City | Bureau of Aircraft Accidents Archives

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:

Comp Air CA-9

Operator:

Roger Agnelli

Registration:

PR-ZRA

Flight Phase:

Takeoff (climb)

Flight Type:

Private

Survivors:

Site:

City

Schedule:

Campo de Marte – Rio de Janeiro

MSN:

0420109T01

YOM:

2012

Location:

Campo de Marte AFB (São Paulo)

São Paulo

Country:

Brazil

Region:

South America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

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

Type of aircraft:

Beechcraft 200 Super King Air

Operator:

Registration:

VT-BSA

Flight Phase:

Takeoff (climb)

Flight Type:

Survey / Patrol / Reconnaissance

Survivors:

Site:

City

Schedule:

New Delhi - Ranchi

MSN:

BB-1485

YOM:

1994

Location:

New Delhi-Indira Gandhi

National Capital Territory of Delhi

Country:

India

Region:

Asia

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

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:

Crash of a Piper PA-31-310 in Guatemala City

Date & Time: Nov 21, 2015 at 1240 LT

Type of aircraft:

Piper PA-31-310 Navajo

Operator:

Three T’s Auto Sale

Registration:

C6-TAK

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Guatemala City - Guatemala City

MSN:

31-228

YOM:

1968

Location:

Guatemala City-La Aurora

Guatemala

Country:

Guatemala

Region:

Central America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

191

Copilot / Total flying hours:

4735

Aircraft flight hours:

7600

Circumstances:

The crew departed Guatemala City-La Aurora Airport on a local training flight. Shortly after takeoff from runway 02, while in initial climb, the aircraft entered a right turn then lost height and crashed near an industrial building located about 900 metres from the runway 20 threshold. The aircraft was destroyed by impact forces and a post crash fire. Both pilots escaped uninjured.

Probable cause:

The aircraft stalled at low height after takeoff due to a poor crew coordination about flight controls.

Final Report:

Crash of a Cessna 402B in Acandí: 2 killed

Date & Time: Nov 17, 2015 at 1054 LT

Type of aircraft:

Cessna 402

Operator:

Registration:

HK-4981G

Flight Phase:

Takeoff (climb)

Flight Type:

Charter/Taxi (Non Scheduled Revenue Flight)

Survivors:

Yes

Site:

City

Schedule:

Acandí – Medellín

MSN:

402B-1042

YOM:

1976

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

Shortly after takeoff from Acandí-Alcides Fernandez Airport, while in initial climb, the twin engine aircraft stalled and crashed in a house located in the district of Miramar, near the airport. The pilot and a passenger were killed and eight other occupants were injured. There were no victims on the ground and the aircraft was destroyed.

Probable cause:

Stall during initial climb due to the combination of the following factors:
- The total weight of the aircraft was above the MTOW,
- The CofG was outside the enveloppe,
- Poor flight planning.

Crash of a BAe 125-700A in Akron: 9 killed

Date & Time: Nov 10, 2015 at 1453 LT

Type of aircraft:

BAe 125

Operator:

Registration:

N237WR

Flight Phase:

Landing (descent or approach)

Flight Type:

Charter/Taxi (Non Scheduled Revenue Flight)

Survivors:

Site:

City

Schedule:

Dayton – Akron

MSN:

257072

YOM:

1979

Flight number:

EFT1526

Location:

Akron-Canton

Ohio

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

6170

Captain / Total hours on type:

1020.00

Copilot / Total flying hours:

4382

Copilot / Total hours on type:

482

Aircraft flight hours:

14948

Aircraft flight cycles:

11075

Circumstances:

The aircraft departed controlled flight while on a non precision localizer approach to runway 25 at Akron Fulton International Airport (AKR) and impacted a four-unit apartment building in Akron, Ohio. The captain, first officer, and seven passengers died; no one on the ground was injured. The airplane was destroyed by impact forces and post crash fire. The airplane was registered to Rais Group International NC LLC and operated by Execuflight under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as an on-demand charter flight. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight departed from Dayton-Wright Brothers Airport, Dayton, Ohio, about 1413 and was destined for AKR. Contrary to Execuflight’s informal practice of the captain acting as pilot flying on flights carrying revenue passengers, the first officer was the pilot flying, and the captain was the pilot monitoring. While en route, the flight crew began preparing for the approach into AKR. Although company standard operating procedures (SOPs) specified that the pilot flying was to brief the approach, the captain agreed to the first officer’s request that the captain brief the approach. The ensuing approach briefing was unstructured, inconsistent, and incomplete, and the approach checklist was not completed. As a result, the captain and first officer did not have a shared understanding of how the approach was to be conducted. As the airplane neared AKR, the approach controller instructed the flight to reduce speed because it was following a slower airplane on the approach. To reduce speed, the first officer began configuring the airplane for landing, lowering the landing gear and likely extending the flaps to 25° (the airplane was not equipped with a flight data recorder, nor was it required to be). When the flight was about 4 nautical miles from the final approach fix (FAF), the approach controller cleared the flight for the localizer 25 approach and instructed the flight to maintain 3,000 ft mean sea level (msl) until established on the localizer. The airplane was already established on the localizer when the approach clearance was issued and could have descended to the FAF minimum crossing altitude of 2,300 ft msl. However, the first officer did not initiate a descent, the captain failed to notice, and the airplane remained level at 3,000 ft msl. As the first officer continued to slow the airplane from about 150 to 125 knots, the captain made several comments about the decaying speed, which was well below the proper approach speed with 25° flaps of 144 knots. The first officer’s speed reduction placed the airplane in danger of an aerodynamic stall if the speed continued to decay, but the first officer apparently did not realize it. The first officer’s lack of awareness and his difficulty flying the airplane to standards should have prompted the captain to take control of the airplane or call for a missed approach, but he did not do so. Before the airplane reached the FAF, the first officer requested 45° flaps and reduced power, and the airplane began to descend. The first officer’s use of flaps 45° was contrary to Execuflight’s Hawker 700A non precision approach profile, which required the airplane to be flown at flaps 25° until after descending to the minimum descent altitude (MDA) and landing was assured; however, the captain did not question the first officer’s decision to conduct the approach with flaps 45°. The airplane crossed the FAF at an altitude of about 2,700 ft msl, which was 400 ft higher than the published minimum crossing altitude of 2,300 ft msl. Because the airplane was high on the approach, it was out of position to use a normal descent rate of 1,000 feet per minute (fpm) to the MDA. The airplane’s rate of descent quickly increased to 2,000 fpm, likely due to the first officer attempting to salvage the approach by increasing the rate of descent, exacerbated by the increased drag resulting from the improper flaps 45° configuration. The captain instructed the first officer not to descend so rapidly but did not attempt to take control of the airplane even though he was responsible for safety of the flight. As the airplane continued to descend on the approach, the captain did not make the required callouts regarding approaching and reaching the MDA, and the first officer did not arrest the descent at the MDA. When the airplane reached the MDA, which was about 500 ft above the touchdown zone elevation, the point at which Execuflight’s procedures dictated that the approach must be stabilized, the airspeed was 11 knots below the minimum required airspeed of 124 knots, and the airplane was improperly configured with 45° flaps. The captain should have determined that the approach was unstabilized and initiated a missed approach, but he did not do so. About 14 seconds after the airplane descended below the MDA, the captain instructed the first officer to level off. As a result of the increased drag due to the improper flaps 45° configuration and the low airspeed, the airplane entered a stalled condition when the first officer attempted to arrest the descent. About 7 seconds after the captain’s instruction to level off, the cockpit voice recorder (CVR) recorded the first sounds of impact.

Probable cause:

The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s mismanagement of the approach and multiple deviations from company standard operating procedures, which placed the airplane in an unsafe situation and led to an unstabilized approach, a descent below minimum descent altitude without visual contact with the runway environment, and an aerodynamic stall. Contributing to the accident were Execuflight’s casual attitude toward compliance with standards; its inadequate hiring, training, and operational oversight of the flight crew; the company’s lack of a formal safety program; and the Federal Aviation Administration’s insufficient oversight of the company’s training program and flight operations.

Final Report:

Crash of a Beechcraft B60 Duke in Bogotá: 9 killed

Date & Time: Oct 18, 2015 at 1619 LT

Type of aircraft:

Beechcraft 60 Duke

Operator:

Registration:

HK-3917G

Flight Phase:

Takeoff (climb)

Flight Type:

Charter/Taxi (Non Scheduled Revenue Flight)

Survivors:

Site:

City

Schedule:

Bogotá - Bogotá

MSN:

P-410

YOM:

1977

Location:

Bogotá-El Dorado

Bogotá Capital District

Country:

Colombia

Region:

South America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

4916

Aircraft flight hours:

1788

Circumstances:

The twin engine aircraft departed Bogotá-El Dorado on a short flight to Bogotá-Guaymaral Airport, carrying three passengers and one pilot. Three minutes after takeoff from runway 13L, while climbing to a height of 200 feet in VFR conditions, the airplane entered a left turn then descended into the ground and crashed into several houses located in the district of Engativá, near the airport, bursting into flames. The aircraft as well as several houses and vehicles were destroyed. All four occupants as well as five people on the ground were killed. Thirteen others were injured, seven seriously.

Probable cause:

The pilot lost control of the airplane following a loss of power on the left engine during initial climb. Investigations were unable to determine the exact cause of this loss of power. The aircraft's speed dropped to 107 knots and the pilot likely did not have time to identify the problem. Operation from a high density altitude airport contributed to the accident.

Final Report:

Crash of a Dornier DO228-212 in Kaduna: 7 killed

Date & Time: Aug 29, 2015 at 0647 LT

Type of aircraft:

Dornier DO228

Operator:

Registration:

NAF030

Flight Phase:

Takeoff (climb)

Flight Type:

Military

Survivors:

Site:

City

Schedule:

Kaduna – Abuja

MSN:

8219

YOM:

1993

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

Shortly after takeoff from the Kaduna Military Airfield, while climbing, the aircraft went out of control and crashed into a house located in the Ribadu Cantonment, bursting into flames. All seven occupants (two pilots, two engineers and three passengers) were killed.

Crash of a Piper PA-46-350P Malibu Mirage in Chofu: 3 killed

Date & Time: Jul 26, 2015 at 1058 LT

Type of aircraft:

Piper PA-46 (Malibu/Meridian/Mirage/Matrix/M-Class)

Operator:

Registration:

JA4060

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Chōfu - Amami

MSN:

46-22011

YOM:

1989

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

1300

Captain / Total hours on type:

120.00

Aircraft flight hours:

2284

Circumstances:

On Sunday, July 26, 2015 at around 10:58 Japan Standard Time (JST: UTC + 9 hrs: unless otherwise stated, all times are indicated in JST using the 24-hour clock), a privately owned Piper PA-64-350P, registered JA4060, crashed into a private house at Fujimi Town in Chōfu City, right after its takeoff from Runway 17 of Chōfu Airport There were five people on board, consisting of the captain and four passengers. The captain and one passenger died and three passengers were seriously injured. In addition, one resident died and two residents had minor injuries. The aircraft was destroyed and a fire broke out. Furthermore, the house where the Aircraft crashed into were consumed in a fire, and neighboring houses sustained damage due to the fire and other factors.

Probable cause:

It is highly probable that this accident occurred as the speed of the Aircraft decreased during takeoff and climb, which led the Aircraft to stall and crashed into a residential area near Chōfu Airport. It is highly probable that decreased speed was caused by the weight of the Aircraft exceeding the maximum takeoff weight, takeoff at low speed, and continued excessive nose-up attitude. As for the fact that the Captain made the flight with the weight of the Aircraft exceeding the maximum takeoff weight, it is not possible to determine whether or not the Captain was aware of the weight of the Aircraft exceeded the maximum takeoff weight prior to the flight of the accident because the Captain is dead. However, it is somewhat likely that the Captain had insufficient understanding of the risks of making flights under such situation and safety awareness of observing relevant laws and regulations. It is somewhat likely that taking off at low speed occurred because the Captain decided to take a procedure to take off at such a speed; or because the Captain reacted and took off due to the approach of the Aircraft to the runway threshold. It is somewhat likely that excessive nose-up attitude was continued in the state that nose-up tended to occur because the position of the C.G. of the Aircraft was close to the aft limit, or the Captain maintained the nose-up attitude as he prioritized climbing over speed. Adding to these factors, exceeding maximum takeoff weight, takeoff at low speed and continued excessive nose-up attitude, as the result of analysis using mathematical models, it is somewhat likely that the decreased speed was caused by the decreased engine power of the Aircraft; however, as there was no evidence of showing the engine malfunction, it was not possible to determine this.

Final Report:

Crash of a Lockheed KC-130B Hercules in Medan: 139 killed

Date & Time: Jun 30, 2015 at 1150 LT

Type of aircraft:

Lockheed C-130 Hercules

Operator:

Registration:

A-1310

Flight Phase:

Takeoff (climb)

Flight Type:

Military

Survivors:

Site:

City

Schedule:

Medan – Tanjung Pinang

MSN:

3616

YOM:

1961

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

111

Pax fatalities:

Other fatalities:

Total fatalities:

139

Circumstances:

Two minutes after takeoff from Medan-Soewondo AFB Airport Runway 23, while climbing in good weather conditions, the crew reported technical problem. The aircraft encountered difficulties to gain height, banked to the right, hit a utility pole and the roof of a building then crashed inverted in a huge explosion in a suburb located less than 5 km from the airport. The aircraft was destroyed by impact forces and a post crash fire and several buildings were destroyed as well. All 122 occupants as well as 17 people on the ground were killed. 20 others were injured. It is believed that an engine failed during initial climb.
Crew:
1st Lt Sandi Permana, pilot,
1st Lt Pandu Setiawan, copilot,
Lt Dian Sukman P, copilot,
Cpt Riri Setiawan, navigator,
Serma Bambang H, radio operator,
Peltu Ibnu Kohar, flight engineer,
Pelda Andik S, flight engineer,
Peltu Ngateman, load master,
Peltu Yahya Komari,
Pelda Agus P,
Dan Prada Alvian.

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