Crash of a Piper PA-31 Cheyenne in Bankstown: 2 killed

Date & Time: Jun 15, 2010 at 0805 LT
Type of aircraft:
Operator:
Registration:
VH-PGW
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Bankstown - Brisbane - Albury
MSN:
31-8414036
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2435
Captain / Total hours on type:
779.00
Aircraft flight hours:
6266
Circumstances:
The twin engine aircraft, with a pilot and a flight nurse on board, was being operated by Skymaster Air Services under the instrument flight rules (IFR) on a flight from Bankstown Airport, New South Wales (NSW) to Archerfield Airport, Queensland. The aircraft was being positioned to Archerfield for a medical patient transfer flight from Archerfield to Albury, NSW. The aircraft departed Bankstown at 0740 Eastern Standard Time. At 0752, the pilot reported to air traffic control (ATC) that he was turning the aircraft around as he was having ‘a few problems. At about 0806, the aircraft collided with a powerline support pole located on the eastern side of the intersection of Sackville Street and Canley Vale Road, Canley Vale, NSW. The pilot and flight nurse sustained fatal injuries and the aircraft was destroyed by impact damage and a post-impact fire.
Probable cause:
Contributing safety factors:
• While the aircraft was climbing to 9,000 feet the right engine sustained a power problem and the pilot subsequently shut down that engine.
• Following the shutdown of the right engine, the aircraft's descent profile was not optimized for one engine inoperative flight.
• The pilot conducted a descent towards Bankstown Airport that was consistent with a normal arrival profile without first verifying that the aircraft was capable of achieving adequate performance with one engine inoperative.
• Following the engine problem, the aircraft's flightpath and the pilot’s communication with air traffic control indicated that the pilot's situation awareness was less than optimal.
• The aircraft collided with a powerline support pole on the eastern side of the intersection of Sackville Street and Canley Vale Road, Canley Vale, about 6 km north-west of Bankstown Airport.
Other safety factors:
• The pilot did not broadcast a PAN following the engine shutdown and did not provide air traffic control with further information about the nature of the problem in order for the controller to positively establish the severity of the situation.
• Section 4 of Civil Aviation Advisory Publication (CAAP) 5.23-2(0), Multi-engine Aeroplane Operations and Training of July 2007 did not contain sufficient guidance material to support the flight standard in Appendix A subsection 1.2 of the CAAP relating to Engine Failure in the Cruise. [Minor safety issue]
Other key finding:
• Given the pilot’s extensive experience and testing in the PA-31 aircraft type, and subsequent endorsement training on a high performance turboprop multi-engine aircraft since the issue by CASA in 2008 of a safety alert in respect of the pilot’s PA-31 endorsement, it was unlikely that any deficiencies in that endorsement training contributed to the accident.
Final Report:

Crash of a Piper PA-31-325 Navajo C/R (Panther) in Guatemala City: 4 killed

Date & Time: May 26, 2010 at 0855 LT
Type of aircraft:
Registration:
TG-LAP
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Guatemala City - San Salvador
MSN:
31-8012043
YOM:
1980
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The twin engine aircraft departed Guatemala City-La Aurora Airport at 0840LT on a flight to San Salvador-Ilopango Airport, carrying two passengers and one pilot. About 4-5 minutes after takeoff, while climbing in IMC conditions, the pilot reported technical problems with the instruments and was cleared for an immediate return. Shortly later, the aircraft entered an uncontrolled descent and crashed in a meat packing plant located in the approach path. The aircraft was destroyed by impact forces as well as the building. All three occupants as well as one people in the factory were killed.
Probable cause:
Loss of control following the failure of the attitude indicator while climbing in IMC conditions.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Clearwater

Date & Time: May 16, 2010 at 1013 LT
Operator:
Registration:
XB-LTH
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Clearwater – Port-au-Prince
MSN:
46-36428
YOM:
2007
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2662
Captain / Total hours on type:
23.00
Aircraft flight hours:
207
Circumstances:
The airplane was loaded more than 500 pounds (about 12 percent) over the certificated maximum gross weight. The airplane lifted off from the 3,500-foot-long runway about one-half to two-thirds down the length of the runway. The pilot retracted the airplane's landing gear and flaps before reaching the airplane manufacturer's recommended retraction speeds. The airplane was unable to gain sufficient altitude and subsequently impacted trees and a house located beyond the departure end of the runway. A postaccident examination of the wreckage and recorded non-volatile memory revealed no evidence of any preimpact mechanical abnormalities.
Probable cause:
The overweight condition of the airplane due to the pilot's inadequate preflight planning, resulting in the airplane's degraded climb performance. Contributing to the accident was the pilot's retraction of the flaps prior to reaching the manufacturer's recommended flap retraction speed.
Final Report:

Crash of a Cessna T303 Crusader in Louisa: 1 killed

Date & Time: Mar 4, 2010 at 1245 LT
Type of aircraft:
Registration:
N9305T
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Manassas - Louisa - Danville
MSN:
303-00001
YOM:
1981
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2255
Aircraft flight hours:
1374
Circumstances:
During takeoff, one witness noted that at least one engine seemed to be running rough and not making power. Several other witnesses, located about 1/2 mile northwest of the airport, observed the accident airplane pass overhead in a right turn. They reported that the engine noise did not sound normal. Two of the witnesses noted grayish black smoke emanating from the airplane. The airplane then rolled left and descended nose down into the front yard of a residence. Review of maintenance records revealed the airplane underwent an annual inspection and extensive maintenance about 3 months prior to the accident. One of the maintenance issues was to troubleshoot the right engine that was reportedly running rough at cruise. During the maintenance, the right engine fuel pump, metering valve, and fuel manifold were removed and replaced with overhauled units. Additionally, the right engine fuel flow was reset contrary to procedures contained in an engine manufacturer service information directive; however, the fuel pump could not be tested due to thermal damage and the investigation could not determine if the fuel flow setting procedure contributed to the loss of power on the right engine. On-scene examination of the wreckage and teardown examination of both engines did not reveal any preimpact mechanical malfunctions. Teardown examination of the right propeller revealed that the blades were not at or near the feather position, which was contrary to the emergency procedure published by the manufacturer, to secure the engine and feather the propeller in the event of an engine power loss. The right propeller exhibited signatures consistent with low or no power at impact, while the left propeller exhibited signatures consistent of being operated with power at impact.
Probable cause:
The pilot's failure to maintain aircraft control and secure the right engine during a loss of engine power after takeoff. Contributing to the accident was the loss of engine power on the right engine for undetermined reasons.
Final Report:

Crash of a GAF Nomad N.22B in Cotabato City: 9 killed

Date & Time: Jan 28, 2010 at 1138 LT
Type of aircraft:
Operator:
Registration:
18
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Cotabato City - Zamboanga
MSN:
18
YOM:
1975
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
Shortly after takeoff from Cotabato City Airport, while in initial climb, the twin engine aircraft lost height and crashed in a residential area near the airport. The aircraft was destroyed and all 8 occupants were killed as well as one person on ground. It it believed that one of the engine failed shortly after rotation.

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Aurora: 2 killed

Date & Time: Jan 23, 2010 at 1852 LT
Registration:
N222AQ
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Aurora – Broomfield
MSN:
61-0164-004
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
555
Circumstances:
The visibility at the time of the accident was 1/2 mile with fog and the vertical visibility was 100 feet. A witness stated that the pilot checked the weather, but that he appeared to be in a hurry and took off without performing a preflight inspection of the aircraft. After takeoff, air traffic control instructed the pilot to turn left to a heading of 270 degrees. The pilot reported to the controller that he was at 1,300 feet climbing to 3,000 feet and the controller cleared the pilot to climb to 4,000 feet; the pilot acknowledged the clearance. Witnesses on the ground noted that the airplane was loud; one witness located about 1.5 miles from the departure airport reported that the airplane flew overhead at treetop height. The airplane impacted trees and a residence about 2.3 miles north-northeast of the departure airport. The airplane's turning ground track and the challenging visibility conditions were conducive to the onset of pilot spatial disorientation. Post accident inspection failed to reveal any mechanical failure that would have resulted in the accident. The pilot purchased the airplane about three months prior to the accident; at that time he reported having 72.6 hours of instrument flight experience and 25 hours of multi-engine experience, with none in the accident airplane make and model. After purchasing the airplane, the pilot received 52 hours of flight instruction in the accident airplane in 7 days. Logbook records were not located to establish subsequent flight experience.
Probable cause:
The pilot's spatial disorientation and subsequent failure to maintain airplane control.
Final Report:

Crash of a Fletcher FU-24-950 in Ketapang: 2 killed

Date & Time: Dec 31, 2009 at 0826 LT
Type of aircraft:
Operator:
Registration:
PK-PNX
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Ujung Tanjung - Jambi - Pangkal Pinang - Ketapang - Tangar
MSN:
187
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2892
Captain / Total hours on type:
641.00
Circumstances:
The aircraft was completing a ferry flight from Ujung Tanjung/Pekanbaru home base to Tangar airstrip, Center of Kalimantan, with reference flight approval number D09-038960 and Security Clearance number AU05-033328, person on board was one pilot and one engineer. On 29 December 2009, the aircraft departed from Ujung Tanjung, transit at Jambi and stop overnight at Pangkal Pinang Airport, Bangka with total flight time was 3 hours. On the next day 30 December 2009, the aircraft continuing flight from Pangkal Pinang to Rahadi Oesman Airport, Ketapang, West Kalimantan and overnight at Ketapang with total flight time is 1:40 hours. On the next day 31 December 2009, the aircraft plan to continued flight to Tangar Airstrip. The aircraft was airworthy prior departure and dispatched from Ketapang with the following sequence:
a. The pilot requested for start the engine at 01:17 UTC4 (08:17 Local Time);
b. At 01:24 the pilot requested for taxi, and the ATC gave clearance via taxiway “A”. The pilot requested intersection runway 17 and approved by ATC
c. The ATC requested for reported when ready for departure, and the pilot reported ready for departure, then the ATC gave the departure clearance.
d. At 01:25, the aircraft was departed and crashed at 01:26 striking the roof of the hospital and broken down into pieces at the parking area in which have had approximate 1.5 Kilometer to the left side from the flight path centreline. The aircraft was substantially damage and the crew on board consist of one pilot in command and one aircraft maintenance engineer; both of them were fatally injured.
Probable cause:
The investigation concluded that the aircraft engine was not in power during impact with the hospital roof. There was a corroded fuel pump, that indicated of contaminated fuel.
Findings:
• The aircraft was airworthy prior departure.
• The pilot was fit for flight.
• The booster pump was found of an evident of surface corrosion on the spring, plate and van pump indicated that contaminated fuel.
• Referred to the Fletcher Flight Manual and Pilot Operating Handbook chapter 3.10. Fuel System Failure, the booster pump must have been operated prior to flight.
• The propeller blades were on fine pitch and no sign of rotating impact. The engine was not in powered when hit the ground.
• No evidence damage related to the engine prior to the occurrence.
Final Report:

Crash of a Douglas DC-3C in Manila: 4 killed

Date & Time: Oct 17, 2009 at 1214 LT
Type of aircraft:
Registration:
RP-C550
Flight Type:
Survivors:
No
Site:
Schedule:
Manila - Puerto Princesa
MSN:
14292/25737
YOM:
1944
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
On October 17, 2009at about 12:04 pm, RP-C550 a DC-3type of aircraft took off from Manila Domestic airport bound for Puerto Princesa, Palawan. Approximately 5 mins after airborne, the Pilot-in-Command (PIC) informed Manila Tower that they were turning back due to technical problem. The PIC was asked by the air controller whether he was declaring an “emergency” and the response was negative. The PIC was directed to proceed South Mall and wait for further instruction (a standard procedures for VFR arrivals for runway 13). At South Mall, RP-C550 was cleared to cross the end of runway 06, still without declaring an emergency. The tower controller sensed that something was wrong with the aircraft due to its very low altitude, immediately granted clearance to land runway 06. However, the aircraft was not able to make it to runway 06. At about 12:14, RP-C550 crashed at an abandoned warehouse in Villa Fidela Subd., Brgy. Elias Aldana Las Piñas City about 4 kms. from the threshold of runway 06. As a result, the aircraft was totally destroyed and all aboard suffered fatal injuries due to impact and post crash fire.
Probable cause:
The Aircraft Accident Investigation and Inquiry Board determine that the probable causes of this accident were the following:
- Non-procedural application of power during take-off and initial climb that led to left engine malfunction.
- The questionable qualifications of the flight crew.
- Low level of competence of the pilots.
- Not feathering the left engine.
- Turning towards the bad engine.
- Not declaring an emergency.
Final Report:

Crash of a Beechcraft 99 Airliner in Évora: 2 killed

Date & Time: Aug 14, 2009 at 1908 LT
Type of aircraft:
Operator:
Registration:
F-BTME
Survivors:
No
Site:
Schedule:
Évora - Évora
MSN:
U-79
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
22993
Aircraft flight cycles:
17449
Circumstances:
The aircraft, a Beechcraft model BE-99, s/n U79, with French registration F-BTME, belonging to the operator “Avioarte Serviços Aéreos, Lda”, was involved all that day, 14th of August, 2009, flying locally, carrying parachutists for skydiving exercises, in the vicinity of Évora aerodrome (LPEV), working for the enterprise “Skydive”. With twelve full equipped parachutists and one pilot on board, the aircraft took-off on runway 01 at 18:47, intending to climb to an altitude of 13000ft (4000m), at which altitude the jumping would take place. When passing about 9500ft (2900m), left engine (#1) flame-out and respective propeller was automatically feathered. The pilot stop climb at around 10500ft (3200m), informed the parachutists that one engine had stopped and they should jump a little lower than it was expected, while he would proceed for landing at same aerodrome, with one engine inoperative. All parachutists left the aircraft, on sequence, but one, who, after being next to the exit, returned to the cockpit and remained on board, with the pilot. The aircraft started a dive, turning around the field, and the pilot contacted the tower on left base leg for runway 01, but said nothing about the inoperative engine or any assistance required. He was told to report on final, which he never did. He continued the approach for runway 01, with landing gear down and flaps at initial setting (13º), but keeping high speed. The aircraft made a low pass, over all runway length, without the wheels touching the ground. Once passing runway end it continued flying, the pilot increased power on right engine (#2) and the aircraft started deviating to the left, with wings levelled and without showing significant climb tendency. Observers, at the aerodrome, lost the sight of the aircraft for some moments and saw it reappearing close to Almeirim residential quarter (in the outskirts of Évora). One testimony, sited at the aerodrome, referred seeing the aircraft executing a sudden manoeuvre, like a left roll, pointing the wheels up to the sky. Moments later a collision sound was heard, the engine became silent and some flames and a black smoke cloud appeared. The aircraft collided with a residential building, in Maria Auxiliadora street, Almeirim residential quarter, sited about 1160m far from runway end, on track 330º. After the collision with the building, the aircraft fell to the ground, upside-down, a fire sparked immediately and the plane was engulfed by flames. Fire brigades from Évora, Viana do Alentejo, Montemor-o-Novo and Arraiolos arrived at the scene, promptly, but it took some time for the fire to be extinguished (after burning all aircraft fuel) and the burned bodies recovered from the wreckage.
Probable cause:
Primary Cause:
Primary cause for this accident was pilot inability, as he was not qualified to fly this class of aircraft, to carry a single engine landing or maintain directional control during go-around with one engine inoperative.
Contributory Factors:
The following were considered as Contributory factors:
- The pilot was not qualified to operate multi-engine aircrafts and had no knowledge and training to fly this kind of aircraft;
- Unsuitable fuel monitoring and omission on manufacturer recommended procedures accomplishment;
- Inadequate flying technique, without consideration to the airplane special flying characteristics;
- Inadequate supervision, by the competent authorities, on flying activities carried by pilots and aircrafts with foreign licenses and registrations, inside Portuguese territory.
Final Report:

Crash of a Partenavia P.68 Observer II in Sant Pere de Vilamajor: 2 killed

Date & Time: Jun 23, 2009 at 1045 LT
Type of aircraft:
Operator:
Registration:
EC-IPG
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Sabadell - Sabadell
MSN:
421-21-OB2
YOM:
2003
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5686
Captain / Total hours on type:
155.00
Copilot / Total flying hours:
6689
Copilot / Total hours on type:
9
Circumstances:
The airplane, a Vulcan Air PA68 Observer 2, registration EC-IPG, had taken off from Sabadell airport to conduct a local flight. Onboard were the instructor and a pilot who was being tested for a CRI (SPA) (Class Rating Instructor). As they were flying over the town of Sant Pere de Vilamajor (Barcelona), the aircraft plunged to the ground, falling within the property limit of a private dwelling (a chalet). Several eyewitnesses reported that they stopped hearing the engine noise and that they then saw the airplane spinning in a nose down attitude. The front part of the airplane (cockpit) impacted the ground first. The crash resulted in a fire, the flames from which reached a part of the aircraft and an arbor next to the house, but not the house itself, though it was affected by the smoke. The two occupants perished immediately and were trapped inside the airplane. They were extracted by emergency personnel. The aircraft was destroyed by the impact and subsequent fire. The post-accident inspection did not reveal any signs of a fault or malfunction of any aircraft component. It has been determined that the accident resulted from a stall caused by flying the aircraft at a low speed. It has also been concluded that there were three contributing factors: the low altitude, the very likely possibility that the crew did not establish guidelines for action prior to the flight and the absence of an authority gradient between the crew members.
Probable cause:
The accident was caused when the aircraft stalled during the performance of a slow flying maneuver with the right engine stopped. Factors that contributed to the accident were the low altitude, the possibility that the crew did not define the responsibilities of each prior to the flight and which may have resulted in a lack of coordination when faced with the circumstances in the final moments of the flight, and the lack of an authority gradient between the crew members.
Final Report: