Crash of a Cessna 550 Citation Bravo in Vienna

Date & Time: Sep 3, 2015 at 1227 LT
Type of aircraft:
Operator:
Registration:
OE-GLG
Survivors:
Yes
Schedule:
Salzburg - Vienna
MSN:
550-0977
YOM:
2001
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5000
Captain / Total hours on type:
1800.00
Copilot / Total flying hours:
1200
Copilot / Total hours on type:
350
Aircraft flight hours:
7525
Aircraft flight cycles:
5807
Circumstances:
Following an uneventful flight from Salzburg, the crew was cleared to descent to Vienna-Schwechat Airport. On approach to runway 34, the crew completed the checklist and lowered the landing gear when he realized the the left main gear remained stuck in its wheel well and that the green light failed to come on on the cockpit panel. The crew agreed to continue. After touchdown on runway 34, the aircraft deviated to the left, veered off runway and came to rest in a grassy area located near taxiway D and taxiway B5 and B6. All five occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The accident was caused by a metallic foreign body between valve seat and ball of the spring loaded ball check valve in the undercarriage servo valve of the left main landing gear caused the check valve not to close as intended and hydraulic fluid was directed directly to the landing gear cylinder without moving the piston rod. Due to the fact that the piston rod of the undercarriage servo valve did not move as intended, the mechanical unlocking hook of the left undercarriage was also not controlled - the landing gear was therefore not deployed.
Contributing factors:
- The possibility to abort the approach, to Go Around and fly a holding to carry out troubleshooting, as described in the operations manual of the aviation company as well as in the "Emergency / Abnormal Procedures" manual of the aircraft manufacturer, was not used.
- The emergency extension system of the landing gear was not used.
Final Report:

Crash of a Technoavia SMG-92 Turbo Finist in Casale Monferrato

Date & Time: Aug 29, 2015 at 1430 LT
Operator:
Registration:
HA-YDJ
Flight Phase:
Survivors:
Yes
Schedule:
Casale Monferrato - Casale Monferrato
MSN:
02-001
YOM:
1993
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
600
Captain / Total hours on type:
35.00
Aircraft flight hours:
800
Circumstances:
The single engine aircraft departed Casale Monferrato-Francesco Cappa Airfield on a local skydiving mission, the 13th sortie of the day, carrying seven skydivers, three tourists and one pilot). Shortly after rotation from a grassy runway, the pilot encountered engine problems. The aircraft continued in a flat attitude, collided with a hedge and few trees before coming to rest in a wooded area located 300 metres past the runway end. All 11 occupants were injured, some of them seriously. The aircraft was damaged beyond repair.
Probable cause:
The accident is the consequence of an engine failure caused by the loss of connection in the power module between the quill shaft and the PT shaft.
The following contributing factors were identified:
- A control system of the aircraft as part of 'aircraft operator CAMO not sufficiently thorough,
- The inaccurate, non-timely and incorrect reporting by the user of the aircraft of critical parameters for monitoring engine life,
- A national regulation, in force at the time of the accident, relating to the flight activity for launching paratroopers, which did not provide, in fact, adequate surveillance technique by the aeronautical authority on the aircraft used in this activity,
- The absence of adequate retention and safety devices for paratroopers on board the aircraft.
Final Report:

Crash of a Boeing 737-3Q8 in Wamena

Date & Time: Aug 28, 2015 at 1547 LT
Type of aircraft:
Operator:
Registration:
PK-BBY
Flight Type:
Survivors:
Yes
Schedule:
Jayapura – Wamena
MSN:
23535/1301
YOM:
1986
Flight number:
8F189
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13880
Captain / Total hours on type:
4877.00
Copilot / Total flying hours:
608
Copilot / Total hours on type:
342
Aircraft flight hours:
54254
Aircraft flight cycles:
38422
Circumstances:
On 28 August 2015 a Boeing 737-300 Freighter, registered PK-BBY was being operated by PT. Cardig Air on a scheduled cargo flight from Sentani Airport (WAJJ) Jayapura to Wamena Airport (WAVV) Papua, Indonesia. At 1234 LT (0334 UTC), the aircraft departed to Wamena and on board the aircraft were two pilots, and 14,610 kg of cargo. The Pilot in Command (PIC) acted as Pilot Flying (PF) while the Second in Command (SIC) who was under line training acted as Pilot Monitoring (PM). There was no reported or recorded aircraft system abnormality during the flight until the time of occurrence. At 0637 UTC, when the aircraft approaching PASS VALLEY, the Wamena Tower controller provided information that the runway in use was runway 15 and the wind was 150°/18 knots, QNH was 1,003 mbs and temperature was 23 °C. At 0639 UTC, the pilot reported position over PASS VALLEY, descended passing FL135. The Wamena Tower controller instructed the pilot to report position over JIWIKA. At 0645 UTC, the pilot reported position over JIWIKA and continued to final runway 15. At 0646 UTC, the pilot reported position on final runway 15 and Wamena Tower controller provided landing clearance with additional information of wind 150°/15 knots and QNH 1,003 mbs. At 0647 UTC, the aircraft touched down about 35 meter before the beginning runway 15 with vertical acceleration of 3.68 G. The left main landing gear collapsed and the left engine contacted to the runway surface. The aircraft stopped at about 1,500 meters from runway threshold. No one was injured on this occurrence.
Probable cause:
According to factual information during the investigation, the Komite Nasional Keselamatan Transportasi determines the findings of the investigation are listed as follows:
1. The pilots held valid licenses and medical certificates.
2. The aircraft had a valid Certificate of Airworthiness (C of A) and Certificate of Registration (C of R), and was operated within the weight and balance envelope.
3. There were no reports of aircraft system abnormalities during the flight.
4. After passed JIWIKA on altitude 10,000 feet, the FDR recorded the engines were on idle, the average rate of descend was approximately 2,000 feet per minute.
5. At altitude approximately 8,000 feet, the flap selected to 40 position and moved to 39.9° one minute 25 seconds later.
6. The BMKG weather report was wind 150°/14-19 knots and the Wamena Tower controller reported to the pilot that the wind was 150°/15 knots. The information of gust wind, which indicated the possibility of windshear, was not reported to the pilot.
7. The EGPWS “CAUTION WINDSHEAR” active on altitude of 5,520 feet.
8. 06:45:43 UTC, the engine power increased when the aircraft altitude was on 5,920 feet prior the EGPWS altitude call “ONE HUNDRED” heard.
9. Started from 06:45:45 UTC, the FDR recorded the CAS increased from 148 knots to 154 knots followed by N1 decreased gradually from 73% to 38%. Three seconds before touched down, the rate of descend was constant on value 1,320 feet per minute followed by EGPWS warning “SINK RATE”.
10. The aircraft touched down at about 35 meters before the beginning runway 15 with the vertical acceleration recorded of 3.68 G.
11. The trunnion link of the left Main Landing Gear (MLG) assembly was found broken and the left main landing gear collapsed.
12. The FDR data contained of 107 flight hours consisted of 170 flight sectors which recorded five times of the vertical acceleration more than 2 G during landing at Wamena. The accumulation of such value of vertical acceleration might lead to landing gear strength degradation.
13. The Visual Approach Slope Indicator (VASI) of runway 15 was not operated after the runway extension.
14. The investigation found several touchdown marks on the pavement before the runway 15.
15. Excessive rubber deposit was found on the surface of runway 15 at about 600 meter started from the runway threshold.
16. The absence of speed correction following the information of headwind of 15 knots and pilot crew briefing after activation of EGPWS caution windshear indicated that the pilot did not aware of the existing windshear, that might be contributed by the absence of gust wind information.
17. The large thrust reduction was not in accordance with the FCOM for windshear precaution and resulted in rapid descend.
18. The accident flight collapsed the landing gear, the FDR recorded the vertical acceleration was 3.683 G which was within the landing gear design limit. This indicated the degradation of landing gear strength.

Contributing Factor:
The large thrust reduction during the windshear resulted in rapid descend and the aircraft touched down with 3.683 G then collapsed the landing gear that had strength degradation.
Final Report:

Crash of a Beechcraft E90 King Air in Fayetteville

Date & Time: Aug 28, 2015 at 1400 LT
Type of aircraft:
Operator:
Registration:
N891PC
Flight Type:
Survivors:
Yes
Schedule:
Shelbyville – Huntsville
MSN:
LW-40
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1882
Captain / Total hours on type:
230.00
Aircraft flight hours:
11283
Circumstances:
Shortly after takeoff in day visual meteorological conditions, when the airplane was climbing through 3,000 ft mean sea level, a complete electrical failure occurred that affected electrical instrumentation and additional airplane equipment, including the landing gear. The pilot reported that he performed the electrical failure checklists and could not restore power. After additional troubleshooting with no success, he chose to divert to and land at another airport. While in the traffic pattern at his diversion airport, he attempted to lower the landing gear using the emergency landing gear extension procedures but could not confirm the landing gear were down and locked. Without any capability to communicate or confirmation that the landing gear were down, he decided to leave the airport traffic pattern and land on a nearby field to avoid airport traffic; the airplane sustained substantial damage to the fuselage, landing gear doors, engines, and propellers during the off-airport landing. The reason for the loss of electrical power could not be determined. Examination of the cockpit revealed that the landing gear's emergency engage handle, also known as the "J" handle, was not pulled up and turned, which was one of the steps listed in the airplane flight manual for the manual landing gear extension procedure. The "J" handle engages the clutch and allows for the handle to operate the landing gear chain. Without engaging the "J" handle, the landing gear handle pumping action would not have worked, which resulted in the gear-up landing.
Probable cause:
A total loss of electrical power for reasons that could not be determined and the pilot's subsequent failure to properly follow the manual landing gear extension procedures, which resulted in the landing gear not extending.
Final Report:

Crash of a Cessna 750 Citation X in Toluca

Date & Time: Aug 27, 2015 at 0015 LT
Type of aircraft:
Operator:
Registration:
XA-KYE
Flight Type:
Survivors:
Yes
MSN:
750-0204
YOM:
2002
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was apparently completing a positioning flight to Toluca Airport. Following a night landing on runway 15, the crew started the braking procedure when the aircraft deviated to the left. The crew applied full brake but the aircraft veered off runway. While contacting soft ground, the nose gear collapsed and the aircraft came to rest about 2,700 metres from the runway threshold. Both pilots escaped uninjured and the aircraft was damaged beyond repair.

Crash of a Cessna S550 Citation II in Charallave

Date & Time: Aug 26, 2015 at 2230 LT
Type of aircraft:
Operator:
Registration:
YV3125
Survivors:
Yes
Schedule:
Oranjestad – Barcelona – Charallave
MSN:
S550-0085
YOM:
1986
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing a charter flight from Oranjestad (Aruba) to Charallave with an intermediate stop in Barcelona. While on a night approach to runway 10, the captain initiated a go-around procedure for unknown reasons. During the second attempt to land, the aircraft landed long and the touchdown point appeared to be half way down the runway 10 which is 2,000 meters long. Unable to stop within the remaining distance, the aircraft overran, went down an embankment and came to rest. All eight occupants evacuated safely while the aircraft was damaged beyond repair. The passengers were members of the pop band 'Los Cadillac's' accompanied by the Venezuelan singer and actor Arán de las Casas.

Crash of an Eclipse EA500 in Danbury

Date & Time: Aug 21, 2015 at 1420 LT
Type of aircraft:
Operator:
Registration:
N120EA
Flight Type:
Survivors:
Yes
Schedule:
Oshkosh – Danbury
MSN:
199
YOM:
2008
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7846
Captain / Total hours on type:
1111.00
Aircraft flight hours:
858
Circumstances:
**This report was modified on April 2, 2020. Please see the public docket for this accident to view the original report.**
After the airplane touched down on the 4,422-ft-long runway, the airline transport pilot applied the brakes to decelerate; however, he did not think that the brakes were operating. He continued "pumping the brakes" and considered conducting a go-around; however, there was insufficient remaining runway to do so. The airplane subsequently continued off the end of the runway, impacted a berm, and came to rest upright, which resulted in substantial damage to the right wing. During postaccident examination of the airplane, brake pressure was obtained on both sets of brake pedals when they were depressed, and there was no bleed down or reduction in pedal firmness when the brakes were pumped several times. Examination revealed no evidence off any preimpact anomalies with the brake system that would have precluded normal operation. In addition, the pilot indicated that he was not aware of and was not trained on the use of the ALL INTERRUPT button, which is listed as a step in the Emergency Procedures section of the airplane flight manual and is used to disable the anti-skid brake system functions and restore normal braking when the brakes are ineffective; thus, the pilot did not follow proper checklist procedures. According to data downloaded from the airplane's diagnostic storage unit (DSU), the airplane touched down 1,280 ft beyond the runway threshold, which resulted in 2,408 ft of runway remaining (the runway had a displaced threshold of 734 ft) and that it traveled 2,600 ft before coming to rest about 200 ft past the runway. The airplane's touchdown speed was about 91 knots. Comparing DSU data from previous downloaded flights revealed that the airplane's calculated deceleration rate during the accident landing was indicative of braking performance as well as or better than the previous landings. Estimated landing distance calculations revealed that the airplane required about 3,063 ft when crossing the threshold at 50 ft above ground level. The target touchdown speed was 76 knots. However, the airplane touched down with only 2,408 ft of remaining runway faster than the target touchdown speed, which resulted in the runway overrun.
Probable cause:
The pilot's failure to attain the proper touchdown point and exceedance of the target touchdown speed, which resulted in a runway overrun.
Final Report:

Crash of a Beechcraft A100 King Air in Margaree

Date & Time: Aug 16, 2015 at 1616 LT
Type of aircraft:
Operator:
Registration:
C-FDOR
Survivors:
Yes
Schedule:
Halifax – Margaree
MSN:
B-103
YOM:
1972
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1723
Captain / Total hours on type:
298.00
Copilot / Total flying hours:
532
Copilot / Total hours on type:
70
Aircraft flight hours:
14345
Circumstances:
On 16 August 2015, a Maritime Air Charter Limited Beechcraft King Air A100 (registration C-FDOR, serial number B-103) was on a charter flight from Halifax Stanfield International Airport, Nova Scotia, to Margaree Aerodrome, Nova Scotia, with 2 pilots and 2 passengers on board. At approximately 1616 Atlantic Daylight Time, while conducting a visual approach to Runway 01, the aircraft touched down hard about 263 feet beyond the threshold. Almost immediately, the right main landing gear collapsed, then the right propeller and wing contacted the runway. The aircraft slid along the runway for about 1350 feet, then veered right and departed off the side of the runway. It came to rest about 1850 feet beyond the threshold and 22 feet from the runway edge. There were no injuries and there was no post-impact fire. The aircraft was substantially damaged. The occurrence took place during daylight hours. The 406-megahertz emergency locator transmitter did not activate.
Probable cause:
Findings:
Findings as to causes and contributing factors:
1. Neither pilot had considered that landing on a short runway at an unfamiliar aerodrome with known high terrain nearby and joining the circuit directly on a left base were hazards that may create additional risks, all of which would increase the crew’s workload.
2. The presence of the tower resulted in the pilot not flying focusing his attention on monitoring the aircraft’s location, rather than on monitoring the flight or the actions of the pilot flying.
3. The crew’s increased workload, together with the unexpected distraction of the presence of the tower, led to a reduced situational awareness that caused them to omit the Landing Checks checklist.
4. At no time during the final descent was the engine power increased above about 400 foot-pounds of torque.
5. Using only pitch to control the rate of descent prevented the pilot flying from precisely controlling the approach, which would have ensured that the flare occurred at the right point and at the right speed.
6. Neither pilot recognized that the steep rate of descent was indicative of an unstable approach.
7. Advancing the propellers to full would have increased the drag and further increased the rate of descent, exacerbating the already unstable approach.
8. The aircraft crossed the runway threshold with insufficient energy to arrest the rate of descent in the landing flare, resulting in a hard landing that caused the right main landing gear to collapse.
Findings as to risk:
1. If data recordings are not available to an investigation, then the identification and communication of safety deficiencies to advance transportation safety may be precluded.
2. If organizations do not use modern safety management practices, then there is an increased risk that hazards will not be identified and risks will not be mitigated.
3. If passenger seats installed in light aircraft are not equipped with shoulder harnesses, then there is an increased risk of passenger injury or death in the event of an accident.
4. If the experience and proficiency of pilots are not factored into crew selection, then there is a risk of suboptimal crew pairing, resulting in a reduction of safety margins.
5. If pilots do not carry out checklists in accordance with the company’s and manufacturer’s instructions, then there is a risk that a critical item may be missed, which could jeopardize the safety of the flight.
6. If crew resource management is not used and continuously fostered, then there is a risk that pilots will be unprepared to avoid or mitigate crew errors encountered during flight.
7. If organizations do not have a clearly defined go-around policy, then there is a risk that flight crews will continue an unstable approach, increasing the risk of an approach-and-landing accident.
8. If pilots are not prepared to conduct a go-around on every approach, then there is a risk that they may not respond to situations that require a go-around.
9. If operators do not have a stable approach policy, then there is a risk that an unstable approach will be continued to a landing, increasing the risk of an approach-andlanding accident.
10. If an organization’s safety culture does not fully promote the goals of a safety management system, then it is unlikely that it will be effective in reducing risk.
Other findings:
1. There were insufficient forward impact forces to automatically activate the emergency locator transmitter.
Final Report:

Crash of a Rockwell Sabreliner 60SC in San Diego: 4 killed

Date & Time: Aug 16, 2015 at 1103 LT
Type of aircraft:
Operator:
Registration:
N442RM
Flight Type:
Survivors:
No
Schedule:
San Diego - San Diego
MSN:
306-073
YOM:
1974
Flight number:
Eagle 1
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
4485
Captain / Total hours on type:
347.00
Copilot / Total flying hours:
6400
Aircraft flight hours:
13418
Circumstances:
The Cessna 172 (N1285U) was conducting touch-and-go landings at Brown Field Municipal Airport (SDM), San Diego, California, and the experimental North American Rockwell NA265-60SC Sabreliner (N442RM, call sign Eagle1) was returning to SDM from a mission flight. SDM has two parallel runways, 8R/26L and 8L/26R; it is common in west operations for controllers to use a right traffic pattern for both runways 26R and 26L due to the proximity of Tijuana Airport, Tijuana, Mexico, to the south of SDM. On the morning of the accident, the air traffic control tower (ATCT) at SDM had both control positions (local and ground control) in the tower combined at the local control position, which was staffed by a local controller (LC)/controller-in-charge, who was conducting on-the-job training with a developmental controller (LC trainee). The LC trainee was transmitting control instructions for all operations; however, the LC was monitoring the LC trainee's actions and was responsible for all activity at that position. About 13 minutes before the accident, the N1285U pilot contacted the ATCT and requested touch-andgo landings in the visual flight rules (VFR) traffic pattern. About that time, another Cessna 172 (N6ZP) and a helicopter (N8360R) were conducting operations in the VFR traffic pattern, and a Cessna 206 Stationair (N5058U) was inbound for landing. Over the next 5 minutes, traffic increased, with two additional aircraft inbound for landing. (Figure 1 in the factual report for this accident shows the aircraft in the SDM traffic pattern about 8 minutes before the accident.) The LC trainee cleared the N1285U pilot for a touch-and-go on runway 26R; the pilot acknowledged the clearance and then advised the LC trainee that he was going to go around. The LC trainee advised the N1285U pilot to expect runway 26L on the next approach. At that time, three aircraft were using runway 26R (Global Express [N18WZ] was inbound for landing, N6ZP was on a right base for a touch-and-go, and a Cessna Citation [XALVV] was on short final) and three aircraft were using runway 26L (N1285U was turning right downwind for the touch-and-go, a Skybolt [N81962] was on a left downwind for landing, and N8360R was conducting a touch-and-go landing). After N1285U completed the touch-andgo on runway 26L, the pilot entered a right downwind for runway 26R. Meanwhile, Eagle1 was 9 miles west of the airport and requested a full-stop landing; the LC trainee instructed the Eagle1 flight crew to enter a right downwind for runway 26R at or above an altitude of 2,000 ft mean sea level. At this time, about 3 minutes before the accident, the qualified LC terminated the LC trainee's training and took over control of radio communications. From this time until the collision occurred, the LC was controlling nine aircraft. (Figure 2 and Figure 4 in the factual report for this accident show the total number of aircraft under ATCT control shortly before the accident.) During the next 2 minutes, the LC made several errors. For example, after N6ZP completed a touch-andgo on runway 26R, the pilot requested a right downwind departure from the area, which the LC initially failed to acknowledge. The LC also instructed the N5058U pilot, who had been holding short of runway 26L, that he was cleared for takeoff from runway 26R. Both errors were corrected. In addition, the LC instructed the helicopter pilot to "listen up. turn crosswind" before correcting the instruction 4 seconds later to "turn base." (Figure 2 in the factual report for this accident shows the aircraft in the traffic pattern about 2 minutes before the accident.) About 1 minute before the collision, the Eagle1 flight crew reported on downwind midfield and stated that they had traffic to the left and right in sight. At that time, N1285U was to Eagle1's right, between Eagle1 and the tower, and established on a right downwind about 500 ft below Eagle1's position. N6ZP was about 1 mile forward and to the left of Eagle1, heading northeast and departing the area. Mistakenly identifying the Cessna to the right of Eagle1 as N6ZP, the LC instructed the N6ZP pilot to make a right 360° turn to rejoin the downwind when, in fact, N1285U was the airplane to the right of Eagle1. (The LC stated in a postaccident interview that he thought the turn would resolve the conflict with Eagle1 and would help the Cessna avoid Eagle1's wake turbulence.) The N6ZP pilot acknowledged the LC's instruction and began turning; N1285U continued its approach to runway 26R. However, the LC never visually confirmed that the Cessna to Eagle1's right (N1285U) was making the 360° turn. Ten seconds later, the LC instructed the Eagle1 flight crew to turn base and land on runway 26R, which put the accident airplanes on a collision course. The LC looked to ensure that Eagle1 was turning as instructed and noticed that the Cessna on the right downwind (which he still mistakenly identified as N6ZP) had not begun the 360° turn that he had issued. The LC called the N6ZP pilot, and the pilot responded that he was turning. In the first communication between the LC and the N1285U pilot (and the first between the controllers in the ATCT and that airplane's pilot in almost 6 minutes), the LC transmitted the call sign of N1285U, which the pilot acknowledged. N1285U and Eagle1 collided as the LC tried to verify N1285U's position. A postaccident examination of both airplanes did not reveal any mechanical anomalies that would have prevented the airplanes from maneuvering to avoid an impact.
Probable cause:
The local controller's (LC) failure to properly identify the aircraft in the pattern and to ensure control instructions provided to the intended Cessna on downwind were being performed before turning Eagle1 into its path for landing. Contributing to the LC's actions was his incomplete situational awareness when he took over communications from the LC trainee due to the high workload at the time of the accident. Contributing to the accident were the inherent limitations of the see-and-avoid concept, resulting in the inability of the pilots involved to take evasive action in time to avert the collision.
Final Report:

Crash of a Pacific Aerospace PAC750XL in Ninia: 1 killed

Date & Time: Aug 12, 2015 at 0748 LT
Operator:
Registration:
PK-KIG
Survivors:
Yes
Schedule:
Wamena – Ninia
MSN:
170
YOM:
2010
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1537
Captain / Total hours on type:
395.00
Aircraft flight hours:
757
Aircraft flight cycles:
1315
Circumstances:
On 12 August 2015, a PAC-750XL aircraft, registered PK-KIG, was being operated by PT. Komala Indonesia on an unscheduled passenger flight from Wamena Airport (WAJW) Papua to Ninia Airstrip , Yahukimo, Papua that was located on radial 127° from Wamena with a distance of approximately 26 Nm. At 0733 LT (2233 UTC), the aircraft departed from Wamena Airport with an estimated time of arrival at Ninia of 2248 UTC. The flight was uneventful until approaching Ninia. On board the aircraft were one pilot, one engineer and 4 passengers. According to the pilot statement, an airspeed indicator malfunction occurred during flight. Video footage taken by a passenger showed that, during the approach at an altitude of approximately 6,500 feet, the airspeed indicators indicated zero and the aural stall warning activated. The aircraft then flew on the left side and parallel to the runway. Thereafter the aircraft climbed, turned left and impacted the ground about 200 meters south-west of the runway. The engineer on board was fatally injured, one passenger had minor injuries and the other occupants, including the pilot, were seriously injured. Two occupants were evacuated to a hospital in Jayapura Airport and four others, including the fatally injured, were evacuated to a hospital in Wamena.
Probable cause:
The following findings were identified:
1. Continuing the flight with both airspeed indicators unserviceable increased the complexity of the flight combined with high-risk aerodrome increased the pilot workload.
2. The improper corrective action at the time of the aural stall warning activating on the final approach, and the aircraft flew to insufficient area for a safe maneuver.
3. The unfamiliarity to the airstrip resulted in inappropriate subsequent escape maneuver and resulted in the aircraft stalling.
4. The pilot was not provided with appropriate training and familiarization to fly into a high-risk airstrip
Final Report: