Crash of an Embraer EMB-505 Phenom 300 in Altenrhein

Date & Time: Aug 6, 2012 at 1540 LT
Type of aircraft:
Operator:
Registration:
CN-MBR
Survivors:
Yes
Schedule:
Geneva - Altenrhein
MSN:
505-00025
YOM:
2011
Flight number:
DLI211
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7025
Captain / Total hours on type:
75.00
Copilot / Total flying hours:
5854
Copilot / Total hours on type:
465
Aircraft flight hours:
510
Circumstances:
On 6 August 2012 the Embraer EMB-505 Phenom 300 aircraft, registration CN-MBR, took off at 12:59 UTC from Geneva (LSGG) on a commercial flight to St. Gallen-Altenrhein (LSZR). After the initial call to the aerodrome control centre St. Gallen tower, the crew quickly decided, after an enquiry from the air traffic controller, on a direct approach on the runway 10 instrument landing system (ILS). Shortly thereafter, the landing gear and flaps were extended. The flaps jammed at approximately 10 degrees and the FLAP FAIL warning message was displayed. The crew carried out a go-around shortly before landing. The landing gear subsequently remained extended. The flaps remained jammed for the remainder of the flight. The crew decided immediately on a second ILS approach with jammed flaps, which according to the manufacturer's information required an increased approach speed. During the approach, the crew had difficulty in reducing the airspeed to this increased approach speed. At 13:40 UTC, the aircraft subsequently touched down on the wet runway at an indicated air speed of 136 kt, approximately 290 m after the runway threshold, and could not be brought to a standstill on the remaining length of runway. The aircraft then rolled over the end of runway 10, broke through the aerodrome perimeter fence and overrun the road named Rheinholzweg running perpendicular to the runway centreline, on which a public transport bus was travelling. The aircraft rolled very close behind the bus and came to a standstill in a maize field, approximately 30 m from the end of the runway. The female passenger and the two pilots were not injured in the accident. The aircraft was badly damaged. There was crop damage and damage to the aerodrome perimeter fence.
Probable cause:
The accident is attributable to the fact that the aircraft touched down late and at an excessively high speed on the wet runway after an unstabilized final approach and consequently rolled over the end of the runway.
The following factors contributed to the accident:
- The insufficient teamwork and deficient situation analysis by the crew.
- The flaps remained jammed at approximately 10 degrees, a position that is almost consistent with the flaps 1 position.
- Late initiation of full brake application after landing.
Final Report:

Crash of a Cessna 500 Citation I in Santiago de Compostela: 2 killed

Date & Time: Aug 2, 2012 at 0618 LT
Type of aircraft:
Operator:
Registration:
EC-IBA
Flight Type:
Survivors:
No
Schedule:
Oviedo - Santiago de Compostella
MSN:
500-0178
YOM:
1974
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3600
Captain / Total hours on type:
500.00
Copilot / Total flying hours:
678
Copilot / Total hours on type:
412
Aircraft flight hours:
9460
Circumstances:
Based on the information available, at 20:40 the ONT (National Transplant Organization) informed the Santiago Airport (LEST) that they were going to make a “hospital flight”. The aircraft was refueled at the Santiago Airport with 1062 liters of fuel. According to communications, the crew of aircraft EC-IBA contacted the Santiago tower at 21:46 to request permission to start up and information on the weather and the runway in use at Asturias. At 21:54 they were cleared to take off. According to the airport operations office, the aircraft landed in Asturias (LEAS) at 22:27. The hospital flight service commenced at 22:15. The RFFS accompanied the ambulance to the aircraft at 22:30 and at 22:44 the aircraft took off en route to Porto. The aircraft was transferred from Madrid control to Santiago approach at 22:52 at flight level 200 and cleared straight to Porto (LPPR). Based on the information provided by Porto Airport, the aircraft landed at 23:40. While waiting for the medical team to return, the crew remained in the airport’s facilities. According to some of the personnel there, the crew made some comments regarding the bad weather. There was fog, especially on the arrival route. At 01:34 and again at 02:01 the crew was supplied with the flight plan information, information from the ARO-LPPR office and updated weather data. The aircraft was refueled at the Porto Airport with 1,000 l of fuel and took off at 02:34. At 02:44 the aircraft contacted approach control at Santiago to report its position. Four minutes later the crew contacted the Santiago tower directly to ask about the weather conditions at the field (see Appendix C). The aircraft landed once more in Asturias at 03:28. At 03:26 the RFFS was again activated to escort the ambulance to the aircraft. The service was deactivated at 04:00. The crew requested updated weather information from the tower, which provided the information from the 03:00 METAR. According to the flight plan filed, the estimated off-block time (EOBT) for departing from the Asturias Airport was 03:45, with an estimated flight time to Santiago of 40 minutes. The alternate destination airport was Vitoria (LEVT). The aircraft took off from Asturias at 03:38. At 03:56 the crew established contact with Santiago approach control, which provided the crew with the latest METAR from 03:30, which informed that the runway in use was 17, winds were calm, visibility was 4,000 m with mist, few clouds at 600 ft, temperature and dew point of 13° and QNH of 1,019. The aircraft was then cleared to conduct an ILS approach to runway 17 at the Santiago Airport. At 04:15 the crew contacted the tower controller, who reported calm winds and cleared them to land on runway 17. At 04:18 the COSPAS-SARSAT system detected the activation of an ELT. The system estimated the position for the beacon as being in the vicinity of the LEST airport. At 04:38 the tower controller informed airport operations of a call he had received from SAR that a beacon was active in the vicinity of the airport, and requested that a marshaller go to the airport where the airplane normally parked to see if it was there. At 04:44 the marshaller confirmed that the aircraft was not in its hangar and the emergency procedure was activated, with the various parties involved in the search for the airplane being notified. At 05:10 the control tower called the airport to initiate the preliminary phase (Phase I) before activating the LVP. At 05:15 the RFFS reported that the aircraft had been found in the vicinity of the VOR. At 05:30 the LVP was initiated (Phase II). At 07:51 the LVP was terminated. The last flight to arrive at the Santiago Airport before the accident had landed at 23:33, and the next flight to arrive following the accident landed at 05:25.
Probable cause:
The ultimate cause of the accident could not be determined. In light of the hypothesis considered in the analysis, the most likely scenario is that the crew made a non-standard precision approach in manual based primarily on distances. The ILS frequency set incorrectly in the first officer’s equipment and the faulty position indicated on the DME switch would have resulted in the distance being shown on the captain’s HSI as corresponding to the VOR and not to the runway threshold. The crew shortened the approach maneuver and proceeded to a point by which the aircraft should already have been established on the localizer, thus increasing the crew’s workload. The crew then probably lost visual contact with the ground when the aircraft entered a fog bank in the valleys near the airport and did not realize they were making an approach to the VOR and not to the runway.
The contributing factors were:
- The lack of operational procedures of an aircraft authorized to be operated by a single pilot operated by a crew with two members.
- The overall condition of the aircraft and the instruments and the crew’s mistrust of the onboard instruments.
- The fatigue built up over the course of working at a time when they should have been sleeping after an unplanned duty period.
- The concern with having to divert to the alternate without sufficient fuel combined with the complacency arising from finally reaching their destination.
Final Report:

Crash of a Beechcraft B200 Super King Air in Juiz de Fora: 8 killed

Date & Time: Jul 28, 2012 at 0745 LT
Operator:
Registration:
PR-DOC
Survivors:
No
Schedule:
Belo Horizonte - Juiz de Fora
MSN:
BY-51
YOM:
2009
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
14170
Captain / Total hours on type:
2170.00
Copilot / Total flying hours:
730
Copilot / Total hours on type:
415
Aircraft flight hours:
385
Aircraft flight cycles:
305
Circumstances:
The twin engine aircraft departed Belo Horizonte-Pampulha Airport at 0700LT on a flight to Juiz de Fora, carrying six passengers and two pilots. In contact with Juiz de Fora Radio, the crew learned that the weather conditions at the aerodrome were below the IFR minima due to mist, and decided to maintain the route towards the destination and perform a non-precision RNAV (GNSS) IFR approach for landing on runway 03. During the final approach, the aircraft collided first with obstacles and then with the ground, at a distance of 245 meters from the runway 03 threshold, and exploded on impact. The aircraft was totally destroyed and all 8 occupants were killed, among them both President and Vice-President of the Vilmas Alimentos Group.
Probable cause:
The following factors were identified:
- The pilot may have displayed a complacent attitude, both in relation to the operation of the aircraft in general and to the need to accommodate his employers’ demands for arriving in SBJF. It is also possible to infer a posture of excessive self-confidence and confidence in the aircraft, in spite of the elements which signaled the risks inherent to the situation.
- It is possible that the different levels of experience of the two pilots, as well as the copilot’s personal features (besides being timid, he showed an excessive respect for the captain), may have resulted in a failure of communication between the crewmembers.
- It is possible that the captain’s leadership style and the copilot’s personal features resulted in lack of assertive attitudes on the part of the crew, hindering the exchange of adequate information, generating a faulty perception in relation to all the important elements of the environment, even with the aircraft alerts functioning in a perfect manner.
- The meteorological conditions in SBJF were below the minima for IFR operations on account of mist, with a ceiling at 100ft.
- The crew did not inform Juiz de Fora Radio about their passage of the MDA and, even without visual contact with the runway, deliberately continued in their descent, not complying with the prescriptions of the items 10.4 and 15.4 of the ICA 100-12 (Rules of the Air and Air Traffic Services).
- The crew judged that it would be possible to continue descending after the MDA, even without having the runway in sight.
Final Report:

Crash of a Beechcraft B60 Duke in Sedona: 3 killed

Date & Time: Jul 26, 2012 at 0830 LT
Type of aircraft:
Registration:
N880LY
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sedona – Albuquerque
MSN:
P-524
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
663
Captain / Total hours on type:
94.00
Aircraft flight hours:
3924
Circumstances:
Several witnesses observed the airplane before and during its takeoff roll on the morning of the accident. One witness observed the airplane for the entire event and stated that the run-up of the engines sounded normal. During the takeoff roll, the acceleration of the airplane appeared a little slower but the engines continued to sound normal. Directional control was maintained, and at midfield, the airplane had still not rotated. As the airplane continued down the 5,132-foot-long runway, it did not appear to be accelerating, and, about 100 yards from the end of the runway, it appeared that it was not going to stop. The airplane maintained contact with the runway and turned slightly right before it overran the end of the runway. The airplane was subsequently destroyed by impact forces and a postaccident fire. The wreckage was located at the bottom of a deep gully off the end of the runway. Postaccident examination of the area at the end of the runway revealed two distinct tire tracks, both of which crossed the asphalt and dirt overrun of 175 feet. A review of the airplane's weight and balance and performance data revealed that it was within its maximum gross takeoff weight and center of gravity limits. At the time of the accident, the density altitude was calculated to be 7,100 feet; the airport's elevation is 4,830 feet. For the weight of the airplane and density altitude at the time of the accident, it should have lifted off 2,805 feet down the runway; the distance to accelerate to takeoff speed and then to safely abort the takeoff and stop the airplane was calculated to be 4,900 feet. It is unknown whether the pilot completed performance calculations accounting for the density altitude. All flight control components were accounted for at the accident site. Although three witnesses indicated that the engines did not sound right at some point during the runup or takeoff, examination of the engine and airframe revealed no evidence of any preexisting mechanical malfunctions or failures that would have precluded normal operation. Propeller signatures were consistent with rotational forces being applied at the time of impact. No conclusive evidence was found to explain why the airplane did not rotate or why the pilot did not abort the takeoff once reaching the point to safely stop the airplane.
Probable cause:
The airplane's failure to rotate and the pilot's failure to reject the takeoff, which resulted in a runway overrun for reasons that could not be undetermined because postaccident examination of the airplane and engines did not reveal any malfunctions or failures that would have precluded normal operation.
Final Report:

Crash of a Let 410UVP-E3 in Bol'shoye Gryzlovo: 1 killed

Date & Time: Jul 22, 2012
Type of aircraft:
Operator:
Registration:
RF-00138
Survivors:
Yes
Schedule:
Bol’shoye Gryzlovo - Bol’shoye Gryzlovo
MSN:
87 09 08
YOM:
1987
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Following a skydiving mission, the crew was returning to his base at Bol’shoye Gryzlovo Aerodrome. For unknown reasons, the aircraft landed hard, lost its nose gear and came to rest. Both pilots were seriously injured and the aircraft was damaged beyond repair. The captain died from his injuries three days after the accident and the copilot died on 06 September 2012. DOSAAF is the name given to the Voluntary Society for Cooperation with the Army, Aviation, and Fleet, known till 2009 under the name of ROSTO.

Crash of a Canadair CRJ-200ER in Saint George: 1 killed

Date & Time: Jul 17, 2012 at 0100 LT
Operator:
Registration:
N865AS
Flight Phase:
Flight Type:
Survivors:
No
MSN:
7507
YOM:
2001
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Registered N865AS, the landed at Saint George Airport, Utah, at 2236LT after completing flight DL7772 from Salt Lake City. All occupants deplaned and the aircraft was parked on the ramp for the night. Shortly after midnight, a commercial pilot climbed over the barbed wire fence, open the door of the aircraft (which was not closed by key) and managed to start the engines. The aircraft rolled for several metres before then impacted the terminal building, went through the fence and came to rest in a parking lot. The pilot shot himself in the cockpit. Polices forces confirmed later that he wanted to stole the aircraft after his girlfriend was killed that day in Colorado Springs.
Probable cause:
Aircraft stolen by a commercial pilot who shot himself in the cockpit after trying to take off without any clearance (illegal flight). No investigations were conducted by the NTSB on this event.

Crash of a Gulfstream GIV in Le Castellet: 3 killed

Date & Time: Jul 13, 2012 at 1518 LT
Type of aircraft:
Operator:
Registration:
N823GA
Flight Type:
Survivors:
No
Schedule:
Nice - Le Castellet
MSN:
1005
YOM:
1987
Flight number:
UJT823
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
22129
Captain / Total hours on type:
690.00
Copilot / Total flying hours:
1350
Copilot / Total hours on type:
556
Aircraft flight hours:
12210
Aircraft flight cycles:
5393
Circumstances:
The crew, consisting of a Captain and a co-pilot, took off at around 6 h 00 for a flight between Athens and Istanbul Sabiha Gokcen (Turkey). A cabin aid was also on board the aeroplane. The crew then made the journey between Istanbul and Nice (06) with three passengers. After dropping them off in Nice, the aeroplane took off at 12 h 56 for a flight to Le Castellet aerodrome in order to park the airplane for several days, the parking area at Nice being full. The Captain, in the left seat, was Pilot Monitoring (PM). The copilot, in the right seat, was Pilot Flying (PF). Flights were operated according to US regulation 14 CFR Part 135 (special rules applicable for the operation of flights on demand). The flight leg was short and the cruise, carried out at FL160, lasted about 5 minutes. At the destination, the crew was cleared to perform a visual approach to runway 13. The autopilot and the auto-throttle were disengaged, the gear was down and the flaps in the landing position. The GND SPOILER UNARM message, indicating nonarming of the ground spoilers, was displayed on the EICAS and the associated single chime aural warning was triggered. This message remained displayed on the EICAS until the end of the flight since the crew forgot to arm the ground spoilers during the approach. At a height of 25 ft, while the aircraft was flying over the runway threshold slightly below the theoretical descent path, a SINK RATE warning was triggered. The PF corrected the flight path and the touchdown of the main landing gear took place 15 metres after the touchdown zone - that’s to say 365 metres from the threshold - and slightly left of the centre line of runway 13(3). The ground spoilers, not armed, did not automatically deploy. The crew braked and actuated the deployment of the thrust reversers, which did not deploy completely(4). The hydraulic pressure available at brake level slightly increased. The deceleration of the aeroplane was slow. Four seconds after touchdown, a MASTER WARNING was triggered. A second MASTER WARNING(5) was generated five seconds later. The nose landing gear touched down for the first time 785 metres beyond the threshold before the aeroplane’s pitch attitude increased again, causing a loss of contact of the nose gear with the ground. The aircraft crossed the runway centre line to the right, the crew correcting this by a slight input on the rudder pedals to the left. They applied a strong nose-down input and the nose gear touched down on the runway a second time, 1,050 metres beyond the threshold. The speed brakes were then manually actuated by the crew with an input on the speed brake control, which then deployed the panels. Maximum thrust from the thrust reversers was reached one second later(6). The aircraft at this time was 655 metres from the runway end and its path began to curve to the left. In response to this deviation, the crew made a sharp input on the right rudder pedal, to the stop, and an input on the right brake, but failed to correct the trajectory. The aeroplane, skidding to the right(7), ran off the runway to the left 385 metres from the runway end at a ground speed of approximately 95 knots. It struck a runway edge light, the PAPI of runway 31, a metal fence then trees and caught fire instantly. An aerodrome firefighter responded quickly onsite but did not succeed in bringing the fire under control. The occupants were unable to evacuate the aircraft.
Probable cause:
Forgetting to arm the ground spoilers delayed the deployment of the thrust reversers despite their selection. Several MASTER WARNING alarms were triggered and the deceleration was low. The crew then responded by applying a strong nose-down input in order to make sure that the aeroplane stayed in contact with the ground, resulting in unusually high load for a brief moment on the nose gear. After that, the nose gear wheels deviated to the left as a result of a left input on the tiller or a failure in the steering system. It was not possible to establish a formal link between the high load on the nose gear and this possible failure. The crew was then unable to avoid the runway excursion at high speed and the collision with trees. The aerodrome fire-fighter, alone at the time of the intervention, was unable to bring the fire under control after the impact. Although located outside of the runway safety
area on either side of the runway centre line, as provided for by the regulations, the presence of rocks and trees near the runway contributed to the consequences of the accident.
The accident was caused by the combination of the following factors:
- The ground spoilers were not armed during the approach,
- A lack of a complete check of the items with the ‘‘before landing’’ checklist, and more generally the UJT crews’ failure to systematically perform the checklists as a challenge and response to ensure the safety of the flight,
- Procedures and ergonomics of the aeroplane that were not conducive to monitoring the extension of the ground spoilers during the landing,
- A possible left input on the tiller or a failure of the nose gear steering system having caused its orientation to the left to values greater than those that can be commanded using the rudder pedals, without generating any warning,
- A lack of crew training in the ‘‘Uncommanded Nose Wheel Steering’’ procedure, provided to face uncommanded orientations of the nose gear,
- An introduction of this new procedure that was not subject to a clear assessment by Gulfstream or the FAA,
- Failures in updating the documentation of the manufacturer and the operator,
- Monitoring by the FAA that failed to detect both the absence of any updates of this documentation and the operating procedure for carrying out checklists by the operator.
Final Report:

Crash of a Harbin Yunsunji Y-12-II in Nouakchott: 7 killed

Date & Time: Jul 12, 2012 at 0745 LT
Type of aircraft:
Operator:
Registration:
5T-MAE
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Nouakchott - Tasiast
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The twin engine aircraft was engaged in a special flight to the Tasiast Airstrip deserving the Gold Mine of Tasiast on behalf of the Kinross Gold Corporation. Shortly after take off from Nouakchott, while in initial climb, the aircraft stalled and crashed in a desert area located past the runway end, bursting into flames. All seven occupants were killed and aircraft was destroyed by impact forces and a post crash fire. Both pilots were Mauritanian Customs Officers while among the passengers were three Security Officers of the Kinross Gold Corporation who were in charge to transfer a load of gold back to Nouakchott.

Crash of a Rockwell Sabreliner 75A at El Palomar AFB

Date & Time: Jul 4, 2012 at 1900 LT
Type of aircraft:
Operator:
Registration:
AE-175
Flight Type:
Survivors:
Yes
MSN:
380-13
YOM:
1974
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was returning to El Palomar AFB, near Buenos Aires, carrying three crew members and six passengers, among them General Luis Pozzi, Chief of the Argentinian Army. Upon landing, the left main gear collapsed. The aircraft slid on runway then veered to the right before coming to rest in a grassy area. All 9 occupants escaped uninjured while the aircraft was damaged beyond repair. General Pozzi was returning to El Palomar Air Base following a review of the troops in the Pampa Province.

Crash of a Technoavia SM-92G Turbo Finist in Bollullos de la Mitación

Date & Time: Jul 1, 2012 at 1045 LT
Registration:
HA-NAH
Flight Phase:
Survivors:
Yes
Schedule:
Bollullos de la Mitación - Bollullos de la Mitación
MSN:
003
YOM:
1994
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
340
Captain / Total hours on type:
24.00
Aircraft flight hours:
2575
Circumstances:
The aircraft started taking off from runway 27 threshold. Upon reaching a speed deemed proper by the pilot for rotation, the pilot noticed that the aircraft was not taking off, so he decided to abort the takeoff. While trying to stop the aircraft, it exited via the left side of the runway near the end, breaking through the fence that surrounds the aerodrome before coming to rest in trees. While all ten occupants were uninjured, the aircraft was damaged beyond repair with both wings sheared off.
Probable cause:
Whenever this aircraft is doing a short-field takeoff with a high weight, it is recommended that the flaps be set to their takeoff position of 20°. The evidence indicates that the pilot was attempting to take off on runway 27 and forgot to place the flaps in the takeoff position (20°).
Final Report: