Crash of an Embraer ERJ-190-100AR in Cuenca

Date & Time: Apr 28, 2016 at 0751 LT
Type of aircraft:
Operator:
Registration:
HC-COX
Survivors:
Yes
Schedule:
Quito – Cuenca
MSN:
190-00372
YOM:
2010
Flight number:
EQ173
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
87
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17523
Captain / Total hours on type:
2113.00
Copilot / Total flying hours:
3545
Copilot / Total hours on type:
2077
Aircraft flight hours:
11569
Aircraft flight cycles:
9707
Circumstances:
Following en uneventful flight from Quito, the crew initiated the descent to Cuenca-Mariscal La Mar Airport Runway 23. Weather conditions at destination were poor with rain falls and a contaminated runway. The pilot-in-command continued the approach below the glide and the aircraft passed over the runway threshold at a height of 37 feet instead the recommended 50 feet. The airplane landed 277 metres past the runway threshold at a speed of 127 knots and the crew activated the spoilers and the reverse thrust systems. Due to poor braking action, the captain activated the autobrake system, without success. As the aircraft could not be stopped within the remaining distance, the captain intentionally turn to the right when the aircraft ground looped, overran and came to rest in a grassy area. All 93 occupants were rescued, among them two passengers were slightly injured. The aircraft was damaged beyond repair.
Probable cause:
The following findings were identified:
- The condition of the runway at Cuenca airport, which at the time of the plane's landing was contaminated with water and slippery.
- The landing was made after a non-stabilized approach with a tailwind.
- During seven seconds, the crew continued the approach with an excessive rate of descent of 1,186 feet, 186 feet above the limit of 1,000 feet.
- The non-application of the Maximum Performance Landing procedure recommended by the aircraft manufacturer for landing on contaminated runways.
- The dispatch of the flight with 1,500 kg of fuel more than the amount of fuel usually used for this flight.
- Omission of the runway length calculation necessary to perform the landing using the braking efficiency information.
- The crew's decision to make the final approach with three red and one white lights, using the PAPI system, induced by the information in the Terminal Information document issued by the company, which authorized this procedure.
- The use of confusing terminology in the Terminal Information document, which used terms applicable to the Airbus fleet, instead of Embraer's.
- The crew's decision not to perform the thwarted approach maneuver after the maximum allowable vertical speed was exceeded and visibility was apparently limited after the minima were exceeded.
- Incorrect use of aircraft braking aids, in this case reverse braking aids
- The application of the emergency brake that inhibits the antiskid system.
- Lack of implementation of adequate management of crew resources, particularly within the cockpit.
- Lack of training in the use of tables for track distance calculation.
- In reference to landing conditions, the aircraft needed a runway length of 2,122 metres while the available distance was 1,900 metres.
Final Report:

Crash of a Swearingen SA226T Merlin III in Andorra

Date & Time: Apr 26, 2016 at 1535 LT
Operator:
Registration:
N125WG
Flight Type:
Survivors:
Yes
Schedule:
Alicante - Andorra
MSN:
T-250
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4750
Captain / Total hours on type:
1200.00
Circumstances:
The twin engine airplane departed Alicante-Mutxamel Airport at 1221LT on a private flight to Andorra, carrying four passengers and one pilot. Following an uneventful flight at an altitude of 12,500 feet, the pilot informed ATC about electrical problems then initiated the descent to Andorra. About two minutes later, the electrical system totally failed. The pilot continued the approach to Andorra-La Seu d'Urgell Airport. After touchdown on runway 21, the undercarriage collapsed. The aircraft veered off runway to the right and came to rest in a grassy area. All five occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
It is considered that the accident was caused by an error in the application of the emergency extension procedure of the landing gear following a total failure of the electrical system.
Contributing factors :
- Start a visual flight with a deferred pending repair in the electrical system, specifically with the generator on the right side.
- Lack of recent training and simulation with emergency procedures.
- The versatility of the pilot and diversity of different aircraft types flown.
- The non-activation of the warning light on the left-hand side of the cockpit panel when the electrical system failed about 30 minutes prior to the total exhaustion of all batteries.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Foley

Date & Time: Apr 26, 2016 at 1424 LT
Registration:
N3372Q
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Foley - Carrollton
MSN:
421B-0256
YOM:
1972
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5450
Circumstances:
The private pilot of the twin-engine airplane departed on the personal flight. During the takeoff roll, all indications were normal. When the airplane accelerated to between 75 and 80 knots, the pilot pulled back on the yoke slowly, and the airplane began to climb. After he raised the landing gear, the pilot noticed that the airplane was not continuing to climb and that the airspeed was 80 knots; he then heard the stall warning horn. The airplane impacted trees about 1/4 mile from the runway, caught fire, and was destroyed; the pilot egressed with minor injuries. The airplane's published minimum control speed was 86 knots and the break ground and climb speed was 106 knots. Given that information, it is likely that the pilot's attempt to rotate and climb the airplane below 80 knots resulted in the airplane being unable to gain altitude and climb above trees at the end of the runway.
Probable cause:
The pilot's failure to obtain proper takeoff speed before breaking ground, which resulted in the airplane's failure to gain altitude and a collision with trees and terrain.
Final Report:

Crash of a Swearingen SA226AT Merlin IVA in Girona

Date & Time: Apr 24, 2016 at 1520 LT
Operator:
Registration:
EC-GFK
Flight Type:
Survivors:
Yes
Schedule:
Girona - Girona
MSN:
AT-062
YOM:
1977
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2402
Captain / Total hours on type:
27.00
Copilot / Total flying hours:
7992
Copilot / Total hours on type:
6868
Aircraft flight hours:
16128
Circumstances:
The crew (one pilot under supervision and one instructor) departed Girona-Costa Brava on a local training flight. Following two successful landings and touch-and-go manoeuvres, the crew initiated a new approach to complete a full stop landing. The aircraft belly landed and slid for few dozen metres before coming to rest on the runway. Both pilots evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The cause of the accident was that the crew failed to actuate the lever used to deploy the landing gear. Inadequate presentation, in the operator's operating manuals, of the flight tasks to be performed by each crew member and the timing of these tasks is identified as a contributing factor.
Final Report:

Crash of a Beechcraft 300 Super King Air in Porto Seguro

Date & Time: Apr 21, 2016 at 1140 LT
Registration:
PT-MCM
Flight Type:
Survivors:
Yes
Schedule:
Rio de Janeiro – Porto Seguro
MSN:
FA-52
YOM:
1985
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8000
Captain / Total hours on type:
1000.00
Circumstances:
On final approach to Porto Seguro-Terravista Golf Club Airport Runway 15, the twin engine aircraft descended too low, causing the left main gear to impact the ground short of runway threshold. On impact, the left main landing gear was torn off. The aircraft slid on runway for few dozen metres then veered to the left and came to a halt. All 10 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The following factors were identified:
- Application of the commands - contributed
There was no effective action on the aircraft controls during the final approach to avoid a brutal impact with the ground prior to the runway threshold.
- Adverse weather conditions - undetermined
It is possible that the aircraft was under the effect of the phenomenon known as windshear, which affected the approach profil and the subsequent impact with the ground short of runway.
- Pilot judgement - contributed
The risks of a possible windshear during the final approach were not adequately considered by the pilot. The decision to proceed for the landing, to the detriment of the alternative recommended by experts to perform a missed approach, proved decisive for the development of the accident.
Final Report:

Crash of a Beechcraft 1900D in Gander

Date & Time: Apr 20, 2016 at 2130 LT
Type of aircraft:
Operator:
Registration:
C-FEVA
Survivors:
Yes
Schedule:
Goose Bay – Gander
MSN:
UE-126
YOM:
1994
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2381
Captain / Total hours on type:
1031.00
Copilot / Total flying hours:
1504
Copilot / Total hours on type:
174
Aircraft flight hours:
32959
Circumstances:
The Exploits Valley Air Services Beechcraft 1900D (registration C-FEVA, serial number UE-126), operating as Air Canada Express flight EV7804, was on a scheduled passenger flight from Goose Bay International Airport, Newfoundland and Labrador, to Gander International Airport, Newfoundland and Labrador. At 2130 Newfoundland Daylight Time, while landing on Runway 03, the aircraft touched down right of the centreline and almost immediately veered to the right. The nosewheel struck a compacted snow windrow on the runway, causing the nose landing gear to collapse. As the aircraft’s nose began to drop, the propeller blades struck the snow and runway surface. All of the left-side propeller blades and 3 of the right-side propeller blades separated at the blade root. A portion of a blade from the right-side propeller penetrated the cabin wall. The aircraft slid to a stop on the runway. All occupants on board — 14 passengers and 2 crew members — were evacuated. Three passengers sustained minor injuries. The aircraft was substantially damaged. There was no post-impact fire. There were insufficient forward impact forces to automatically activate the 121.5 MHz emergency locator transmitter. The accident occurred during the hours of darkness.
Probable cause:
Findings as to causes and contributing factors:
1. Neither pilot had considered that the combination of landing at night, in reduced visibility, with a crosswind and blowing snow, on a runway with no centreline lighting, was a hazard that may create additional risks.
2. The blowing snow made it difficult to identify the runway centreline markings, thereby reducing visual cues available to the captain. This situation was exacerbated by the absence of centreline lighting and a possible visual illusion caused by blowing snow.
3. Due to the gusty crosswind conditions, the aircraft drifted to the right during the landing flare, which was not recognized by the crew.
4. It is likely that the captain had difficulty determining aircraft position during the landing flare.
5. The flight crew’s decision to continue with the landing was consistent with plan continuation bias.
6. During landing, the nosewheel struck the compacted snow windrow on the runway, causing the nose landing gear to collapse.

Findings as to risk:
1. If aircraft are not equipped with a 406 MHz-capable emergency locator transmitter, flight crews and passengers are at increased risk of injury or death following an accident because search-and-rescue assistance may be delayed.
2. If operators do not have defined crosswind limits, there is a risk that pilots may land in crosswinds that exceed their abilities, which could jeopardize the safety of flight.
3. If composite propeller blades contact objects and separate, and then strike or penetrate the cabin, there is a risk of injury or death to occupants seated in the propeller’s plane of rotation.
4. If modern crew resource management training is not a regulatory requirement, then it is less likely to be introduced by operators and, as a result, pilots may not be fully prepared to recognize and mitigate hazards encountered during flight.
5. If organizations do not use modern safety management practices and do not have a robust safety culture, then there is an increased risk that hazards will not be identified and mitigated.
6. When testing an emergency locator transmitter’s (ELT) automatic activation system, a sticking g-switch may go undetected if more than 1 football throw is necessary to activate the ELT. As a result, the ELT might not activate during an accident, and search-and-rescue assistance may be delayed, placing flight crews and passenger at an increased risk for injury or death.
Final Report:

Crash of a Beechcraft 65-A90-1 King Air in Slidell: 2 killed

Date & Time: Apr 19, 2016 at 2115 LT
Type of aircraft:
Operator:
Registration:
N7MC
Survivors:
No
Schedule:
Slidell - Slidell
MSN:
LM-106
YOM:
1968
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
18163
Captain / Total hours on type:
614.00
Copilot / Total flying hours:
7769
Copilot / Total hours on type:
22
Aircraft flight hours:
15208
Circumstances:
The airline transport pilot and commercial copilot were conducting a mosquito abatement application flight. Although flight controls were installed in both positions, the pilot typically operated the airplane. During a night, visual approach to landing at their home airfield, the airplane was on the left base leg and overshot the runway's extended centerline and collided with 80-ft-tall power transmission towers and then impacted terrain. Examination of the airplane did not reveal any preimpact anomalies that would have precluded normal operation. Both pilots were experienced with night operations, especially at their home airport. The pilot had conducted operations at the airport for 14 years and the copilot for 31 years, which might have led to crew complacency on the approach . Adequate visibility and moon disk illumination were available; however, the area preceding the runway is a marsh and lacks cultural lighting, which can result in black-hole conditions in which pilots may perceive the airplane to be higher than it actually is while conducting an approach visually. The circumstances of the accident are consistent with the pilot experiencing the black hole illusion which contributed to him flying an approach profile that was too low for the distance remaining to the runway. It is likely that the pilot did not maintain adequate crosscheck of his altimeter and radar altimeter during the approach and that the copilot did not monitor the airplane's progress; thus, the flight crew did not recognize that they were not maintaining a safe approach path. Further, it is likely that neither pilot used the visual glidepath indicator at the airport, which is intended to be a countermeasure against premature descent in visual conditions.
Probable cause:
The unstable approach in black-hole conditions, resulting in the airplane overshooting the runway extended centerline and descending well below a safe glidepath for the runway. Contributing to the accident was the lack of monitoring by the copilot allowing the pilot to fly well below a normal glidepath.
Final Report:

Crash of a Britten-Norman BN-2T Islander in Kiunga: 12 killed

Date & Time: Apr 13, 2016 at 1420 LT
Type of aircraft:
Operator:
Registration:
P2-SBC
Survivors:
No
Schedule:
Oksapmin – Kiunga
MSN:
3010
YOM:
1983
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
4705
Captain / Total hours on type:
254.00
Aircraft flight hours:
2407
Aircraft flight cycles:
2886
Circumstances:
On the afternoon of 13 April 2016, a Pilatus Britten Norman Turbine Islander (BN-2T) aircraft, registered P2-SBC, operated by Sunbird Aviation Ltd, departed from Tekin, West Sepik Province for Kiunga, Western Province, as a charter flight under the visual flight rules. On board were the pilot-in-command (PIC) and 11 passengers (eight adults and three children). The aircraft was also carrying vegetables. The pilot reported departing Oksapmin at 13:56. The pilot had flight planned, Kiunga to Oksapmin to Kiunga. However, the evidence revealed that without advising Air Traffic Services, the pilot flew from Oksapmin to Tekin. On departure from Tekin the pilot transmitted departure details to ATS, stating departure from Oksapmin. The recorded High Frequency radio transmissions were significantly affected by static and hash. The weather at Kiunga was reported to be fine. As the aircraft entered the Kiunga circuit area, the pilot cancelled SARWATCH with Air Traffic Services (ATS). The pilot did not report an emergency to indicate a safety concern. Witnesses reported that during its final approach, the aircraft suddenly pitched up almost to the vertical, the right wing dropped, and the aircraft rolled inverted and rapidly “fell to the ground”. It impacted the terrain about 1,200 metres west of the threshold of runway 07. The impact was vertical, with almost no forward motion. The aircraft was destroyed, and all occupants were fatally injured.
Probable cause:
The aircraft’s centre of gravity was significantly aft of the aft limit. When landing flap was set, full nose-down elevator and elevator trim was likely to have had no effect in lowering the nose of the aircraft. Unless the flaps had been retracted immediately, the nose-up pitch may also have resulted in tail plane stall, exacerbating the pitch up. The wings stalled, followed immediately by the right wing dropping. Recovery from the stall at such a low height was not considered possible.
Other factors:
Other factors is used for safety deficiencies or concerns that are identified during the course of the investigation, that while not causal to the accident, nevertheless should be addressed with the
aim of accident and serious incident prevention, and the safety of the travelling public.
a) Following the reweighing of SBC, the operator did not make adjustments to account for the shift of the moment arm as a result of the reweighing. Specifically, a reduction of allowable maximum weight in the baggage compartment.
b) The pilot, although signing the flight manifest on previous flights attesting that the aircraft was loaded within c of g limits, had not computed the c of g. No documentation was available to confirm that the pilot had computed the c of g for the accident flight, or any recent flights.
c) All of the High Frequency radio transmissions between Air Traffic Services and SBC were significantly affected by static interference and a lot of hash, making reception difficult, and many transmissions unclear and unreadable. This is a safety concern to be addressed to ensure that vital operational radio transmissions are not missed for the safety of aircraft operations, and the travelling public.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 100 in Fentress

Date & Time: Apr 9, 2016 at 1700 LT
Operator:
Registration:
N122PM
Survivors:
Yes
Schedule:
Fentress - Fentress
MSN:
15
YOM:
1966
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6000
Captain / Total hours on type:
1000.00
Aircraft flight hours:
53624
Circumstances:
The pilot reported that he was landing in gusty crosswind conditions following a parachute jump flight, and that the gusty conditions had persisted for the previous 10 skydiving flights that day. The pilot further reported that during the landing roll, when the nose wheel touched down, the airplane became "unstable" and veered to the left. He reported that he applied right rudder and added power to abort the landing, but the airplane departed the runway to the left and the left wing impacted a tree. The airplane spun 180 degrees to the left and came to rest after the impact with the tree. The left wing was substantially damaged. The pilot did not report any mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause:
The pilot's failure to maintain directional control during the aborted landing in gusty crosswind conditions, which resulted in a runway excursion and a collision with a tree.
Final Report:

Crash of a Douglas DC-3C in Puerto Gaitán

Date & Time: Apr 6, 2016 at 0625 LT
Type of aircraft:
Operator:
Registration:
HK-2663
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Puerto Gaitán – Villavicencio
MSN:
10210
YOM:
1945
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4058
Copilot / Total flying hours:
7934
Aircraft flight hours:
23291
Circumstances:
Shortly after takeoff from Puerto Gaitán Airport Runway 04, while on a cargo flight to Villavicencio, the left engine exploded and caught fire. As the aircraft was losing speed and height, the crew attempted an emergency landing when the aircraft crash landed in an open field located 2,6 km southwest from the airport, bursting into flames. All three crew members escaped with minor injuries and the aircraft was destroyed by a post crash fire.
Probable cause:
Failure of the left engine following the detachment of the head of a cylinder shortly after takeoff. Deficiencies in maintenance processes contributed to this situation. The crew failed to follow the emergency procedures when the left engine caught fire and exploded, reducing the power on the right engine. In such conditions, the aircraft was unable to maintain a safe altitude and the crew was forced to attempt an emergency landing.
Final Report: