Crash of a Cessna T303 Crusader off Jersey: 2 killed

Date & Time: Sep 4, 2013 at 1013 LT
Type of aircraft:
Operator:
Registration:
N289CW
Flight Type:
Survivors:
No
Schedule:
Dinan - Jersey
MSN:
303-00032
YOM:
1981
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
524
Captain / Total hours on type:
319.00
Circumstances:
The aircraft was on a VFR flight from Dinan, France, to Jersey, Channel Islands and had joined the circuit on right base for Runway 09 at Jersey Airport. The aircraft turned onto the runway heading and was slightly left of the runway centreline. It commenced a descent and a left turn, with the descent continuing to 100 ft. The pilot made a short radio transmission during the turn and then the aircraft’s altitude increased rapidly to 600 ft before it descended and disappeared from the radar. The aircraft probably stalled in the final pull-up manoeuvre, leading to loss of control and impact with the sea, fatally injuring those on board, Carl Whiteley and his wife.
Probable cause:
The accident was probably as a result of the pilot’s attempt to recover to normal flight following a stall or significant loss of airspeed at a low height, after a rapid climb manoeuvre having become disoriented during the approach in fog.
Final Report:

Crash of a Piper PA-46R-350T Matrix off Cat Cay

Date & Time: Aug 25, 2013 at 1406 LT
Registration:
N720JF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cat Cay - Kendall-Miami
MSN:
46-92004
YOM:
2008
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12250
Captain / Total hours on type:
210.00
Aircraft flight hours:
1000
Circumstances:
According to the pilot, he applied full power, set the flaps at 10 degrees, released the brakes, and, after reaching 80 knots, he rotated the airplane. The pilot further reported that the engine subsequently lost total power when the airplane was about 150 ft above ground level. The airplane then impacted water in a nose-down, right-wing-low attitude about 300 ft from the end of the runway. The pilot reported that he thought that the runway was 1,900 ft long; however, it was only 1,300 ft long. Review of the takeoff ground roll distance charts contained in the Pilot’s Operating Handbook (POH) revealed that, with flap settings of 0 and 20 degrees, the ground roll would have been 1,700 and 1,150 ft, respectively. Takeoff ground roll distances were not provided for use of 10 degrees of flaps; however, the POH stated that 10 degrees of flaps could be used. Although the distance was not specified, it is likely that the airplane would have required more than 1,300 ft for takeoff with 10 degrees of flaps. Examination of the engine revealed saltwater corrosion throughout it; however, this was likely due to the airplane’s submersion in water after the accident. No other mechanical malfunctions or abnormalities were noted. Examination of data extracted from the multifunction display (MFD) and primary flight display (PFD) revealed that the engine parameters were performing in the normal operating range until the end of the recordings. The data also indicated that, 7 seconds before the end of the recordings, the airplane pitched up from 0 to about 17 degrees and then rolled 17 degrees left wing down while continuing to pitch up to 20 degrees. The airplane then rolled 77 degrees right wing down and pitched down about 50 degrees. The highest airspeed recorded by the MFD and PFD was about 70 knots, which occurred about 1 second before the end of the recordings. The POH stated that, depending on the landing gear position, flap setting, and bank angle, the stall speed for the airplane would be between 65 and 71 knots. Based on the evidence, it is likely that the engine did not lose power as reported by the pilot. As the airplane approached the end of the runway and the pilot realized that it was not long enough for his planned takeoff, he attempted to lift off at an insufficient airspeed and at too high of a pitch angle, which resulted in an aerodynamic stall at a low altitude. If the pilot had known the actual runway length, he might have used a flap setting of 20 degrees, which would have provided sufficient distance for the takeoff.
Probable cause:
The pilot’s attempt to rotate the airplane before obtaining sufficient airspeed and his improper pitch control during takeoff, which resulted in the airplane exceeding its critical angle-of-attack and subsequently experiencing an aerodynamic stall at a low altitude. Contributing to the accident was the pilot’s lack of awareness of the length of the runway, which led to his attempting to take off with the airplane improperly configured.
Final Report:

Crash of a De Havilland DHC-3 Otter near Ivanhoe Lake: 1 killed

Date & Time: Aug 22, 2013 at 1908 LT
Type of aircraft:
Operator:
Registration:
C-FSGD
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Scott Lake Lodge - Ivanhoe Lake
MSN:
316
YOM:
1959
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1600
Captain / Total hours on type:
248.00
Circumstances:
The float-equipped Transwest Air Limited Partnership DHC-3 turbine Otter (registration C-FSGD, serial number 316) departed Scott Lake, Northwest Territories, at approximately 1850 Central Standard Time on a 33-nautical mile, day, visual flight rules flight to Ivanhoe Lake, Northwest Territories. The aircraft did not arrive at its destination, and was reported overdue at approximately 2100. The Joint Rescue Coordination Centre Trenton was notified by the company. There was no emergency locator transmitter signal. A search and rescue C-130 Hercules aircraft was dispatched; the aircraft wreckage was located on 23 August 2013, in an unnamed lake, 10 nautical miles north of the last reported position. The pilot, who was the sole occupant of the aircraft, sustained fatal injuries.
Probable cause:
Findings as to causes and contributing factors:
1. During approach to landing on the previous flight, the right-wing leading-edge and wing tip were damaged by impact with several trees.
2. The damage to the aircraft was not evaluated or inspected by qualified personnel prior to take-off.
3. Cumulative unmanaged stressors disrupted the pilot’s processing of safety-critical information, and likely contributed to an unsafe decision to depart with a damaged, uninspected aircraft.
4. The aircraft was operated in a damaged condition and departed controlled flight likely due to interference between parts of the failing wing tip, acting under air loads, and the right aileron.
Findings as to risk:
Not applicable.
Other findings:
1. The emergency locator transmitter did not activate, due to crash damage and submersion in water.
2. The aircraft was not fitted with FM radio equipment that is usually carried by aircraft servicing the lodge. Lodge personnel did not have a means to contact the pilot once the aircraft moved away from the dock.
Final Report:

Crash of a Beechcraft 200C Super King Air in Lake Manyara

Date & Time: Aug 22, 2013
Operator:
Registration:
5H-TZW
Flight Phase:
Survivors:
Yes
Schedule:
Bukoba - Zanzibar - Dar es-Salaam
MSN:
BL-17
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
En route to Zanzibar, while cruising at an altitude of 21,000 feet, the right engine failed. The pilot decided to divert to Arusha Airport when few minutes later, while passing 16,000 feet on descent, the left engine failed as well. The pilot attempted to ditch the aircraft into Lake Manyara. The aircraft belly landed and came to rest in shallow water, bent in two. All seven occupants were rescued by fishermen and the aircraft was damaged beyond repair.

Crash of a Canadair CL-415 in Moosehead Lake

Date & Time: Jul 3, 2013 at 1415 LT
Type of aircraft:
Operator:
Registration:
C-FIZU
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Wabush - Wabush
MSN:
2076
YOM:
2010
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12500
Captain / Total hours on type:
120.00
Copilot / Total flying hours:
1700
Copilot / Total hours on type:
138
Aircraft flight hours:
461
Circumstances:
On 03 July 2013, at about 1415 Atlantic Daylight Time, the Government of Newfoundland and Labrador Air Services Division Bombardier CL-415 amphibious aircraft (registration C-FIZU, serial number 2076), operating as Tanker 286, departed Wabush, Newfoundland and Labrador, to fight a nearby forest fire. Shortly after departure, Tanker 286 touched down on Moosehead Lake to scoop a load of water. About 40 seconds later, the captain initiated a left-hand turn and almost immediately lost control of the aircraft. The aircraft water-looped and came to rest upright but partially submerged. The flight crew exited the aircraft and remained on the top of the wing until rescued by boat. There was an insufficient forward impact force to activate the onboard 406-megahertz emergency locator transmitter. There were no injuries to the 2 crew members. The aircraft was destroyed. The accident occurred during daylight hours.
Probable cause:
Findings as to causes and contributing factors:
- It is likely that the PROBES AUTO/MANUAL switch was inadvertently moved from the AUTO to the MANUAL selection when the centre pedestal cover was removed.
- The PROBES AUTO/MANUAL switch position check was not included on the Newfoundland and Labrador Government Air Services CL-415 checklist.
- The flight crew was occupied with other flight activities during the scooping run and did not notice that the water quantity exceeded the predetermined limit until after the tanks had filled to capacity.
- The flight crew decided to continue the take-off with the aircraft in an overweight condition.
- The extended period with the probes deployed on the water resulted in a longer take-off run, and the pilot flying decided to alter the departure path to the left.
- The left float contacted the surface of the lake during initiation of the left turn. Aircraft control was lost and resulted in collision with the water.
Findings as to risk:
- If safety equipment is installed in a manner that hampers its access and removal, then there is an increased risk that occupants may not be able to retrieve the safety equipment in a timely manner to ensure their survival.
- If individuals are not trained on safety equipment installed on the aircraft, then there is an increased risk that the individuals may not be aware of how to effectively use the equipment.
- If a checklist does not include a critical item, and flight crews are expected to rely on their memory, then there is a risk that that item will be missed, which could jeopardize the safety of flight.
- If flight crews do not adhere to standard operating procedures, then there is a risk that errors and omissions can be introduced, which could jeopardize the safety of flight.
- If a person is not restrained during flight and the aircraft either makes an abrupt manoeuvre or loses control, then that person is at a much greater risk of injury or death.
- If an overweight take-off is carried out, there may be an adverse effect on the aircraft’s performance, which could jeopardize the safety of flight.
- If companies do not have procedures for recording overweight take-offs and flight crews do not report them, then the overall condition of the aircraft’s structures will not be accurately known, which could jeopardize the safety of flight.
- If organizations do not use formal and documented processes to manage operational risks, there is an increased risk that hazards will not be identified and mitigated.
- If organizations do not have measures in place to raise awareness of the potential impact of stress on performance or to promote the early recognition and mitigation of stress, then there is an increased risk that errors will occur when an individual is affected by stress that has become chronic.
Other findings:
- Utilizing the locking position of the PROBES AUTO/MANUAL switch for the MANUAL selection allows the switch to be inadvertently moved from the AUTO to the MANUAL position.
Final Report:

Crash of a Beechcraft D18S off Red Lake: 2 killed

Date & Time: May 30, 2013 at 1727 LT
Type of aircraft:
Registration:
C-FWWV
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Red Lake - Red Lake
MSN:
A-618
YOM:
1951
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The pilot and his wife, a couple from Phoenix, were performing a flight from the Red Lake Seaplane base to a tourist Camp located north of Red Lake. The twin engine aircraft took off at 1727LT in marginal weather conditions consisting of wind and rain showers. Shortly after departure, the aircraft crashed into the Bruce Channel located between Cochenour and McKenzie Island. The aircraft sank and both occupants were killed.

Crash of a Harbin SH-5 (Shuishang Hongzha 5) off Qingdao: 5 killed

Date & Time: May 30, 2013
Operator:
Registration:
9113
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Qingdao - Qingdao
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The four engine aircraft Harbin SH-5 (Shuishang Hongzha 5) was engaged in a training mission off Qingdao with a crew of five on board. In unknown circumstances, the seaplane crashed in the Jiaozhou Bay few km offshore, killing all five occupants.

Crash of a Grumman G-44 Widgeon in Catskill: 1 killed

Date & Time: May 2, 2013 at 1629 LT
Type of aircraft:
Registration:
N8AS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Copake - Copake
MSN:
1315
YOM:
1943
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5735
Captain / Total hours on type:
411.00
Aircraft flight hours:
2251
Circumstances:
Michael B. Braunstein, aged 72, was the owner of this vintage aircraft built in 1943 and was performing a local flight within the State of New York. Aircraft was destroyed when it impacted the waters of the Hudson River, near Catskill, New York. The certificated airline transport pilot was fatally injured. Visual meteorological conditions prevailed, and no flight plan had been filed for the local personal flight conducted under Title 14 Code of Federal Regulations Part 91, which departed from B Flat Farm Airport (3NK8), Copake, New York about 1600. Approximately 25 witnesses were interviewed. Witnesses reported observing the twin-engine amphibious airplane flying southbound low above a river and hearing the engine running. The airplane then made a 180-degree left turn, which was consistent with the pilot flying a tight traffic pattern before attempting a water landing. The airplane then descended, leveled off above the water, and suddenly banked left. The airplane’s nose and left pontoon then struck the water, and the airplane nosed over, caught fire, and sank. Postrecovery examination of the wreckage revealed that the landing gear was in the “up” position and that the flaps were extended, which indicates that the airplane had been configured for a water landing. No evidence of any preimpact failures or malfunctions of the airplane or engines was found that would have precluded normal operation. At the time of the accident, a light breeze was blowing, the river was at slack tide, and the water conditions were calm, all of which were conducive to glassy water conditions. It is likely that the glassy water conditions adversely affected the pilot’s depth perception and led to his inability to correctly judge the airplane’s height above the water. He subsequently flared the airplane too high, which resulted in the airplane exceeding its critical angle-of-attack, entering an aerodynamic stall, and impacting the water in a nose-low attitude.
Probable cause:
The pilot’s misjudgment of the airplane’s altitude above the water and early flare for a landing on water with a glassy condition, which led to the airplane exceeding its critical angle-of-attack and experiencing an aerodynamic stall.
Final Report:

Crash of a Boeing 737-8GP off Denpasar

Date & Time: Apr 13, 2013 at 1510 LT
Type of aircraft:
Operator:
Registration:
PK-LKS
Survivors:
Yes
Schedule:
Bandung - Denpasar
MSN:
38728/4350
YOM:
2013
Flight number:
LNI904
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
101
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15000
Captain / Total hours on type:
6173.00
Copilot / Total flying hours:
1200
Copilot / Total hours on type:
923
Aircraft flight hours:
142
Aircraft flight cycles:
104
Circumstances:
On 13 April 2013, a Boeing 737-800 aircraft, registered PK-LKS, was being operated by PT. Lion Mentari Airlines (Lion Air) on a scheduled passenger flight as LNI 904. The aircraft departed from Husein Sastranegara International Airport (WICC) Bandung at 0545 UTC to Ngurah Rai International Airport (WADD), Bali, Indonesia. The flight was the last sector of four legs scheduled for the crew on that day which were Palu (WAML) - Balikpapan (WALL) - Banjarmasin (WAOO) - Bandung (WICC) - Bali (WADD). The aircraft flew at FL 390, while the Second in Command (SIC) was the Pilot Flying (PF) and the Pilot in Command (PIC) was the Pilot Monitoring (PM). There were 2 pilots, 5 flight attendants and 101 passengers comprising 95 adults, 5 children and 1 infant making a total of 108 persons on board. The flight from the departure until start of the approach into Bali was uneventful. At 0648 UTC, the pilot made first communications with the Bali Approach controller (Bali Director) when the aircraft was located 80 Nm from BLI VOR. The pilot received clearance to proceed direct to the TALOT IFR waypoint and descend to 17,000 feet. At 0652 UTC, the Bali Director issued a further clearance for the pilot direct to KUTA point and descent to 8,000 feet. At 0659 UTC, the aircraft was vectored for a VOR DME approach for runway 09 and descent to 3,000 feet. At 0703 UTC, while the aircraft was over KUTA point, the Bali Director transferred communications with the aircraft to Bali Control Tower (Ngurah Tower). At 0704 UTC, the pilot contacted Ngurah Tower controller and advised that the aircraft was leaving KUTA point. The Ngurah Tower controller instructed the pilot to continue the approach and to reduce the aircraft speed to provide sufficient separation distance with another aircraft. At 0707 UTC, the Ngurah Tower issued take-off clearance for a departing aircraft on runway 09. At 0708 UTC, with LKS at approximately 1,600 feet AGL, the Ngurah Tower controller saw the aircraft on final approach and gave a landing clearance with additional information that the wind was from 120° at 05 knots. At 0708:47 UTC, the aircraft Enhance Ground Proximity Warning System (EGPWS) aural alert called “ONE THOUSAND”, the SIC said one thousand, stabilized, continue, prepare for go-around missed approach three thousand. The FDR showed that the pilot flown using LNAV (Lateral Navigation) and VNAV (Vertical Navigation) during the approach until disengagement of the Auto Pilot. The sequence of events during the final approach is based on the recorded CVR and FDR data, and information from crew interviews as follows: At 0708:56 UTC, while the aircraft altitude was approximately 900 feet AGL, the SIC commented that the runway was not in sight, whereas the PIC commented “OK. Approach light in sight, continue”. At 0709:33 UTC, after the EGPWS aural alert “MINIMUM” sounded at an aircraft altitude of approximately 550 feet AGL, the SIC disengaged the autopilot and the auto-throttle and then continued the approach. At 0709:43 UTC, the EGPWS called “THREE HUNDRED”. At 0709:47 UTC, the CVR recorded a sound similar to rain hitting the windshield. At 0709:49 UTC, the EGPWS called “TWO HUNDRED”. At 0709:53 UTC, while the aircraft altitude was approximately 150 feet AGL, the PIC took over control of the aircraft. The SIC handed control to the PIC and stated that he could not see the runway. At 0710:01 UTC, after the EGPWS called “TWENTY”, the PIC commanded for go-around. At 0710:02 UTC, the aircraft impacted the water, short of the runway. The aircraft stopped facing to the north at about 20 meters from the shore or approximately 300 meters south-west of the beginning of runway 09. Between 0724 UTC to 0745 UTC, three other aircraft took-off and six aircraft landed using runway 09. At 0750 UTC, the airport was closed until 0850 UTC. At 0755 UTC, all occupants were completely evacuated, the injured passengers were taken to the nearest hospitals and uninjured occupants to the airport crisis centre.
Probable cause:
The National Transportation Safety Committee initial findings on the accident flight are as follows:
- The aircraft was airworthy prior to impact and has an item on the DMI (deferred maintenance item) category C (right engine oil filter).
- All crew has valid licenses and medical certificates.
- The Second in Command (SIC) acted as Pilot Flying (PF).
- The flight performed a VOR DME approach runway 09, and the published Minimum Descent Altitude (MDA) was 465 ft AGL.
- The approach configuration used was flap 40.
- At 900 ft AGL the PF did not have the runway in sight.
- Upon reaching the MDA the flight profile indicated a constant path.
- The PIC took over control of the aircraft at about 150 ft radio altitude.
- The SIC handed over control to the PIC at about 150 ft and stated that he could not see the runway.
- The final approach phase of the flight profile was outside the envelope of the EGPWS warning, therefore no EGPWS warning was recorded on the CVR.
The NTSC concluded in its final report that the accident was caused by the following factors:
- The aircraft flight path became unstable below minimum descends altitude (MDA) with the rate of descend exceeding 1000 feet per minute and this situation was recognized by both pilots.
- The flight crew loss of situational awareness in regards of visual references once the aircraft entered a rain cloud during the final approach below minimum descends altitude (MDA).
- The PIC decision and execution to go-around was conducted at an altitude which was insufficient for the go-around to be executed successfully.
- The pilots of accident aircraft was not provided with timely and accurate weather condition despite the weather around the airport and particularly on final approach to the airport was changing rapidly.
Final Report:

Crash of a Beechcraft 1900C-1 off São Tomé: 1 killed

Date & Time: Apr 7, 2013 at 1613 LT
Type of aircraft:
Operator:
Registration:
ZS-PHL
Flight Type:
Survivors:
No
Schedule:
Johannesburg – Ondangwa – São Tomé – Accra – Bamako
MSN:
UC-74
YOM:
1989
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10756
Aircraft flight hours:
23388
Aircraft flight cycles:
29117
Circumstances:
The aircraft was planned to fly from Lanseria airport (FALA) in Republic of South Africa to Bamako airport (GABS) in Mali with a stopover in Ondangwa airport (FYOA) in Namibia, São Tomé International airport (FPST) in São Tomé and Príncipe and Accra airport (DGAA) in Ghana, with a rough estimating time of approximately 15hrs flying, not including the ground time at airports of stopover. The aircraft had been in Lanseria airport (FALA) in Republic of South Africa (RSA) for maintenance check (including but not limited to engine work and interior refurbishing). Prior to the planned flight, the aircraft underwent flight check for 45 minutes after completed planned maintenance on Saturday, April 6th, flown by the Captain and another SAS company pilot. The aircraft departed FALA to FYOA for its first stop over whose flight time was 03:35h. The planned departure from FYOA was delayed due to trouble in starting the right engine. The aircraft took off at 1021hrs contrary to planned 0830hrs. For the second leg of the flight, the aircraft departed FYOA to FPST with filed flight plan of 05 hours and 20 minutes (flight time) having FYOA as alternate. Leaving the Namibian airspace the pilot only contacted Luanda ATC and São Tomé Tower as destination, and at no time did he contact Brazzaville or Libreville for any further clearance within Brazzaville FIR: It is important to emphasize that on that day, the west coast of Africa in the vicinity of Gulf of Guinea had widespread moderate to severe thunderstorm activity with lighting and heavy rain. When initiating descent to São Tomé from FL 200 to 4000 feet as instructed by São Tomé ATC, the pilot was advised that weather was gradually deteriorating at airport vicinity. At 1610hrs the pilot had last transmission with Control Tower informing them about his position which was 9 nm inbound to São Tomé VOR at 4000 feet and also informed the ATC that he was encountering heavy rain. Having lost contact with aircraft at 1613hrs, the São Tomé ATC tried several times to contact the airplane by VHF118.9, 127.5, 121.5 and HF 8903 without success. Facing this situation the ATC sent messages to FIRs of Brazzaville and Accra and Libreville Control as well, some airlines flying within São Tomean an adjacent airspace were contacted for any information but all responses were negative. A Search and Rescue operation started on 7 April 2013 the same day the accident occurred and was conducted on the sea and on the island; no trace of aircraft or its debris, pilot or any cargo were found. The search was terminated on 20 April at 1730hrs.
Probable cause:
By the fact that there is no evidence of the crash, the cause of the accident cannot be conclusively decided, however the investigation discovered series of discrepancies and noncompliance which includes:
Pilot:
- Planned long flight as solo pilot from Lanseria to Bamako is excessive for pilot fatigue perspective (over 15 hours flying).
- The First Class FAA (USA) medical Certificate issued on April 23rd 2012 had expired on October 31st 2012.
Meteorological Conditions:
- Adverse weather conditions enroute and on arrival on that day, the west coast of Africa in the vicinity of Gulf of Guinea had widespread moderate to severe thunderstorm activity with lighting and heavy rain. When initiating descent to Sao Tome, the pilot was advised that weather was gradually deteriorating at airport vicinity.
Final Report: