Crash of a Beechcraft G18 in Taylorville: 1 killed

Date & Time: Aug 11, 2012 at 1124 LT
Type of aircraft:
Operator:
Registration:
N697Q
Flight Phase:
Survivors:
No
Site:
Schedule:
Taylorville - Taylorville
MSN:
BA-468
YOM:
1959
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1429
Captain / Total hours on type:
7.00
Aircraft flight hours:
13833
Circumstances:
The airplane was substantially damaged when it impacted terrain in a residential neighborhood in Taylorville, Illinois. The commercial pilot sustained fatal injuries. Twelve parachutists on-board the airplane exited and were not injured. No persons on the ground were injured. The airplane was registered to Barron Aviation, LLC; Perry, Missouri, and operated by Barron Aviation Private Flight Services, LLC; Hannibal, Missouri, under the provisions of 14 Code of Federal Regulations Part 91, as a sport parachuting flight. Day visual meteorological conditions prevailed and no flight plan was filed. The local flight originated from Taylorville Municipal Airport (TAZ), Taylorville, Illinois, about 1100. The airplane had climbed to an altitude of about 11,000 feet mean sea level (msl) and the parachutists were seated inside the airplane on two rear facing "straddle benches". As the airplane arrived at the planned drop location, the parachutists stood up, opened the door, and moved further aft in the airplane in preparation for their jump. Five of the parachutists were positioned hanging on to the outside of the airplane with several others standing in the door and the remainder were standing in the cabin forward of the door. Several parachutists reported that they were almost ready to jump when they heard the sounds of the airplane's stall warning system. The airplane then suddenly rolled and all twelve parachutists quickly exited the airplane. Several of those who were last to exit reported that the airplane was inverted or partially inverted as they went out the door. The pilot, seated in the left front cockpit seat, did not exit the airplane. Several witnesses reported seeing the airplane turning and descending in an inverted attitude when the airplane appeared to briefly recover, but then entered a nearly vertical dive. The airplane impacted a tree and terrain in the back yard of an occupied residence. Emergency personnel who first responded to the accident scene reported a strong smell of gasoline and ordered the evacuation of several nearby homes. There was no post impact fire.
Probable cause:
The pilot's failure to maintain adequate airspeed and use the appropriate flaps setting during sport-parachuting operations, which resulted in an aerodynamic stall/spin and a subsequent loss of control. Contributing to the accident was the pilot’s failure to follow company guidance by allowing more than four passengers in the door area during exit, which shifted the airplane’s center of gravity aft.
Final Report:

Crash of a McDonnell Douglas MD-83 in Lagos: 159 killed

Date & Time: Jun 3, 2012 at 1545 LT
Type of aircraft:
Operator:
Registration:
5N-RAM
Survivors:
No
Site:
Schedule:
Abuja - Lagos
MSN:
53019/1783
YOM:
1990
Flight number:
DAV992
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
147
Pax fatalities:
Other fatalities:
Total fatalities:
159
Captain / Total flying hours:
18116
Captain / Total hours on type:
7466.00
Copilot / Total flying hours:
1143
Copilot / Total hours on type:
808
Aircraft flight hours:
60850
Aircraft flight cycles:
35220
Circumstances:
On 3rd June, 2012 at about 1545:00hrs, 5N-RAM, a Boeing MD-83, a domestic scheduled commercial flight, operated by Dana Airlines (Nig.) Limited as flight 0992 (DANACO 0992), crashed into a densely populated area of Iju-Ishaga, a suburb of Lagos, following engine number 1 loss of power seventeen minutes into the flight and engine number 2 loss of power while on final approach to Murtala Muhammed Airport Lagos, Nigeria. Visual Meteorological Conditions prevailed at the time and the airplane was on an instrument flight plan. All 153 persons onboard the airplane, including the six crew were fatally injured. There were also six confirmed ground fatalities. The airplane was destroyed. There was post impact fire. The flight originated at Abuja (ABV) and the destination was Lagos (LOS). The airplane was on the fourth flight segment of the day, consisting of two round-trips between Lagos and Abuja. The accident occurred during the return leg of the second trip. DANACO 0992 was on final approach to runway 18R at LOS when the crew declared a Mayday call “Dual Engine Failure – negative response from the throttles.” According to records, the flight arrived ABV as Dana Air flight 0993 at about 1350:00hrs and routine turn-around activities were carried out. DANACO 0992 initiated engine start up at 1436:00hrs. Abuja Control Tower cleared the aircraft to taxi to the holding point of runway 04. En-route ATC clearance was passed on to DANACO 0992 on approaching holding point of runway 04. According to the ATC ground recorder transcript, the aircraft was cleared to line-up on runway 04 and wait, but the crew requested for some time before lining-up. DANACO 0992 was airborne at 1458:00hrs after reporting a fuel endurance of 3 hours 30 minutes. The aircraft made contact with Lagos Area Control Centre at 1518:00hrs and reported 1545:00hrs as the estimated time of arrival at LOS at cruising altitude of 26,000 ft. The Cockpit Voice Recorder (CVR) retained about 30 minutes 53 seconds of the flight and started recording at 1513:44hrs by which time the Captain and First Officer (F/O) were in a discussion of a non-normal condition regarding the correlation between the engine throttle setting and an engine power indication. However, they did not voice concerns then that the condition would affect the continuation of the flight. The flight crew continued to monitor the condition and became increasingly concerned as the flight transitioned through the initial descent from cruise altitude at 1522:00hrs and the subsequent approach phase. DANACO 0992 reported passing 18,100ft and 7,700ft, at 1530:00hrs and 1540:00hrs respectively. After receiving radar vectors in heading and altitude from the Controller, the aircraft was issued the final heading to intercept the final approach course for runway 18R. According to CVR transcript, at 1527:30hrs the F/O advised the Captain to use runway 18R for landing and the request was made at 1531:49hrs and subsequently approved by the Radar Controller. The crew accordingly changed the decision height to correspond with runway 18R. At 1531:12hrs, the crew confirmed that there was no throttle response on the left engine and subsequently the Captain took over control as Pilot Flying (PF) at 1531:27hrs. The flight was however continued towards Lagos with no declaration of any distress message. With the confirmation of throttle response on the right engine, the engine anti-ice, ignition and bleed-air were all switched off. At 1532:05hrs, the crew observed the loss of thrust in No.1 Engine of the aircraft. During the period between 1537:00hrs and 1541:00hrs, the flight crew engaged in prelanding tasks including deployment of the slats, and extension of the flaps and landing gears. At 1541:46hrs the First Officer inquired, "both engines coming up?" and the Captain replied “negative” at 1541:48hrs. The flight crew subsequently discussed and agreed to declare an emergency. At 1542:10hrs, DANACO 0992 radioed an emergency distress call indicating "dual engine failure . . . negative response from throttle." At 1542:35hrs, the flight crew lowered the flaps further and continued with the approach and discussed landing alternatively on runway 18L. At 1542:45hrs, the Captain reported the runway in sight and instructed the F/O to retract the flaps and four seconds later to retract the landing gears. At 1543:27hrs, the Captain informed the F/O, "we just lost everything, we lost an engine. I lost both engines". During the next 25 seconds until the end of the CVR recording, the flight crew attempted to recover engine power without reference to any Checklist. The airplane crashed into a densely populated residential area about 5.8 miles north of LOS. The airplane wreckage was approximately on the extended centreline of runway 18R, with the main wreckage concentrated at N 06o 40.310’ E 003o 18.837' coordinates, with elevation of 177ft. During the impact sequence, the airplane struck an uncompleted building, two trees and three other buildings. The wreckage was confined in a small area, with the separated tail section and engines located at the beginning of the debris trail. The airplane was mostly consumed by post crash fire. The tail section, both engines and portions of both wings representing only about 15% of the airplane, were recovered from the accident site for further examination.
Probable cause:
Probable Causal Factors:
1. Engine number 1 lost power seventeen minutes into the flight, and thereafter on final approach, Engine number 2 lost power and failed to respond to throttle movement on demand for increased power to sustain the aircraft in its flight configuration.
2. The inappropriate omission of the use of the Checklist, and the crew’s inability to appreciate the severity of the power-related problem, and their subsequent failure to land at the nearest suitable airfield.
3. Lack of situation awareness, inappropriate decision making, and poor airmanship.

Tear down of the engines showed that the no.1 engine was overhauled in the U.S in August 2011 and was not in compliance with Service Bulletin SB 6452. Both engines had primary and secondary fuel manifold assemblies fractured, cracked, bent, twisted or pinched which led to fuel leaks, fuel discharge to bypass duct, loss of engine thrust and obvious failure of engine responding to
throttle movement. This condition was similar to the no.1 engine of a different Dana Air MD-80, 5N-SAI, that was involved in an incident in October 2013 when the aircraft returned to the departure airport with the engine not responding th throttle movements. This engine also was not in compliance with Service Bulletin SB 6452. This bulletin was issued in 2003 and called for the installation of new secondary fuel manifold assemblies, incorporating tubes fabricated from new material which has a fatigue life that was approximately 2 times greater than the previous tube material.
Final Report:

Crash of a Socata TBM-700 in Morristown: 5 killed

Date & Time: Dec 20, 2011 at 1005 LT
Type of aircraft:
Operator:
Registration:
N731CA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Teterboro - Atlanta
MSN:
332
YOM:
2005
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
1400
Aircraft flight hours:
702
Circumstances:
Although the pilot filed an instrument flight rules flight plan through the Direct User Access Terminal System (DUATS), no evidence of a weather briefing was found. The flight departed in visual meteorological conditions and entered instrument meteorological conditions while climbing through 12,800 feet. The air traffic controller advised the pilot of moderate rime icing from 15,000 feet through 17,000 feet, with light rime ice at 14,000 feet. The controller asked the pilot to advise him if the icing worsened, and the pilot responded that he would let them know and that it was no problem for him. The controller informed the pilot that he was coordinating for a higher altitude. The pilot confirmed that, while at 16,800 feet, "…light icing has been present for a little while and a higher altitude would be great." About 15 seconds later, the pilot stated that he was getting a little rattle and requested a higher altitude as soon as possible. About 25 seconds after that, the flight was cleared to flight level 200, and the pilot acknowledged. About one minute later, the airplane reached a peak altitude of 17,800 feet before turning sharply to the left and entering a descent. While descending through 17,400 feet, the pilot stated, "and N731CA's declaring…" No subsequent transmissions were received from the flight. The airplane impacted the paved surfaces and a wooded median on an interstate highway. A postaccident fire resulted. The outboard section of the right wing and several sections of the empennage, including the horizontal stabilizer, elevator, and rudder, were found about 1/4 mile southwest of the fuselage, in a residential area. Witnesses reported seeing pieces of the airplane separating during flight and the airplane in a rapid descent. Examination of the wreckage revealed that the outboard section of the right wing separated in flight, at a relatively low altitude, and then struck and severed portions of the empennage. There was no evidence of a preexisting mechanical anomaly that would have precluded normal operation of the airframe or engine. An examination of weather information revealed that numerous pilots reported icing conditions in the general area before and after the accident. At least three flight crews considered the icing "severe." Although severe icing was not forecasted, an Airmen's Meteorological Information (AIRMET) advisory included moderate icing at altitudes at which the accident pilot was flying. The pilot operating handbook warned that the airplane was not certificated for flight in severe icing conditions and that, if encountered, the pilot must exit severe icing immediately by changing altitude or routing. Although the pilot was coordinating for a higher altitude with the air traffic controller at the time of the icing encounter, it is likely that he either did not know the severity of the icing or he was reluctant to exercise his command authority in order to immediately exit the icing conditions.
Probable cause:
The airplane’s encounter with unforecasted severe icing conditions that were characterized by high ice accretion rates and the pilot's failure to use his command authority to depart the icing conditions in an expeditious manner, which resulted in a loss of airplane control.
Final Report:

Crash of a Beechcraft 65-80 Queen Air in Manila: 13 killed

Date & Time: Dec 10, 2011 at 1415 LT
Type of aircraft:
Registration:
RP-C824
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Manila - San Jose
MSN:
LD-21
YOM:
1962
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
13
Circumstances:
On December 10, 2011, BE-65-80QA (Queen Air) with Registry RP-C824 took off from RWY 13, Manila Domestic Airport on/or about 0610 UTC (1410H) southbound for San Jose, Mindoro. There were three (3) persons on board, the PIC and two (2) other persons; one was seated at the right-hand cockpit seat and the other one at the passenger seat. After airborne, the ATC gave instructions to the pilot o turn right and report five (5) miles out. After performing the right turn, the pilot requested for a reland which was duly acknowledged but the ATC with instructions to cross behind traffic on short final Rwy 06 (a perpendicular international runway) and to confirm if experiencing difficulty. However, there was no more response from the pilot. From a level flight southward at about 200 feet AGL, three (3) loud sputtering/burst sounds coming from the aircraft were heard (by people on the ground) then the aircraft was observed making a left turn that progressed into a steep bank and roll-over on a dive. After about one complete roll on a dive the aircraft hit ground at point of impact (Coordinates 14.48848 N 121.025811 E), a confined area beside a creek surrounded by shaties where several people were in a huddle. Upon impact, the aircraft exploded and fire immediately spread to surrounding shanties and a nearby elementary school building. The aircraft was almost burned into ashes and several shanties were severely burned by post-crash fire. A total of thirteen (13) persons were fatality injured composed of: the 3 aircraft occupants who died due to non survivable impact and charred by post-crash fire, and ten (10) other persons on the ground, all residents at vicinity of impact point, incurred non-fatal injuries and were rushed to a nearby hospital for medical treatment. About 20 houses near the impact point were completely burnt and the adjacent Elementary School building was severely affected by fire.
Probable cause:
The Aircraft Accident Investigation and Inquiry Board determined that the probable cause of this accident was:
- Immediate Cause:
(1) Pilot’s Lack of event proficiency in emergency procedures for one (1) engine in-operative condition after-off. Pilot Error (Human Factor)
While a one engine in-operative condition during take-off after V1 is a survivable emergency event during training, the pilot failed to effectively maintain aircraft control the aircraft due to inadequate event proficiency.
- Contributing Cause:
(1) Left engine failure during take-off after V1. (Material Factor)
The left engine failed due to oil starvation as indicated by the severely burnt item 7 crankshaft assembly and frozen connecting rods 5 & 6. This triggered the series of events that led to the failure of the pilot to manage a supposedly survivable emergency event.
- Underlying Causes:
(1) Inadequate Pilot Training for Emergency Procedure. Human Factor
Emergency event such as this (one engine inoperative event – twin engine aircraft) was not actually or properly performed (discussed only) in actual training flights/check-ride and neither provided with corresponding psycho-motor training on a simulator. Hence, pilot’s motor skill/judgment recall was not effective (not free-flowing) during actual emergency event.
(2) Inadequate engine overhaul capability of AMO. Human Factor
There was no document to prove that engine parts scheduled to be overhauled aboard were complied with or included in the overhaul activity. The presence unauthorized welding spot in the left-hand engine per teardown inspection report manifested substandard overhaul activity.
(3) Inadequate regulatory oversight (airworthiness inspection) on the overhaul activity of the AMO (on engine overhaul). Human Factor
The airworthiness inspection on this major maintenance activity (engine overhaul) failed to ensure integrity and quality of replacement parts and work done (presence of welding spots).
(4) Unnecessary Deviation by ATC from the AIP provision on Runway 13 Standard VFR Departure Southbound.
The initiative of the AY+TC for an early right turn southbound after airborne was not in accord with the standard departure in the AIP which provides the safest corridor for takeoff and the ample time to stabilize aircraft parameters in case of a one engine inoperative emergency event for a successful re-land or controlled emergency landing.
Final Report:

Crash of a Beechcraft F90 King Air in Midland

Date & Time: Dec 2, 2011 at 0810 LT
Type of aircraft:
Registration:
N90QL
Flight Type:
Survivors:
Yes
Site:
Schedule:
Wharton - Midland
MSN:
LA-2
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4600
Captain / Total hours on type:
25.00
Aircraft flight hours:
8253
Circumstances:
The aircraft collided with terrain while on an instrument approach to the Midland Airpark (MDD), near Midland, Texas. The commercial pilot, who was the sole occupant, sustained serious injuries. The airplane was registered to and operated by Quality Lease Air Services LLC., under the provisions of 14 Code of Federal Regulations Part 91 as a positioning flight. Instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan had been filed for the cross-country flight. The flight originated from the Wharton Regional Airport (ARM), Wharton, Texas, about 0626. The pilot obtained a weather briefing for the flight to MDD. The briefing forecasted light freezing drizzle for the proposed time and route of flight. While on approach to MDD, the airplane was experiencing an accumulation of moderate to severe icing and the pilot stated that he had all the deicing equipment on. According to the pilot, the autopilot was flying the airplane to a navigational fix called JIBEM. He switched the autopilot to heading mode and flew to the final approach fix called WAVOK. He deployed the deice boots twice before approaching WAVOK. An Airport Traffic Control Tower (ATCT) controller informed the pilot, that according to radar, he appeared to be flying to JIBEM. The pilot responded that he was correcting back and there was something wrong with the GPS. The controller canceled the airplane's approach clearance and the controller issued the pilot a turning and climbing clearance to fly for another approach. The pilot stated that his copilot's window iced up at that point. The pilot was vectored for and was cleared for another approach attempt. The pilot said that his window was "halfway iced up." About two minutes after being cleared for the second approach, the controller advised the pilot that the airplane appeared to be "about a half mile south of the course." The pilot responded, "Yep ya uh I got it." The pilot was given heading and climb instructions in case of a missed approach and was subsequently cleared to change to an advisory frequency. The pilot responded with, "Good day." The pilot had configured the aircraft with approach flaps and extended the landing gear prior to reaching the final approach fix. The pilot stated the aircraft remained in this configuration and he did not retract the gear and flaps. The pilot stated that he descended to 3,300 feet and was just under the cloud deck where he was looking for the runway. The pilot's accident report, in part, said: Everything was flying smooth until I accelerated throttles from about halfway to about three quarters. At this point I lost roll control and the airplane rolled approximately 90 degrees to the left. I disengaged autopilot and began to turn the yoke to the right and holding steady. It was slow to respond and when I thought that I had it leveled off the airplane continued to roll approximately 90 degrees to the right. At this time I was turning the yoke back to the left and pulling back to level it off, but it continued to roll to the left again. I was turning the yoke to the right again as I continued to pull back and the airplane rolled level, and the stall warning horn came on seconds before impact on the ground. The pilot stated he maintained a target airspeed speed of 120 knots on approach and 100 knots while on final approach. He stated he was close to 80 knots when the aircraft was in the 90° right bank. Witnesses in the area observed the airplane flying. A witness stated that the airplane's wings were "rocking." Other witnesses indicated that the airplane banked to the left and then nosed down. The airplane impacted a residential house, approximately 1 mile from the approach end of runway 25, and a post crash fire ensued. The pilot was able to exit the airplane and there were no reported ground injuries.
Probable cause:
The pilot's failure to maintain the recommended airspeed for icing conditions and his subsequent loss of airplane control while flying the airplane under autopilot control in severe
icing conditions, contrary to the airplane's handbook. Contributing to the accident was the pilot's failure to divert from an area of severe icing. Also contributing to the accident was the lack of an advisory for potential hazardous icing conditions over the destination area.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601P) in Tijuana: 3 killed

Date & Time: Oct 31, 2011 at 1110 LT
Registration:
N76VK
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Tijuana – Loreto
MSN:
61-0305-079
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
Shortly after takeoff from runway 09 at Tijuana-General Abelardo L. Rodríguez Airport, while in initial climb, the twin engine aircraft entered an uncontrolled descent and crashed onto a garage, bursting into flames. Both occupants as well as one people in his car were killed.

Crash of a Socata TBM-700 in Hollywood

Date & Time: Oct 12, 2011 at 1334 LT
Type of aircraft:
Operator:
Registration:
N37SV
Flight Type:
Survivors:
Yes
Site:
Schedule:
North Perry - North Perry
MSN:
441
YOM:
2008
Flight number:
SC332
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11071
Captain / Total hours on type:
4053.00
Copilot / Total flying hours:
2500
Copilot / Total hours on type:
5
Aircraft flight hours:
593
Circumstances:
The airplane, registered to SV Leasing Company of Florida, operated by SOCATA North America, Inc., sustained substantial damage during a forced landing on a highway near Hollywood, Florida, following total loss of engine power. Visual meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 maintenance test flight from North Perry Airport (HWO), Hollywood, Florida. The airline transport pilot and pilot-rated other crew member sustained minor injuries; there were no ground injuries. The flight originated from HWO about 1216. The purpose of the flight was a maintenance test flight following a 600 hour and annual inspection. According to the right front seat occupant, in anticipation of the flight, he checked the fuel load by applying electrical power and noted the G1000 indicated the left fuel tank had approximately 36 gallons while the right fuel tank had approximately 108 gallons. In an effort to balance the fuel load with the indication of the right fuel tank, he added 72.4 gallons of fuel to the left fuel tank. At the start of the data recorded by the G1000 for the accident flight, the recorded capacity in the left fuel tank was approximately 105 gallons while the amount in the right fuel tank was approximately 108 gallons. The PIC reported that because of the fuel load on-board, he could not see the level of fuel in the tanks; therefore, he did not visually check the fuel tanks. By cockpit indication, the left tank had approximately 105 gallons and the right tank had approximately 108 gallons. The flight departed HWO, but he could not recall the fuel selector position beneath the thrust lever quadrant. He further stated that the fuel selector switch on the overhead panel was in the "auto" position. After takeoff, the flight climbed to flight level (FL) 280, and levelled off at that altitude about 20 minutes after takeoff. While at that altitude they received a "Fuel Low R" amber warning CAS message on the G1000. He checked the right fuel gauge which indicated 98 gallons, and confirmed that the fuel selector automatically switched to the left tank. After about 10 seconds the amber warning CAS message went out. He attributed the annunciation to be associated with a failure or malfunction of the sensor, and told the mechanic to write this issue down so it could be replaced after the flight. The flight continued and they received an amber warning CAS message, "Fuel Unbalance" which the right fuel tank had more fuel so he switched the fuel selector to supply fuel from the right tank to the engine. The G1000 indicates they remained at that altitude for approximately 8 minutes. He then initiated a quick descent to 10,000 feet mean sea level (msl) and during the descent accelerated to Vmo to test the aural warning horn. They descended to and maintained 10,000 feet msl for about 15 minutes and at an unknown time, they received an amber warning CAS message "Fuel Low R." Once again he checked the right fuel gauge which indicated it had 92 gallons and confirmed that the fuel tank selector automatically switched to the left tank. After about 10 seconds the CAS message went out. Either just before or during descent to 4,000 feet, they received an amber CAS message "Fuel Unbalance." Because the right fuel gauge indicated the fullest tank was the right tank, he switched the fuel selector to supply fuel to the engine from the right tank. The flight proceeded to the Opa-Locka Executive Airport, where he executed an ILS approach which terminated with a low approach. The pilot cancelled the IFR clearance and proceeded VFR towards HWO. While in contact with the HWO air traffic control tower, the flight was cleared to join the left downwind for runway 27L. Upon entering the downwind leg they received another amber CAS message "Fuel Unbalance" and at this time the left fuel gauge indicated 55 gallons while the right fuel gauge indicated 74 gallons. Because he intended on landing within a few minutes, he put the fuel selector to the manual position and switched to the fullest (right) tank. Established on final approach to runway 27L at HWO with the gear down, flaps set to landing, and minimum speed requested by air traffic for separation (85 knots indicated airspeed). When the flight was at 800 feet, the red warning CAS message "Fuel Press" illuminated and the right seat occupant with his permission moved the auxiliary fuel boost pump switch from "Auto" to "On" while he, PIC manually moved the fuel selector to the left tank. In an effort to restore engine power he pushed the power lever and used the manual over-ride but with no change. Assured that the engine had quit, he put the condition lever to cutoff, the starter switch on, and then the condition lever to "Hi-Idle" attempting to perform an airstart. At 1332:42, a flight crew member of the airplane advised the HWO ATCT, "…just lost the engine"; however, the controller did not reply. The PIC stated that he looked to his left and noticed a clear area on part of the turnpike, so he banked left, and in anticipation of the forced landing, placed the power lever to idle, the condition lever to cutoff, the fuel tank selector to off, and put the electrical gang bar down to secure the airplane's electrical system. He elected to retract the landing gear in an effort to shorten the landing distance. The right front seat occupant reported that the airplane was landed in a southerly direction in the northbound lanes of the Florida Turnpike. There were no ground injuries.
Probable cause:
The pilot’s failure to terminate the flight after observing multiple conflicting errors associated with the inaccurate right fuel quantity indication. Contributing to the accident were the total loss of engine power due to fuel starvation from the right tank, the inadequate manufacturing of the right fuel gauge electrical harness, and failure of maintenance personnel to recognize and evaluate the reason for the changing fuel level in the right fuel tank.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Yellowknife: 2 killed

Date & Time: Sep 22, 2011 at 1318 LT
Operator:
Registration:
C-GARW
Survivors:
Yes
Site:
Schedule:
Thor Lake - Yellowknife
MSN:
367
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5817
Captain / Total hours on type:
1037.00
Copilot / Total flying hours:
570
Copilot / Total hours on type:
323
Aircraft flight hours:
33355
Circumstances:
The float-equipped de Havilland DHC-6-300 Twin Otter (registration C-GARW, serial number 367) was landing at the float-plane base (CEN9) located in Yellowknife, Northwest Territories, along the western shore of Great Slave Lake, beside the area known as Old Town. There were 2 crew members and 7 passengers on board, and the first officer was the pilot flying. On touchdown, the aircraft bounced, porpoised and landed hard on the right float. The flight crew initiated a go-around; the aircraft lifted off at low speed in a nose-high, right-wing-low attitude, and it continued in a right turn towards the shore. As the turn continued, the aircraft’s right wing contacted power lines and cables before the float bottoms impacted the side of an office building. The aircraft then dropped to the ground on its nose and cart-wheeled into an adjacent parking lot. Both crew members were fatally injured, 4 passengers were seriously injured, and 3 passengers sustained minor injuries. The aircraft was substantially damaged. The 406-megahertz emergency locator transmitter activated. There was no fire. The accident occurred at 1318 Mountain Daylight Time.
Probable cause:
Findings as to Causes and Contributing Factors:
1. Airspeed fluctuations at touchdown, coupled with gusty wind conditions, caused a bounced landing.
2. Improper go-around techniques during the recovery from the bounced landing resulted in a loss of control.
3. It is possible that confused crew coordination during the attempted go-around contributed to the loss of control.
Final Report:

Crash of a Pilatus PC-12/45 in Faridabad: 10 killed

Date & Time: May 25, 2011 at 2243 LT
Type of aircraft:
Operator:
Registration:
VT-ACF
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Patna - New Delhi
MSN:
632
YOM:
2005
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
1521
Captain / Total hours on type:
1300.00
Copilot / Total flying hours:
300
Copilot / Total hours on type:
70
Aircraft flight hours:
1483
Circumstances:
M/s Air Charter Services Pvt Ltd. offered their aircraft VT-ACF for operating medical evacuation flight to pick one critically ill patient from Patna on 25/05/2011. The Aircraft took off from Delhi to Patna with two crew members, two doctors and one male nurse. The Flight to Patna was uneventful. The Air Ambulance along with patient and one attendant took off from Patna at 20:31:58 IST, the aircraft during arrival to land at Delhi crashed near Faridabad on a Radial of 145 degree and distance of 15.2 nm at 22:42:32 IST. Aircraft reached Patna at 18:31 IST. Flight Plan for the flight from Patna to Delhi was filed with the ATC at Patna via W45-LLK-R594 at FL260, planned ETD being 22:00 hours IST and EET of 2hours for a planned ETA at VIDP being 24:00 hours IST. The crew took self-briefing of the weather and same “Self Briefing” was recorded on the flight plan submitted at ATC Patna. The passenger manifest submitted at Patna indicated a total of 2 crew and 5 passengers inclusive of the patient. Weather at Patna at the time of departure was 3000m visibility with Haze. Total fuel on board for departure at Delhi was 1516 lts. The preflight/transit inspection of the aircraft at Patna was carried out by the crew as per laid down guidelines. The crew requested for startup at 20:21 IST from Patna ATC and reported airborne at 20:33:43 IST. The aircraft climbed and maintained FL 260 for cruise. On handover from Varanasi Area Control (Radar), the aircraft came in contact with Delhi Area Control (East) Radar at 21:53:40 IST at 120.9 MHz. At 21:53:40 IST aircraft was identified on Radar by squawking code 3313. At 22:02:05 IST the crew requested for left deviation of 10° due to weather, the same was approved by the RSR controller. At 22:05:04 IST the crew informed that they have a critical patient on board and requested for priority landing and ambulance on arrival. The same was approved by the RSR controller. The aircraft was handed over to Approach Control on 126.35 MHz at 22:28:03 IST. At 22:28:18 IST VT-ACF contacted TAR (Terminal Approach Radar) on 126.35 MHz and it was maintaining FL160. At 22:32:22 IST, VT-ACF was asked to continue heading to DPN (VOR) and was cleared to descend to FL110. At 22:36:34 IST, the TAR controller informed VT-ACF about weather on HDG 330°, the crew replied in “Affirmative” and requested for left heading. At 22:38:12 IST, TAR controller gave aircraft left heading 285° which was copied by the aircraft. The aircraft started turning left, passing heading 289, it climbed from FL125 to FL141. At 22:40:32 IST the TAR controller gave 3 calls to VT-ACF. At 22:40:43 IST aircraft transmitted a feeble call “Into bad weather”, at that instance the aircraft had climbed FL 146.Thereafter the aircraft was seen turning right in a very tight turn at a low radar ground speed and loosing height rapidly from FL146 to FL 016. Again at 22:41:32 IST TAR controller gave call to VT-ACF, aircraft transmitted a feeble call “Into bad weather. Thereafter the controller gave repeated calls on both 126.35 MHz and also 121.5 MHz, before the blip on radar became static on a radial of 145 degree at 15.2 nm from DPN VOR at 22:42:32 IST. All attempts to raise contact with the aircraft failed. The TAR controller then informed the duty WSO and also the ATC Tower. At 22:50:00 IST, the tower informed the WSO that they have got a call from the City Fire Brigade confirming that an aircraft has crashed near Faridabad in a congested residential area known as Parvatia Colony. After the accident, local residents of the area and police tried to put off the fire and extricate the bodies from the wreckage of the aircraft.
Probable cause:
The probable cause of the accident could be attributed to departure of the aircraft from controlled flight due to an external weather related phenomenon, mishandling of controls, spatial disorientation or a combination of the three.
Final Report:

Crash of a Beechcraft E18S in Miami: 1 killed

Date & Time: May 2, 2011 at 0809 LT
Type of aircraft:
Registration:
N18R
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Miami - Marsh Harbour
MSN:
BA-312
YOM:
1957
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6400
Aircraft flight hours:
13221
Circumstances:
After taking off from runway 9L at his home airport and making an easterly departure, the pilot, who was also the president, director of operations, and chief pilot for the on-demand passenger and cargo operation, advised the air traffic controller that he was turning downwind. According to witnesses, the airplane did not sound like it was developing full power. The airplane climbed to about 100 feet, banked to the left, began losing altitude, and impacted a tree, a fence, and two vehicles before coming to rest in a residential area. A postcrash fire ensued, which consumed the majority of the cabin area and left wing. Examination of the accident site revealed that the airplane had struck the tree with its left inboard wing about 20 feet above ground level. Multiple tree branches exhibiting propeller cuts were found near the base of the tree. Propeller strike marks on the ground also corresponded to the location of the No. 1 (left side) propeller. There were minimal propeller marks from the No. 2 (right side) propeller. Examination of the propellers revealed that the No. 1 propeller blades exhibited chordwise scratching and S-bending, consistent with operation at impact, but the No. 2 propeller blades did not exhibit any chordwise scratching or bending, which indicates that the No. 2 engine was not producing power at the time of impact. There was no evidence that the pilot attempted to perform the manufacturer’s published single engine procedure, which would have allowed him to maintain altitude. Contrary to the procedure, the left and right throttle control levers were in the full-throttle position, the mixture control levers were in the full-rich position, neither propeller was feathered, and the landing gear was down. Postaccident examination of the No. 1 engine revealed no evidence of any preimpact malfunction or failure. However, the No. 2 engine's condition would have resulted in erratic and unreliable operation; the engine would not have been able to produce full rated horsepower as the compression on four of the nine cylinders was below specification and both magnetos were not functioning correctly. Moisture and corrosion were discovered inside the magneto cases; the left magneto sparked internally in a random pattern when tested and its point gap was in excess of the required tolerance. The right magneto's camshaft follower also exhibited excessive wear and its points would not open, rendering it incapable of providing electrical energy to its spark plugs. Additionally, the main fuel pump could not be rotated by hand; it exhibited play in the gear bearings, and corrosion was present internally. When the airplane was not flying, it was kept outdoors. Large amounts of rain had fallen during the week before the accident, which could have led to the moisture and corrosion in the magnetos. Although the pilot had been having problems with the No. 2 engine for months, he continued to fly the airplane, despite his responsibility, particularly as president, director of operations, and chief pilot of the company, to ensure that the airplane was airworthy. During this period, the pilot would take off with the engine shuddering and would circle the departure airport to gain altitude before heading to the destination. On the night before the accident, the director of maintenance (DOM) replaced the No. 1 cylinder on the No. 2 engine, which had developed a crack in the fin area and had oil seeping out of it. After the DOM performed the replacement, he did not do a compression check or check the magnetos; such checks would have likely revealed that four of the remaining cylinders were not producing specified compression, that the magnetos were not functioning correctly, and that further maintenance was necessary. Review of the airplane's maintenance records did not reveal an entry for installation of the cylinder. The last entry in the maintenance records for the airplane was an annual and a 100-hour inspection, which had occurred about 11 months before the accident.
Probable cause:
The pilot’s improper response to a loss of power in the No. 2 engine and his failure to ensure that the airplane was airworthy. Contributing to the accident was the inadequate engine maintenance by the operator's maintenance personnel.
Final Report: