ground extremely hard." Subsequently, the airplane veered to the right off the runway and then back to the left before coming to rest. The airplane sustained substantial damage to the fuselage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The automated weather observation system located at the accident airport reported that, about the time of the accident, the wind was from 270° at 19 knots, gusting to 25 knots. The pilot landed on runway 20.
Probable cause:
The pilot's inadequate compensation for gusting crosswind conditions during the go-around.
Final Report:

Crash of a Swearingen SA227AC Metro III in Thompson

Date & Time: Nov 2, 2017 at 1920 LT
Type of aircraft:
Operator:
Registration:
C-FLRY
Flight Type:
Survivors:
Yes
Schedule:
Gods River – Thompson
MSN:
AC-756
YOM:
1990
Flight number:
PAG959
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1400
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
950
Copilot / Total hours on type:
700
Aircraft flight hours:
24672
Circumstances:
On 02 November 2017, a Perimeter Aviation LP Fairchild SA227-AC Metro III (serial number AC-756B, registration C-FLRY) was operating as flight 959 (PAG959) from Gods River Airport, Manitoba, to Thompson Airport, Manitoba, with 2 flight crew members on board. When the aircraft was approximately 40 nautical miles southeast of Thompson Airport, the crew informed air traffic control that they had received a low oil pressure indication on the left engine that might require the engine to be shut down. The crew did not declare an emergency, but aircraft rescue and firefighting services were put on standby. After touchdown on Runway 24 with both engines operating, the aircraft suddenly veered to the right and exited the runway. The aircraft came to rest in snow north of the runway. The captain and first officer exited the aircraft through the left side over-wing emergency exit and were taken to hospital with minor injuries. The aircraft was substantially damaged. The 406-MHz emergency locator transmitter did not activate. The occurrence took place during the hours of darkness, at 1920 Central Daylight Time.
Probable cause:
Findings as to causes and contributing factors:
1. The left engine low oil pressure indications during the previous and the occurrence flights were likely the result of a steady oil leak past the rear turbine air-oil seal assembly.
2. The loss of engine oil pressure resulted in a loss of propeller control authority on landing and the upset of the aircraft.
3. After consultation with maintenance, the crew considered the risks associated with landing single engine and without hydraulic pressure for the nose-wheel steering, and decided to continue the flight with both engines running, even though this was not consistent with the QRH procedures for low oil pressure indications.
4. Carbon deposits that accumulated within the inside diameter of the bellows convolutions interfered with the bellows’ ability to expand and to provide a positive seal against the rotor seal.

Findings as to risk:
1. If Canadian Aviation Regulations (CARs) subparts 703 and 704 operators do not provide initial or recurrent crew resource management training to pilots, these pilots may not be prepared to avoid, trap, or mitigate crew errors encountered during flight.
2. If operators of the SA227-AC Metro III aircraft rely solely on the emergency procedures listed in the aircraft flight manual, continued engine operation with low oil pressure may result in loss of control of the aircraft.
3. If an engine is not allowed to sufficiently cool down prior to shutdown, oil that remains trapped within hot areas of the engine may heat up to a point where the oil decomposes, creating a carbon deposit.
4. If flight data, voice, and video recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded.

Other findings:
1. The investigation was unable to determine the length of cooldown periods for the occurrence aircraft. However, a random sampling of engine shutdowns for similar company aircraft showed that 50% had not completed the full 3-minute cooldown period.
2. Despite having received limited crew resource management (CRM).
Final Report:

Crash of a Cessna 208B Grand Caravan in Lobo

Date & Time: Oct 25, 2017 at 1430 LT
Type of aircraft:
Operator:
Registration:
5H-THR
Survivors:
Yes
Schedule:
Lake Manyara - Lobo
MSN:
208B-0571
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown at Lobo Airstrip deserving the Lobo Wildlife Lodge located in the Serengeti National park, the single engine aircraft went out of control, veered off runway to the left and came to rest against a tree. The pilot and two passengers were injured while eight other occupants were unhurt. The aircraft was damaged beyond repair. There was no fire.

Crash of a Cessna 401B in Salters: 2 killed

Date & Time: Oct 4, 2017 at 1745 LT
Type of aircraft:
Registration:
N401HH
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Salters - Salters
MSN:
401B-0004
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
15000
Aircraft flight hours:
5557
Circumstances:
The commercial pilot and passenger departed on a local flight in the twin-engine airplane. According to a witness, the pilot took off from the private grass runway and departed the area for about 10 minutes. The airplane then returned to the airport, where the pilot performed a low pass over the runway and entered a steep climb followed by a roll. The airplane entered a nose-low descent, then briefly leveled off in an upright attitude before disappearing behind trees and subsequently impacting terrain. The pilot's toxicology testing was positive for ethanol with 0.185 gm/dl and 0.210 gm/dl in urine and cavity blood samples, respectively. The effects of ethanol are generally well understood; it significantly impairs pilot performance, even at very low levels. Federal Aviation Administration regulations prohibit any person from acting or attempting to act as a crewmember of a civil aircraft while having 0.040 gm/dl or more ethanol in the blood. While the identified ethanol may have come from sources other than ingestion, such as postmortem production, the possibility that the source of some of the ethanol was from ingestion and that pilot was impaired by the effects of ethanol during the accident flight could not be ruled out. Toxicology also identified a significant amount of diphenhydramine in cavity blood (0.122 µg/ml, which is within or above the therapeutic range of 0.0250 to 0.1120 µg/ml; diphenhydramine undergoes postmortem redistribution, and central postmortem levels may be about two to three times higher than peripheral or antemortem levels.). Diphenhydramine is a sedating antihistamine that causes more sedation than other antihistamines; this is the rationale for its use as a sleep aid. In a driving simulator study, a single dose of diphenhydramine impaired driving ability more than a blood alcohol concentration of 0.100%. The pilot had been diagnosed with memory loss about 8 months before the accident. It appears that he had some degree of mild cognitive impairment, but whether his cognitive impairment was severe enough to have contributed to the accident could not be determined from the available evidence. However, it is likely that the pilot's mild cognitive impairment combined with the psychoactive effects of diphenhydramine and possibly ethanol would have further decreased his cognitive functioning and contributed to his decision to attempt an aerobatic maneuver at low altitude in a non-aerobatic airplane.
Probable cause:
The pilot's decision to attempt a low-altitude aerobatic maneuver in a non-aerobatic airplane, and his subsequent failure to maintain control of the airplane during the maneuver.
Contributing to the accident was the pilot's impairment by the effects of diphenhydramine use, and his underlying mild cognitive impairment.
Final Report:

Crash of a Rockwell Aero Commander 500 in Dabajuro: 1 killed

Date & Time: Sep 26, 2017
Operator:
Registration:
HI-560
Flight Type:
Survivors:
Yes
MSN:
500-778-69
YOM:
1959
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Apparently following technical issues, the pilot was forced to attempt an emergency landing at Dabajuro Airport. The twin engine aircraft crash landed near the runway and struck two motorcyclists. One of them was killed while the second was injured. The airplane was damaged beyond repair and the pilot was uninjured.

Crash of a Mitsubishi MU-2B-40 Solitaire in Ainsworth: 1 killed

Date & Time: Sep 23, 2017 at 1028 LT
Type of aircraft:
Registration:
N73MA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ainsworth – Bottineau
MSN:
414
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3775
Captain / Total hours on type:
2850.00
Aircraft flight hours:
5383
Circumstances:
The instrument-rated private pilot departed on a cross-country flight in instrument meteorological conditions (IMC) with an overcast cloud layer at 500 ft above ground level (agl)
and visibility restricted to 1 ¾ miles in mist, without receiving an instrument clearance or opening his filed instrument flight rules flight plan. There was an outage of the ground communications system at the airport and there was no evidence that the pilot attempted to open his flight plan via his cellular telephone. In addition, there was a low-level outage of the radar services in the vicinity of the accident site and investigators were unable to determine the airplane's route of flight before impact. The airport manager observed the accident airplane depart from runway 35 and enter the clouds. Witnesses located to the north of the accident site did not see the airplane but reported hearing an airplane depart about the time of the accident. One witness reported hearing a lowflying airplane and commented that the engines sounded as if they were operating at full power. The witness heard a thud as he was walking into his home but attributed it to a thunderstorm in the area. The airplane impacted a field about 3.5 miles to the northeast of the departure end of the runway and off the track for the intended route of flight. The airplane was massively fragmented during the impact and debris was scattered for about 300 ft. The damage to the airplane and ground scars at the accident site were consistent with the airplane impacting in a left wing low, nose low attitude with relatively high energy. A postaccident examination of the engines and propeller assemblies did not reveal any preimpact anomalies that would have precluded normal operation. Signatures were consistent with both engines producing power and both propellers developing thrust at the time of impact. While the massive fragmentation precluded functional testing of the equipment, there was no damage or failure that suggested preimpact anomalies with the airframe or flight controls.Several days before the accident flight, the pilot encountered a "transient flag" on the air data attitude heading reference system. The pilot reported the flag to both the co-owner of the airplane and an avionics shop; however, exact details of the flag are not known. The unit was destroyed by impact forces and could not be functionally tested. If the flag affecting the display of attitude information had occurred with the unit after takeoff, the instrument panel had adequate stand-by instrumentation from which the pilot could have continued the flight. It is not known if this unit failed during the takeoff and investigators were unable to determine what role, if any, this transient issue may have played in the accident. Based upon the reported weather conditions, the location of the wreckage, and the attitude of the airplane at the time of impact with the ground, it is likely that the pilot experienced spatial disorientation shortly after takeoff which resulted in a loss of control and descent into terrain.
Probable cause:
The pilot's loss of airplane control due to spatial disorientation.
Final Report:

Crash of a Cessna 650 Citation VII in Istanbul

Date & Time: Sep 21, 2017 at 2116 LT
Type of aircraft:
Operator:
Registration:
TC-KON
Survivors:
Yes
Schedule:
Istanbul - Ercan
MSN:
650-7084
YOM:
1998
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Atatürk Airport in Istanbul at 2105LT bound for Ercan with a crew of three and one passenger on board. Shortly after takeoff, an unexpected situation forced the crew to return for an emergency landing. After touchdown on runway 35L, the twin engine aircraft went out of control, veered off runway, struck a concrete drainage ditch and came to rest, broken in two and bursting into flames. All four occupants evacuated safely while the aircraft was destroyed by a post crash fire.

Crash of a Cessna 402B in Nantucket

Date & Time: Sep 13, 2017 at 0723 LT
Type of aircraft:
Registration:
N836GW
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nantucket – Hyannis
MSN:
402B-1242
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1500
Captain / Total hours on type:
1100.00
Aircraft flight hours:
4928
Circumstances:
The commercial pilot stated that, shortly after taking off for a cross-country, personal flight and while accelerating, he noticed high airplane nose-down control forces and that the airplane became increasingly difficult to control. He used manual trim to attempt to trim out the control forces and verified that the autopilot was not engaged; however, the nose-down tendency continued, and the pilot had trouble maintaining altitude. During the subsequent emergency landing, the airframe sustained substantial damage. Postaccident examination of the airplane revealed that the elevator trim push rod assembly was separated from the elevator trim tab actuator, and the end of the elevator trim push rod assembly was found wedged against the elevator's main spar. The elevator trim indicator in the cockpit was found in the nose-up stop position; however, the elevator trim tab was deflected 24° trailing edge up/airplane nose down (the maximum airplane nose-down setting is 6°). A drilled bolt was recovered from inside the right elevator; however, the associated washer, castellated nut, and cotter pin were not found. Examination of the bolt revealed that the threads were damaged and that the bolt hole on one of the clevis yoke halves exhibited deformation, consistent with the bolt separating. About 2 weeks before the accident, the pilot flew the airplane to a maintenance facility for an annual inspection. At that time, Airworthiness Directive (AD) 2016-07-24, which required installation of new hardware at both ends of the pushrod for the elevator trim tab, was overdue. While the airplane was in for the annual inspection, AD 2016-07-24 was superseded by AD 2016-17-08, which also required the installation of new hardware. The ADs were issued to prevent jamming of the elevator trim tab in a position outside the normal limits of travel due to the loss of the attachment hardware connecting the elevator trim tab actuator to the elevator trim tab push-pull rod, which could result in loss of airplane control. While in for the annual inspection, the airplane was stripped and painted, which would have required removal of the right elevator. Although the repair station personnel indicated that they did not disconnect the elevator trim pushrod from the elevator trim tab actuator when they painted the airplane, photographs taken of the airplane while it was undergoing inspection and painting revealed that the pushrod likely had been disconnected. The repair station owner reported that he reinstalled the right elevator and the elevator trim pushrod after the airplane was painted; however, he did not replace the hardware at either end of the pushrod as required by the ADs. Subsequently, the airplane was approved for return to service. After the annual inspection, no work, repairs, or adjustments were made to the elevator trim system. The airplane had accrued about 58 hours since the annual inspection at the time of the accident. Although reusing the self-locking nut might have resulted in it coming off by itself, the cotter pin should have prevented this from happening. Therefore, although the castellated self-locking nut, washer, and cotter pin normally used to secure the elevator trim pushrod at the elevator trim tab actuator were not found, given the evidence it is likely that the hardware, which was not the required hardware, was not properly secured at installation, which allowed it to separate in flight. It is also likely that the pushrod assembly then moved aft and jammed in a position well past the maximum nose-down trim setting, which rendered controlled flight impossible.
Probable cause:
The separation of the pushrod from the elevator trim tab actuator, which rendered controlled flight impossible. Contributing to the separation of the pushrod was the failure of maintenance personnel to properly secure it to the elevator trim tab actuator.
Final Report:

Crash of an Antonov AN-26B in Goma

Date & Time: Sep 10, 2017 at 1130 LT
Type of aircraft:
Operator:
Registration:
9S-AFL
Flight Type:
Survivors:
Yes
Schedule:
Goma – Bunia
MSN:
140 03
YOM:
1985
Location:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Goma Airport, while on a cargo flight to Bunia, the crew reported technical problems with the right engine and was cleared to return for an emergency landing. The crew landed long (about half way down the runway) and after touchdown, the airplane was unable to stop within the remaining distance. It overran and while contacting lava ground, the right main gear and the nose gear collapsed. The airplane came to rest with its right wing bent and all four crew members evacuated safely.