Crash of a Cessna 402B in St Petersburg

Date & Time: Oct 18, 2017 at 1545 LT
Type of aircraft:
Operator:
Registration:
N900CR
Survivors:
Yes
Site:
Schedule:
Tampa – Sarasota
MSN:
402B-1356
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
654
Captain / Total hours on type:
38.00
Aircraft flight hours:
8971
Circumstances:
The pilot departed on the non-scheduled passenger flight with one passenger onboard; the flight was the 3rd leg of a 4-leg trip. About 13 minutes after departure, he advised air traffic control that the airplane was “fuel critical” and requested vectors to the nearest airport, which was about 7 miles away. Both engines subsequently lost total power and the pilot performed a forced landing on a street about 2 miles from the airport, during which the airplane collided with two vehicles. Examination of the airplane revealed substantial damage to the fuel tanks, with evidence of a small fire near the left wingtip fuel tank. Fuel consumption calculations revealed that the airplane would have used about 100 gallons of fuel since its most recent refueling, which was the capacity of the main (wingtip) tanks. Both fuel selectors were found in their respective main tank positions. Given the available information, it is likely that the pilot exhausted all the fuel in the main fuel tanks and starved the engines of fuel. Although the total amount of fuel on board at the start of the flight could not be determined, had all tanks been full, the airplane would have had about 63 gallons remaining in the two auxiliary tanks at the time of the accident. The auxiliary fuel tanks were breached during the accident and quantity of fuel they contained was not determined. Examination of the engines revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation.
Probable cause:
The pilot's mismanagement of the onboard fuel, which resulted in fuel starvation, a total loss of power to both engines, and a subsequent forced landing.
Final Report:

Crash of a Piper PA-31T-620 Cheyenne II in Cascais: 5 killed

Date & Time: Apr 17, 2017 at 1204 LT
Type of aircraft:
Operator:
Registration:
HB-LTI
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Cascais – Marseille
MSN:
31T-8020091
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
4900
Aircraft flight hours:
8323
Circumstances:
On April 17th, at 11:04 UTC, the aircraft turboprop Piper PA-31 Cheyenne II, registration HBLTI, private property, took off from runway 17 of the Cascais aerodrome (LPCS) bound to Marseille airport (LFML), IFR private flight, with 1 pilot and 3 passengers on board. According to several eyewitness testimonies, after takeoff, the Swiss twin-engine started to put the left wing down and consequently to turn left while climbing slowly to about 300’ feet of altitude. The left bank1 increased and the speed decreased leading the aircraft to stall. The aircraft entered a steep dive and impacted the ground next to a logistics dock of a local supermarket, located southeast of the airfield. The crash occurred 700 m from the end of the departure runway. Following the impact, the aircraft exploded and caught fire affecting a logistic dock, a house and a truck. The aircraft was destroyed by impact force and the post-collision fire, all the four occupants were killed. The driver of the truck affected by the explosion of the plane was also killed. The fuselage, wings, the engines and propellers were severely damaged by the impact force and post-impact fuel-fed fire. The structural damage to the aircraft was consistent with the application of extensive structural loads during the impact sequence, and the effects of the subsequent fire. No pre-crash structural defects were found. All aircraft parts and control surfaces were located at the site. The flaps and the landing gear were found retracted at the time of impact.
Probable cause:
- The pilot’s failure to maintain the airplane control following the power loss in the left critical engine. The root cause for the left engine failure could not be determined due to the extensive impact damages and intensive fire.
Contributing factors:
- Lack of proper pilot training especially concerning the emergency scenario of critical engine failure immediately after takeoff.
Final Report:

Crash of a Cessna 500 Citation I in Marietta: 1 killed

Date & Time: Mar 24, 2017 at 1924 LT
Type of aircraft:
Registration:
N8DX
Flight Type:
Survivors:
No
Site:
Schedule:
Cincinnati – Atlanta
MSN:
500-0303
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6000
Aircraft flight hours:
9299
Circumstances:
The private pilot departed on an instrument flight rules flight plan in his twin-engine turbojet airplane. The flight was uneventful until the air traffic controller amended the flight plan, which required the pilot to manually enter the new routing information into the GPS. A few minutes later, the pilot told the controller that he was having problems with the GPS and asked for a direct route to his destination. The controller authorized the direct route and instructed the pilot to descend from 22,000 ft to 6,000 ft, during which time the sound of the autopilot disconnect was heard on the cockpit voice recorder (CVR). During the descent, the pilot told the controller that the airplane had a steering problem and was in the clouds. The pilot was instructed to descend the airplane to 4,100 ft, which was the minimum vectoring altitude. The airplane continued to descend, entered visual meteorological conditions, and then descended below the assigned altitude. The controller queried the pilot about the airplane's low altitude and instructed the pilot to maintain 4,100 ft. The pilot responded that he was unsure if he would be able to climb the airplane back to that altitude due to steering issues. The controller issued a low altitude warning and again advised the pilot to climb back to 4,100 ft. The pilot responded that the autopilot was working again and that he was able to climb the airplane to the assigned altitude. The controller then instructed the pilot to change to another radio frequency, but the pilot responded that he was still having a problem with the GPS. The pilot asked the controller to give him direct routing to the airport. A few minutes later, the pilot told the controller that he was barely able to keep the airplane straight and its wings level. The controller asked the pilot if he had the airport in sight, which he did not. The pilot then declared an emergency and expressed concerns related to identifying the landing runway. Afterward, radio contact between the controller and the pilot was lost. Shortly before the airplane impacted the ground, a witness saw the airplane make a complete 360° roll to the left, enter a steep 90° bank to the left, roll inverted, and enter a vertical nose-down dive. Another witness saw the airplane spiral to the ground. The airplane impacted the front lawn of a private residence, and a postcrash fire ensued.The pilot held a type rating for the airplane, but the pilot's personal logbooks were not available for review. As a result, his overall currency and total flight experience in the accident airplane could not be determined. The airplane was originally certified for operations with a pilot and copilot. To obtain an exemption to operate the airplane as a single pilot, a pilot must successfully complete an approved single-pilot exemption training course annually. The accident airplane was modified, and the previous owner was issued a single-pilot conformity certificate by the company that performed the modifications. However, there was no record indicating that the accident pilot received training under this exemption. Several facilities that have single-pilot exemption training for the accident airplane series also had no record of the pilot receiving training for single-pilot operations in the accident airplane. Therefore, unlikely that the pilot was properly certificated to act as a single-pilot. The GPS was installed in the airplane about 3.5 years before the accident. A friend of the pilot trained him on how to use the GPS. The friend said that the pilot generally was confused about how the unit operated and struggled with pulling up pages and correlating data. The friend of the pilot had flown with him several times and indicated that, if an air traffic controller amended a preprogrammed flight plan while en route, the pilot would be confused with the procedure for amending the flight plan. The friend also said the pilot depended heavily on the autopilot, which was integrated with the GPS, and that he would activate the autopilot immediately after takeoff and deactivate it on short final approach to a runway. The pilot would not trim the airplane before turning on the autopilot because he assumed that the autopilot would automatically trim the airplane, which led to the autopilot working against the mis-trimmed airplane. The friend added that the pilot was "constantly complaining" that the airplane was "uncontrollable." A postaccident examination of the airplane and the autopilot system revealed no evidence of any preimpact deficiencies that would have precluded normal operation. This information suggests that pilot historically had difficulty flying the airplane without the aid of the autopilot. When coupled with his performance flying the airplane during the accident flight without the aid of the autopilot, it further suggests that the pilot was consistently unable to manually fly the airplane. Additionally, given the pilot's previous experience with the GPS installed on the airplane, it is likely that during the accident flight the pilot became confused about how to operate the GPS and ultimately was unable to properly control of the airplane without the autopilot engaged. Based on witness information, it is likely that during the final moments of the flight the pilot lost control of the airplane and it entered an aerodynamic stall. The pilot was then unable to regain control of the airplane as it spun 4,000 ft to the ground.
Probable cause:
The pilot's failure to maintain adequate airspeed while manually flying the airplane, which resulted in the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall. Contributing to the accident was the pilot's inability control the airplane without the aid of the autopilot.
Final Report:

Crash of a Beechcraft B200 Super King Air in Melbourne: 5 killed

Date & Time: Feb 21, 2017 at 0858 LT
Registration:
VH-ZCR
Flight Phase:
Survivors:
No
Site:
Schedule:
Melbourne - King Island
MSN:
BB-1544
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
7681
Captain / Total hours on type:
2400.00
Aircraft flight hours:
6997
Circumstances:
On 21 February 2017, the pilot of a Beechcraft B200 King Air aircraft, registered VH-ZCR (ZCR), and operated by Corporate & Leisure Aviation, was conducting a charter passenger flight from Essendon Airport, Victoria to King Island, Tasmania. There were four passengers on board. ZCR had been removed from a hangar and parked on the apron the previous afternoon in preparation for the flight. The pilot was first seen on the apron at about 0706 Eastern Daylight-saving Time. Closed-circuit television recorded the pilot walking around the aircraft and entering the cabin, consistent with conducting a pre-flight inspection of the aircraft. At about 0712, the pilot entered ZCR’s maintenance provider’s hangar. A member of staff working in the hangar reported that the pilot had a conversation with him that was unrelated to the accident flight. The pilot exited the hangar about 0715 and had a conversation with another member of staff who reported that their conversation was also unrelated to the accident flight. The pilot then returned to ZCR, and over the next 4 minutes he was observed walking around the aircraft. The pilot went into the cabin and re-appeared with an undistinguishable item. The pilot then walked around the aircraft one more time before re-entering the cabin and closing the air stair cabin door. At about 0729, the right engine was started and, shortly after, the left engine was started. Airservices Australia (Airservices) audio recordings indicated that, at 0736, the pilot requested a clearance from Essendon air traffic control (ATC) to reposition ZCR to the southern end of the passenger terminal. ATC provided the clearance and the pilot commenced taxiing to the terminal. At the terminal, ZCR was refueled and the pilot was observed on CCTV to walk around the aircraft, stopping at the left and right engines before entering the cabin. The pilot was then observed to leave the aircraft and wait for the passengers at the terminal. The passengers arrived at the terminal at 0841 and were escorted by the pilot directly to the aircraft. At 0849, the left engine was started and, shortly after, the right engine was started. At 0853, the pilot requested a taxi clearance for King Island, with five persons onboard, under the instrument flight rules. ATC instructed the pilot to taxi to holding point 'TANGO' for runway 17, and provided an airways clearance for the aircraft to King Island with a visual departure. The pilot read back the clearance. Airservices Automatic Dependent Surveillance Broadcast (ADS-B) data (refer to section titled Air traffic services information - Automatic Dependent Surveillance Broadcast data) indicated that, at 0854, ZCR was taxied from the terminal directly to the holding point. The aircraft did not enter the designated engine run-up bay positioned near holding point TANGO. At 0855, while holding at TANGO, the pilot requested a transponder code. The controller replied that he did not have one to issue yet. Two minutes later the pilot contacted ATC and stated that he was ready and waiting for a transponder code. The controller responded with the transponder code and a clearance to lineup on runway 17. At 0858, ATC cleared ZCR for take-off on runway 17 with departure instructions to turn right onto a heading of 200°. The pilot read back the instruction and commenced the takeoff roll. The aircraft’s take-off roll along runway 17 was longer than expected. Witnesses familiar with the aircraft type observed a noticeable yaw to the left after the aircraft became airborne. The aircraft entered a relatively shallow climb and the landing gear remained down. The shallow climb was followed by a substantial left sideslip, while maintaining a roll attitude of less than 10° to the left. Airservices ADS-B data indicated the aircraft reached a maximum height of approximately 160 ft above ground level while tracking in an arc to the left of the runway centreline. The aircraft’s track began diverging to the left of the runway centreline before rotation and the divergence increased as the flight progressed. Following the sustained left sideslip, the aircraft began to descend and at 0858:48 the pilot transmitted on the Essendon Tower frequency repeating the word ‘MAYDAY’ seven times in rapid succession. Approximately 10 seconds after the aircraft became airborne, and 2 seconds after the transmission was completed, the aircraft collided with the roof of a building in the Essendon Airport Bulla Road Precinct - Retail Outlet Centre (outlet centre), coming to rest in a loading area at the rear of the building. CCTV footage from a camera positioned at the rear of the building showed the final part of the accident sequence with post-impact fire evident; about 2 minutes later, first responders arrived onsite. At about 0905 and 0908 respectively, Victoria Police and the Metropolitan Fire Brigade arrived. The pilot and passengers were fatally injured and the aircraft was destroyed. There was significant structural, fire and water damage to the building. Additionally, two people on the ground received minor injuries and a number of parked vehicles were damaged.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain involving Beechcraft B200 King Air, registered VH-ZCR that occurred at Essendon Airport, Victoria on 21 February 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Contributing factors:
- The aircraft's rudder trim was likely in the full nose-left position at the commencement of the take-off.
- The aircraft's full nose-left rudder trim setting was not detected by the pilot prior to take-off.
- Following a longer than expected ground roll, the pilot took-off with full left rudder trim selected. This configuration adversely affected the aircraft's climb performance and controllability, resulting in a collision with terrain.

Other factors that increased risk:
- The flight check system approval process did not identify that the incorrect checklist was nominated in the operator’s procedures manual and it did not ensure the required checks, related to the use of the cockpit voice recorder, were incorporated.
- The aircraft's cockpit voice recorder did not record the accident flight, resulting in a valuable source of safety related information not being available.
- The aircraft's maximum take-off weight was likely exceeded by about 240 kilograms.
- Two of the four buildings within the Bulla Road Precinct Retail Outlet Centre exceeded the obstacle limitation surface (OLS) for Essendon Airport, however, the OLS for the departure runway was not infringed and VH-ZCR did not collide with those buildings.

Other findings:
- The presence of the building struck by the aircraft was unlikely to have increased the severity of the outcome of this accident.
- Both of the aircraft’s engines were likely to have been producing high power at impact.
Final Report:

Crash of a Boeing 747-412F in Bishkek: 39 killed

Date & Time: Jan 16, 2017 at 0719 LT
Type of aircraft:
Operator:
Registration:
TC-MCL
Flight Type:
Survivors:
No
Site:
Schedule:
Hong Kong - Bishkek - Istanbul
MSN:
32897/1322
YOM:
2003
Flight number:
TK6491
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
39
Captain / Total flying hours:
10808
Captain / Total hours on type:
820.00
Copilot / Total flying hours:
5894
Copilot / Total hours on type:
1758
Aircraft flight hours:
46820
Aircraft flight cycles:
8308
Circumstances:
On 16.01.2017, the crew of the Boeing 747-412F TC-MCL aircraft was performing a THY6491 flight from Hong Kong via Bishkek (Manas Airport) to Istanbul (Ataturk Airport) in order to transport the commercial cargo (public consumer goods) of 85 618 kg. The cargo was planned to be offloaded in Istanbul (Ataturk Airport). Manas Airport was planned as a transit airport for crew change and refueling. From 12.01.2017 to 15.01.2017, the crew had a rest period of 69 h in a hotel in Hong Kong. The aircraft takeoff from the Hong Kong Airport was performed at 19:12 on 5.01.2017, with the delay of 2 h 02 min in respect to the planned takeoff time. During the takeoff, the climb and the on-route cruise flight, the aircraft systems operated normally. At 00:41, on 16.01.2017, the aircraft entered the Bishkek ATC Area Control Center over the reference point of KAMUD at flight level of 10 400 m (according to the separation system, established in the People's Republic of China). At 00:51, the crew requested a descent and reached the FL 220 (according to the separation system, established in the Kyrgyz Republic). At 00:59, the crew received the weather information for Manas Airport: "the RVR at the RWY threshold 400 m, the RWY midpoint and RWY end 300 m, the vertical visibility 130 ft". At 01:01, the crew received the specified data: " in the center of the runway RVR three zero zero meters, vertical visibility one five zero feet." At 01:03, the crew requested a descent, the controller cleared for the descent not below FL 180. At 01:05, the crew was handed over to the Approach Control. At 01:06, the crew was cleared for the descent to FL 60, TOKPA 1 ILS approach chart, RWY 26. At 01:10, the controller reported the weather: wind calm, visibility 50 m, RVR 300 m, freezing fog, vertical visibility 160 ft, and requested the crew if they would continue the approach. The crew reported that they would continue the approach. The crew conducted the approach to RWY 26 in accordance with the standard approach chart. At 01:11, the controller informed the crew: "… transition level six zero" and cleared them for the ILS approach to RWY 26. At 01:15, the crew contacted the Tower controller. The Tower controller cleared them for landing on RWY 26 and reported the weather: "…wind calm… RVR in the beginning of the runway four hundred meters, in the middle point three hundred two five meters and at the end of the runway four hundred meters and vertical visibility one six zero... feet". The aircraft approached the RWY 26 threshold at the height significantly higher than the planned height. Continuing to descend, the aircraft flew over the entire length of the RWY and touched the ground at the distance of 900 m away from the farthest end of the runway (in relation to the direction of the approach) (the RWY 08 threshold). After the touchdown and landing roll, the aircraft impacted the concrete aerodrome barrier and the buildings of the suburban settlement and started to disintegrate, the fuel spillage occurred. As a result of the impact with the ground surface and the obstacles, the aircraft was completely disintegrated, a significant part of the aircraft structure was destroyed by the post-crash ground fire. At 01.17 UTC, the Tower controller requested the aircraft position, but the crew did not respond.
Probable cause:
The cause of the Boeing 747-412F TC-MCL aircraft accident was the missing control of the crew over the aircraft position in relation to the glideslope during the automatic approach, conducted at night in the weather conditions, suitable for ICAO CAT II landing, and as a result, the measures to perform a go-around, not taken in due time with the aircraft, having a significant deviation from the established approach chart, which led to the controlled flight impact with terrain (CFIT) at the distance of ≈930 m beyond the end of the active RWY.
The contributing factors were, most probably, the following:
- the insufficient pre-flight briefing of the flight crew members for the flight to Manas aerodrome (Bishkek), regarding the approach charts, as well as the non-optimal decisions taken by the crew when choosing the aircraft descent parameters, which led to the arrival at the established approach chart reference point at a considerably higher flight altitude;
- the lack of the crew's effective measures to decrease the aircraft vertical position and its arrival at the established approach chart reference point while the crew members were aware of the actual aircraft position being higher than required by the established chart;
- the lack of the requirements in the Tower controllers' job instructions to monitor for considerable aircraft position deviations from the established charts while the pertinent technical equipment for such monitoring was available;
- the excessive psycho-emotional stress of the crew members caused by the complicated approach conditions (night time, CAT II landing, long-lasting working hours) and their failure to eliminate the flight altitude deviations during a long time period. Additionally, the stress level could have been increased due to the crew's (especially the PIC's) highly emotional discussion of the ATC controllers' instructions and actions. Moreover, the ATC controllers' instructions and actions were in compliance with the established operational procedures and charts;
- the lack of the crew members' monitoring for crossing the established navigational reference points (the glideslope capture point, the LOM and LIM reporting points);
- the crew's failure to conduct the standard operational procedure which calls for altitude verification at the FAF/FAP, which is stated in the FCOM and the airline's OM. On the other hand, the Jeppesen Route Manual, used by the crew, contains no FAF/FAP in the RWY 26 approach chart;
- the onboard systems' "capture" of the false glideslope beam with the angle of ≈9°;
- the design features of the Boeing 747-400 aircraft type regarding the continuation of the aircraft approach descent in the automatic mode with the constant descent angle of 3° (the inertial path) with the maintained green indication of the armed automatic landing mode (regardless of the actual aircraft position in relation to the RWY) while the aircraft systems detected that the glideslope signal was missing (after the glideslope signal "capture"). With that, the crew received the designed annunciation, including the aural and visual caution alerts;
- the absence of the red warning alert for the flight crew in case of a "false" glideslope capture and the transition to the inertial mode trajectory, which would require immediate control actions from the part of the crew;
- the lack of monitoring from the part of the crew over the aircraft position in regard to the approach chart, including the monitoring by means of the Navigation Display (ND), engaged in the MAP mode;
- the crew's failure to conduct the Airline's Standard Operational Procedures (SOPs), regarding the performance of the go-around procedure in case the "AUTOPILOT" (the AP switching to the inertial mode) and "GLIDESLOPE" (the EGPWS annunciation of the significant glideslope deviation) alerts during the automatic CAT II landing at true heights below 1000 ft (with no visual reference established with either the runway environment or with the lighting system);
- the delayed actions for initiating the go-around procedure with no visual reference established with the runway environment at the decision height (DH). In fact, the actions were initiated at the true height of 58 ft with the established minimum of 99 ft.
Final Report:

Crash of an Epic LT in Port Orange: 2 killed

Date & Time: Dec 27, 2016 at 1756 LT
Type of aircraft:
Registration:
N669WR
Flight Type:
Survivors:
No
Site:
Schedule:
Millington – Port Orange
MSN:
029
YOM:
2009
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4246
Captain / Total hours on type:
956.00
Aircraft flight hours:
822
Circumstances:
The private pilot obtained a full weather briefing before departing on a long cross-country flight. The destination airport was forecast to be under visual meteorological conditions, but there was an AIRMET and Center Weather Advisory (CWA) issued for low instrument flight rules (IFR) conditions later that day. The briefer told the pilot to check the weather again en route to see if the AIRMET and CWA had been updated. At the time the pilot stopped for fuel, another CWA was issued for low IFR conditions at his destination airport; however, there were no records to indicate that the pilot obtained this information during the fuel stop or after departing on the last leg of the flight. A review of air traffic control communications revealed that, about 10 minutes before arriving at the airport, the pilot reported that he had obtained the current weather conditions at his destination airport. The most recent observation, about 1 hour before the accident indicated good visibility; however, the weather reporting equipment did not provide ceiling heights. It is unknown if the pilot obtained weather information from nearby airports, which were reporting low instrument meteorological conditions (visibility between 1/4 and 1/2 mile and ceilings 200-300 ft above ground level [agl]). Additionally, three pilot reports (PIREPs) describing the poor weather conditions were filed within the hour before the accident. The controller did not relay the PIREPs or the CWA information to the pilot, so the pilot was likely unaware of the deteriorating conditions. Based on radar information and statements from witnesses, the pilot's approach to the airport was unstabilized. He descended below the minimum descent altitude of 440 ft, and, after breaking through the fog about 100 ft agl, the airplane reentered the fog and completed a 360° right turn near the approach end of the runway, during which its altitude varied from 100 ft to 300 ft. The airplane then climbed to an altitude about 800 ft before radar contact was lost near the accident site. The airplane came to rest inverted, consistent with one witness's statement that it descended through the clouds in a spin before impact; post accident examination revealed no preimpact anomalies with the airplane or engine that would have precluded normal operation. Although the pilot was instrument rated, his recent instrument experience could not be established. The circumstances of the accident, including the restricted visibility conditions and the pilot's maneuvering of the airplane before the impact, are consistent with a spatial disorientation event. It is likely that the pilot experienced a loss of control due to spatial disorientation, which resulted in an aerodynamic stall and spin.
Probable cause:
The pilot's loss of airplane control due to spatial disorientation, which resulted in the exceedance of the airplane's critical angle of attack and an aerodynamic stall/spin. Contributing to the accident was the pilot's failure to fly a stabilized approach consistent with the published instrument approach procedure.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Bangkok: 1 killed

Date & Time: Aug 1, 2016 at 1605 LT
Operator:
Registration:
HS-FGB
Survivors:
Yes
Site:
Schedule:
Nakhon Ratchasima – Bangkok
MSN:
31-7652156
YOM:
1976
Flight number:
TRB106
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
While descending to Bangkok-Suvarnabhumi Airport, the twin engine aircraft crashed in unknown circumstances in a swamp and came to rest against a wood bridge. The wreckage was found about 15 km from the airport, along the borders of Nong Chok and Min Buri districts. The captain was killed while three other occupants were injured.

Crash of an Embraer EMB-820C Navajo in Londrina: 8 killed

Date & Time: Jul 31, 2016 at 2057 LT
Operator:
Registration:
PT-EFQ
Flight Type:
Survivors:
No
Site:
Schedule:
Cuiabá – Londrina
MSN:
820-030
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
2833
Copilot / Total flying hours:
1567
Aircraft flight hours:
3674
Circumstances:
Owned by Fenatracoop (Federação Nacional dos Trabalhadores Celestitas nas Cooperativas no Brasil), the twin engine aircraft departed Cuiabá-Marechal Rondon Airport on a flight to Londrina, carrying two pilots and six passengers, three adults and three children. On final approach to Londrina-Governador José Richa Runway 13, the pilot informed ATC about a loss of power on the left engine. Shortly later, control was lost and the aircraft crashed on a hangar housing six tanker trucks and located 9,2 km short of runway. Several explosions occurred and the aircraft and the hangar were totally destroyed. All eight occupants were killed but there were no injuries on the ground.
Probable cause:
Contributing factors.
- Communication – undetermined
It is possible that difficulties for the dialogue between pilots on matters related to the operation of the aircraft have favored a prejudicial scenario to the expression of assertiveness in the communication in the cabin, interfering in the effective management of the presented abnormal condition.
- Team dynamics – undetermined
It is possible that a more passive posture of the copilot combined with the commander's decisions and actions from the presentation of the abnormal condition in flight interfered with the quality of the team's integration and in the efficiency of the cabin dynamics during the occurrence, bringing losses to the emergency management presented.
- Emotional state – undetermined
It is not possible to discard the hypothesis that a more anxious emotional state of the pilots contributed to an inaccurate evaluation of the operational context experienced, favoring ineffective judgments, decisions and actions to manage the abnormal condition presented.
- Aircraft maintenance – a contributor
On the right engine, it was found that the fuel tube fixing nut that left the distributor for No. 3 cylinder was loose, favoring the fuel leakage, as well as the bypass valve clamp of the turbocharger that was bad adjusted, providing leakage of gases from the exhaust that would be directed to the compressor and, later to the engine, to equalize its power. On the left engine, impurity composed of an agglomerate of soil and fuel were found on the side of the nozzles n° 2, 4 and 6, which migrated to the inside of these nozzles, causing them to become clogged. It was not possible to determine the origin of this material, but there is a possibility that it may have been deposited during the long period the aircraft spent in the maintenance shop, undergoing general overhaul and the revitalization of its interior (13DEC2012 until 29APR2016).
- Insufficient pilot’s experience – undetermined
The pilots had little experience with the GARMIN GTN 650 navigation system. The lack of familiarity with this equipment may have favored the misidentification of the approach fixes for Londrina. This way, it is possible that they have calculated their descent to the final approach fix (waypoint LO013), believing that it was the position relative to threshold 13 (waypoint RWY13).
- Decision-making process – undetermined
The decision to take off from Cuiabá to Londrina without the identification of the reason for the warning light to be ON in the alarm panel and the possible late declaration of the emergency condition showed little adequate decisions that may have increased the level of criticality of the occurrence.
- Support systems – undetermined
The similarity of the waypoints names in the RNAV procedure, associated with the lack of familiarity of the pilots with the new navigation system installed in the aircraft, may have confused the pilots as to their real position in relation to the runway.
Final Report:

Crash of a Comp Air CA-9 in Campo de Marte: 7 killed

Date & Time: Mar 19, 2016 at 1523 LT
Type of aircraft:
Operator:
Registration:
PR-ZRA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Campo de Marte – Rio de Janeiro
MSN:
0420109T01
YOM:
2012
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
215
Circumstances:
Shortly after takeoff from Campo de Marte Airport runway 30, the single engine airplane entered a right turn without gaining altitude. Less than one minute after liftoff, the aircraft impacted a building located in the Frei Machado Street, some 370 metres from runway 12 threshold. The aircraft was totally destroyed by impact forces and a post crash fire and all seven occupants were killed. One people on the ground was slightly injured. Owned by the Brazilian businessman Roger Agnelli, the aircraft was on its way to Santos Dumont Airport in Rio de Janeiro. Among the victims was Roger Agnelli, his wife Andrea, his both children John and Anna Carolina, the pilot and two other friends. They were enroute to Rio to take part to the wedding of the nephew of Mr. Agnelli.
Probable cause:
Contributing factors
- Pilot judgment - undetermined
The absence of manuals and performance charts to guide the operation and actions based only on empirical knowledge about the aircraft may have taken to an inadequate evaluation of certain parameters related to its operation. In this case, the performance of the aircraft under conditions of weight, altitude and high temperatures may have provided its conduction with reduced margins of safety during takeoff that resulted in the on-screen accident.
- Flight planning - undetermined
The informality present in the field of experimental aviation, associated with the absence of support systems, may have resulted in an inadequacy in the work of flight preparation, particularly with regard to performance degradation in the face of adverse conditions (high weight, altitude and temperature), compromising the quality of the planning carried out, thus contributing to it being carried out a takeoff under marginal conditions.
- Project - undetermined
During the PR-ZRA assembly process, changes were incorporated into the Kit's original design that directly affected the airplane's take-off performance. Since the submission of documentation related to in-flight testing or performance graphics was not required by applicable law, it is possible that the experimental nature of the project has enabled the operation of the aircraft based on
empirical parameters and inadequate to their real capabilities.
- Support systems - undetermined
The absence of a support system, in the form of publications that allowed obtaining equipment performance data in order to carry out proper planning, added risk to operations and may have led to an attempt to take off under unsafe conditions.
Final Report:

Crash of a Beechcraft 200 Super King Air in New Delhi: 10 killed

Date & Time: Dec 22, 2015 at 0938 LT
Operator:
Registration:
VT-BSA
Flight Phase:
Survivors:
No
Site:
Schedule:
New Delhi - Ranchi
MSN:
BB-1485
YOM:
1994
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
964
Captain / Total hours on type:
764.00
Copilot / Total flying hours:
891
Copilot / Total hours on type:
691
Aircraft flight hours:
4766
Aircraft flight cycles:
2745
Circumstances:
Beechcraft Super King Air B-200 aircraft, VT-BSA belonging to BSF Air Wing was involved in an accident on 22.12.2015 while operating a flight from IGI Airport, New Delhi to Ranchi. The flight was under the command of a CPL holder with another CPL holder as Second-in-Command. There were ten persons on board including two flight crew members. As per the scheduling procedure of the Operator, the flying programme for 22.12.2015 was approved by the ADG (Logistics) on the recommendation of the DIG (Air) for VT-BSA on 21.12.2015. The programme included names of the flight crew along with the following sectors: from Delhi to Ranchi ETD 0800 ETA 1030 and from Ranchi to Delhi ETD 1300 ETA 1600. The task was as per instructions on the subject dated 23rd July 2015. As per the weight & load data sheet there were 8 passengers with 20 Kgs. of baggage in the aft cabin compartment. The actual take-off weight shown was 5668.85 Kgs as against the maximum take-off weight of 5669.9 Kgs. Fuel uplifted was 1085 Kgs. The aircraft was taken out of hangar of the Operator at 0655 hrs on 22.12.2015 and parked outside the hangar for operating the subject flight. At around 0745 hrs, the passengers reached the aircraft who were mainly technical personnel supposed to carry out scheduled maintenance of Mi-17 helicopter of the Operator at Ranchi. They were carrying their personnel baggage along with tools and equipment required for the maintenance. At around 0915 hrs the flight crew contacted ATC Delhi and requested for clearance to operate the flight to Ranchi. The aircraft was cleared to Ranchi via R460 and FL210. Runway in use was given as 28. At 0918 hrs the doors were closed and the flight crew had started carrying out the check list. After the ATC issued taxi clearance, the aircraft had stopped for some time after commencing taxiing. The pilot informed the ATC that they will take 10 minutes delay for further taxi due to some administrative reasons. The taxi clearance was accordingly cancelled. After a halt of about 6 to 7 minutes, the pilot again requested the ATC for taxi clearance and the same was approved by the ATC. Thereafter, the aircraft was given take-off clearance from runway 28. The weather at the time of take-off was: Visibility 800 meters with Winds at 100°/03 knots. Shortly after take-off and attaining a height of approximately 400 feet AGL, the aircraft progressively turned left with simultaneous loss of height. It had taken a turn of approximately 180o and impacted some trees before hitting the outside perimeter road of the airport in a left bank attitude. Thereafter, it impacted 'head on' with the outside boundary wall of the airport. After breaking the outside boundary wall, the wings impacted two trees and the aircraft hit the holding tank of the water treatment plant. The tail portion and part of the fuselage overturned and went into the water tank. There was post impact fire and the portion of the aircraft outside the water tank was destroyed by fire. All passengers and crew received fatal injuries due impact and fire. The ELT was operated at 0410 hours UTC (0940 hours IST). The fire fighting team reached the site and extinguished the fire. The bodies were then recovered from the accident site. 08 bodies were recovered from the holding tank of the water treatment plant and bodies of both pilots were recovered from the heavily burnt portion of the cockpit lying adjacent (outside) to the wall of the holding tank of the water treatment tank.
Probable cause:
The accident was caused due to engagement of the autopilot without selecting the heading mode by the flight crew just after liftoff (before attaining sufficient height) in poor foggy conditions and not taking corrective action to control the progressive increase in left bank; thereby, allowing the aircraft to traverse 180° turn causing the aircraft to lose height in a steep left bank attitude followed by impact with the terrain.
Final Report: