Crash of a Cessna 441 Conquest in York: 1 killed

Date & Time: Dec 22, 2011 at 1725 LT
Type of aircraft:
Operator:
Registration:
N48BS
Flight Type:
Survivors:
No
Schedule:
Long Beach - York
MSN:
441-0125
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1409
Captain / Total hours on type:
502.00
Aircraft flight hours:
5995
Circumstances:
Toward the end of a 6 hour, 20 minute flight, during a night visual approach, the pilot flew the airplane to a left traffic pattern downwind leg. At some point, he lowered the landing gear and set the flaps to 30 degrees. He turned the airplane to a left base leg, and after doing so, was heard on the common traffic frequency stating that he had an "engine out." The airplane then passed through the final leg course, the pilot called "base to final," and the airplane commenced a right turn while maintaining altitude. The angle of bank was then observed to increase to where the airplane's wings became vertical, then inverted, and the airplane rolled into a near-vertical descent, hitting the ground upright in a right spin. Subsequent examination of the airplane and engines revealed that the right engine was not powered at impact, and the propeller from that engine was not in feather. No mechanical anomalies could be found with the engine that could have resulted in its failure. The right fuel tank was breeched; however, fuel calculations, confirmed by some fuel found in the right fuel tank as well as fuel found in the engine fuel filter housing, indicated that fuel exhaustion did not occur. Unknown is why the pilot did not continue through a left turn descent onto the final approach leg toward airport, which would also have been a turn toward the operating engine. The pilot had a communication device capable of voice calls, texting, e-mail and alarms, among other functions. E-mails were sent by the device until 0323, and an alarm sounded at 0920. It is unknown if or how much pilot fatigue might have influenced the outcome.
Probable cause:
The pilot's failure to maintain minimum control airspeed after a loss of power to the right engine, which resulted in an uncontrollable roll into an inadvertent stall/spin. Contributing to the accident was the failure of the airplane's right engine for reasons that could not be determined because no preexisting mechanical anomalies were found, and the pilot's subsequent turn toward that inoperative engine while maintaining altitude.
Final Report:

Crash of a Boeing 737-36M in Yogyakarta

Date & Time: Dec 20, 2011 at 1713 LT
Type of aircraft:
Operator:
Registration:
PK-CKM
Survivors:
Yes
Schedule:
Jakarta - Yogyakarta
MSN:
28333/2810
YOM:
1996
Flight number:
SJY230
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
131
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
29801
Copilot / Total flying hours:
562
Aircraft flight hours:
31281
Aircraft flight cycles:
21591
Circumstances:
On 20 December 2011, a Boeing 737-300 aircraft, registered PK-CKM, was being operated by PT. Sriwijaya Air on a schedule passenger flight SJ230 from Soekarno Hatta International Airport (WIII) Jakarta to Adisutjipto International Airport (WARJ), Yogyakarta. There were 141 persons on board; two pilots, four cabin crews and 135 passengers consisted124 adult, 7 children and 4 infant. The aircraft departed from Jakarta at 14.00 LT (07.00 UTC), the pilot in command was the pilot flying and the co-pilot was the pilot monitoring. At 08.10 UTC the aircraft made holding at 8 NM from JOG VOR due to bad weather. After the second holding and the weather was deteriorated, the airport authority closed the airport for takeoff and landing. The pilot requested divert to Juanda Airport (WARR), Surabaya and landed at 08.40 UTC. After refuelling and received the information about weather improvement in Yogyakarta then the aircraft departed, at 09.20 UTC, in this sequence of flight the PIC acted as PF, with 137 persons on board consisted of two pilots, four cabin crews and 131 passengers consisted 120 adult, 7 children and 4 infant. The aircraft was on the fifth sequence from seven aircraft approaching Adisucipto airport Yogyakarta. Passing JOG VOR it was seen on radar screen that the aircraft speed was read 203 Kts at 2700 ft. Approach Controller instructed to reduce the speed. At about 1200 ft, the pilot had the runway insight and disengaged the autopilot and auto throttle. The pilot made correction to the approach profile by roll up to 25 degrees and rate of descend up to 2040 ft per minute. The GPWS warning of ‘pull up’ and sink ‘rate were’ activated. Aircraft touched down at speed 156 Kts of 138 Kts target landing speed. During landing roll, the auto-brake and spoiler activated automatically. The thrust reverse were deployed and the N1 were recorded on the FDR increase and decrease to idle before increased to 80% prior to aircraft stop. The PIC noticed that the aircraft would not be able to stop in the runway and decided to turn the aircraft to the left. The aircraft stopped at 75 meter from the end of runway 09 and 54 meter on the left side of the centre line. Most of the passenger evacuated through left and right forward escape slides. All passengers were evacuated safely. The passenger on the stretcher case was evacuated by the airport rescue. 6 passengers reported minor injured while all crew and the remaining passengers were not injured. The aircraft suffered major damage on the right main and nose wheel.
Probable cause:
Findings:
1. The aircraft was airworthy prior the accident. There was no evidence that the aircraft had malfunction during the flight.
2. The crew had valid license and medical certificate. There was no evidence of crew incapacitation.
3. In this flight Pilot in Command acted as Pilot Flying and Second In command acted as Pilot Monitoring.
4. The flight crew did not conduct approach crew briefing.
5. There was no checklist reading.
6. The PIC as Pilot Flying did not have the instrument approach procedure immediately available to review during approach.
7. During the approach, the PIC course indicator was set at 091 and the SIC was at 084.
8. The rate of descend recorded vary and up to 1920 ft per minute and below 500 ft AGL the rate of descend recorded up to 2040 ft per minute.
9. The approach did not meet the stabilize approach criteria as stated in the FCOM.
10. There were several GPWS warning of ‘sink rate’ and ‘pull up’ activated during approach.
11. The aircraft touched down at speed 156 Kt before bounced, instead of 138 Kt target landing speed.
12. The flap extended to 40 after the aircraft touch down.
13. The FDR recorded reduction in N1 during thrust reverser activation after landing.
14. The CRM was not well implemented.
Factors:
Unsuccessful to recognize the two critical elements, namely fixation and complacency affected pilot decision to land the aircraft while the approach was not meet the criteria of stabilized approach.
Final Report:

Crash of a PZL-Mielec C-145A Skytruck in Walan Rabat

Date & Time: Dec 18, 2011 at 1502 LT
Type of aircraft:
Operator:
Registration:
08-0319
Flight Type:
Survivors:
Yes
Schedule:
Kandahar - Qalat - Walan Rabat - Qalat - Kandahar
MSN:
AJE003-19
YOM:
2009
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3546
Captain / Total hours on type:
434.00
Copilot / Total flying hours:
982
Copilot / Total hours on type:
677
Aircraft flight hours:
1164
Aircraft flight cycles:
1273
Circumstances:
At 0939 hours Zulu time on 18 December 2011, an M-28, Tail Number 08-0319, departed Kandahar Air Base, Afghanistan on a mission to pick up four passengers at Qalat, Afghanistan, transport them to Walan Rabat short takeoff and landing zone, transport two additional personnel from Walan Rabat back to Qalat, then return to Kandahar Air Base. The mishap aircraft and crew were assigned or attached to the 318th Special Operations Squadron, 27th Special Operations Wing at Cannon Air Force Base, New Mexico, and were deployed to the 318th Expeditionary Special Operations Squadron at Kandahar Air Base, Afghanistan. After an uneventful stop at Qalat to onload four passengers and their bags, the mishap crew flew a 20-minute leg to Walan Rabat. Surface winds at Walan Rabat were 190 degrees at 14 knots gusting to 17 knots, 30 degrees off a direct tailwind for runway 34. Because the landing zone has a three percent upslope for runway 34, and a 1,500-foot mountain exists 1½ miles to the north, the pilot elected to land with a tailwind on runway 34, the preferred landing direction. Walan Rabat Landing Zone is a 1,756-foot long, 31-foot wide, semi-prepared dirt strip with poorly defined boundaries. The landing zone was marked with AMP-3 markings, commonly called a “box-and-one” with colored panels. The mishap pilot consulted a wind component chart and incorrectly calculated the tailwind component, mistakenly believing it was within the allowable limit for landing the M-28. The pilot flew a shallow 2½-3 degree approach due to the upsloping landing zone. At approximately 1,000 feet short of the landing zone, the mishap pilot visually acquired the AMP-3 markings and landed the mishap aircraft at 1032 zulu. After a firmer than normal landing, the aircraft veered to the right and departed the prepared surface. The nose gear encountered uneven terrain and collapsed, causing the mishap aircraft to flip tail-over-nose. The mishap crew and passengers then egressed the aircraft through the copilot’s window. There were no serious injuries to crew or passengers. The mishap aircraft, which was valued at approximately $12,300,000 was destroyed. There were no civilian casualties.
Probable cause:
The AIB president found no clear and convincing evidence of the primary cause of the accident. He determined by a preponderance of evidence that the Landing Zone Condition, Cross-Monitoring Performance, Task/Mission-in-Progress Re-planning, Landing with an Excessive Tailwind, and Aircraft Engine Anomalies substantially contributed to the mishap, ultimately causing the mishap aircraft to veer off the prepared surface into rough terrain, resulting in the collapse of the nose landing gear and destruction of the aircraft.
Final Report:

Crash of a PAC 750XL in Abmisibil: 2 killed

Date & Time: Dec 17, 2011 at 0740 LT
Operator:
Registration:
PK-RCD
Survivors:
Yes
Schedule:
Jayapura - Abmisibil
MSN:
149
YOM:
2009
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
After landing on a wet runway at Abmisibil Airport, the single engine aircraft went out of control, veered off runway and came to rest in a ravine, bursting into flames. The pilot was killed and a passenger died few hours later. All three other occupants were seriously injured and the aircraft was destroyed by impact forces and a post crash fire.

Crash of an Antonov AN-32 in Jorhat

Date & Time: Dec 15, 2011
Type of aircraft:
Operator:
Registration:
K2721
Flight Type:
Survivors:
Yes
MSN:
06 06
YOM:
1985
Location:
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft suffered an accident upon landing at Jorhat-Rowriah Airport, Assam. There were no casualties but the aircraft was damaged beyond repair. The exact circumstances of the mishap remain unknown.

Crash of an Antonov AN-2 in Arua

Date & Time: Dec 12, 2011 at 1420 LT
Type of aircraft:
Operator:
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Arua - Nzara
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft was leased by the Uganda Peoples Defence Force Air Wing to carry a group of four Officer to Nzara, South Sudan. Shortly after takeoff from Arua Airport, the aircraft encountered difficulties to gain altitude, hit a tree and crashed in an open field located near the village of Mingoro, bursting into flames. All seven occupants evacuated with minor injuries and the aircraft was destroyed by a post crash fire.
Probable cause:
Engine failure for unknown reasons.

Crash of a Cessna 421C Golden Eagle III in Sioux Falls: 4 killed

Date & Time: Dec 9, 2011 at 1424 LT
Operator:
Registration:
N421SY
Flight Phase:
Survivors:
No
Schedule:
Sioux Falls - Rapid City
MSN:
421C-0051
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3848
Captain / Total hours on type:
357.00
Aircraft flight hours:
4882
Circumstances:
Shortly after the airplane lifted off, the tower controller informed the pilot that a plume of smoke was visible behind the airplane. No communications were received from the pilot after he acknowledged the takeoff clearance. Witnesses reported that white smoke appeared to be trailing from the area of the left engine during takeoff. The witnesses subsequently observed flames at the inboard side of the left engine. The airplane began a left turn. As the airplane continued the turn, the flames and trail of white smoke were no longer visible. When the airplane reached a southerly heading, the nose dropped abruptly, and the airplane descended to the ground. Witnesses stated that they heard an increase in engine sound before impact. A postimpact fire ensued. The accident site was located about 3/4 mile from the airport. A postaccident examination determined that the left engine fuel selector and fuel valve were in the OFF position, consistent with the pilot shutting down that engine after takeoff. However, the left engine propeller was not feathered. Extensive damage to the right engine propeller assembly was consistent with that engine producing power at the time of impact. The landing gear and wing flaps were extended at the time of impact. Teardown examinations of both engines did not reveal any anomalies consistent with a loss of engine power. The left engine oil cap was observed to be unsecured at the accident site; however, postaccident comparison of the left and right engine oil caps revealed disproportionate distortion of the left oil cap, likely due to the postimpact fire. As a result, no determination was made regarding the security of left engine oil cap before the accident. Emergency procedures outlined in the pilot’s operating handbook (POH) noted that when securing an engine, the propeller should be feathered. Performance data provided in the POH for single-engine operations were predicated on the propeller of the inoperative engine being feathered, and the wing flaps and landing gear retracted. Thus, the pilot did not follow the emergency procedures outlined in the POH for single-engine operation.
Probable cause:
The pilot’s failure to maintain adequate airspeed after shutting down one engine, which resulted in an inadvertent aerodynamic stall and impact with terrain. Contributing to the accident was the pilot’s failure to follow the guidance contained in the pilot’s operating handbook, which advised feathering the propeller of the secured engine and retracting the flaps and landing gear.
Final Report:

Crash of a Beechcraft A100 King Air in Pointe-Noire

Date & Time: Dec 4, 2011 at 1422 LT
Type of aircraft:
Operator:
Registration:
9Q-CEM
Survivors:
Yes
Schedule:
Moanda - Pointe-Noire
MSN:
B-105
YOM:
1972
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Moanda, Gabon, the crew initiated the approach in poor weather conditions (rain falls, strong crosswinds and turbulences). After touchdown, the twin engine aircraft skidded then veered off runway to the left. While contacting soft ground, the landing gear collapsed and the left engine was partially torn off. All 10 occupants escaped uninjured while the aircraft was damaged beyond repair. Wind shear conditions are suspected.

Crash of a Casa 212 Aviocar 200 in Larat

Date & Time: Dec 3, 2011 at 1308 LT
Type of aircraft:
Operator:
Registration:
PK-NCZ
Survivors:
Yes
Schedule:
Langur - Larat
MSN:
274/79N
YOM:
1986
Flight number:
MNA9933
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7500
Captain / Total hours on type:
5500.00
Copilot / Total flying hours:
343
Copilot / Total hours on type:
72
Aircraft flight hours:
26935
Aircraft flight cycles:
30064
Circumstances:
The Casa 212-200 aircraft registered PK-NCZ operated by PT. Merpati Nusantara Airlines on a scheduled flight from Langur to Larat, touched down at 224 meters from runway 09, was bouncing twice to the left of runway centre line, out of the runway and stopped at 607 meters from runway 09 touch down area as final position, and 15 meters to the left of runway edge. The Pilot Flying was First Officer, and after second bouncing, PIC took over, and he tried to bring the aircraft to the centre line of the runway without success. The aircraft continued rolled to the shoulder away from the runway and stopped at the final position. This is the second landing at Larat runway on the same day. There were 15 passengers, 3 children, one baby, Pilot In Command, two First Officers, one First Officer was Pilot Flying from Langur to Larat, one engineer on board. One passenger was serious injured, another one passenger minor injured.
Final Report:

Crash of a Beechcraft 1900C in La Paz

Date & Time: Nov 30, 2011 at 1527 LT
Type of aircraft:
Operator:
Registration:
FAB-043
Flight Type:
Survivors:
Yes
Schedule:
Uyuni - La Paz
MSN:
UA-3
YOM:
1983
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft departed Uyuni-La Joya Andina Airport on a flight to La Paz, carrying four passengers and three crew members. On approach to El Alto Airport, the crew encountered an unexpected situation. The captain decided to attempt an emergency landing in an open field. Upon touchdown, the undercarriage were torn off and the aircraft slid for few dozen metres before coming to rest 6 km from the airport. All seven occupants escaped uninjured while the aircraft was damaged beyond repair.