Crash of a Piper PA-46-350P Malibu Mirage in the Caribbean Sea

Date & Time: Nov 24, 2011 at 0823 LT
Operator:
Registration:
N534P
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Aguadilla - Saint George
MSN:
46-36423
YOM:
2007
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2175
Captain / Total hours on type:
643.00
Aircraft flight hours:
215
Circumstances:
While delivering the single-engine, turbine-powered airplane to Brazil during a multiple leg trip, the pilot decided to fly direct from his departure airport in Puerto Rico to his destination airport in Grenada instead of following the island chain and staying within power-off gliding distance of the shore. During the cruise portion of the flight, a total loss of engine power occurred over open water in visual meteorological conditions at 27,000 feet, about 119 miles west of a suitable landing area. During the loss of power, the engine torque indication dropped from the cruise power setting to 0 foot-pounds (ft-lbs) of torque, the engine then began to vibrate, and smoke began emanating from the engine. The pilot ditched the airplane, it sank, and it was not recovered. The pilot and the pilot-rated passenger were rescued by a French Navy helicopter. The pilot said that he had decided to take a direct route instead of staying closer to the island chain between the two airports because he had ferried 3 airplanes down to Brazil in the last year and that it was a judgment call and a calculated risk because the engine was reliable. At the airplane’s planned operating altitude of 27,000 feet, the airplane could have glided about 54 miles; if the route had been planned to take advantage of this glide distance, the pilot could have remained off shore island chain and taken a shorter, although not direct, route. Review of fueling documentation, the Pilot's Operating Handbook (POH), and statements made by the pilot and pilot-rated passenger also revealed that on the accident flight, good operating practices were disregarded. For instance, during fueling, the airplane which was not equipped with fuel heaters, had been topped off with fuel, but no fuel icing additive had been added, even though the pilot was planning to operate the airplane at 27,000 feet. The airplane was also operated in excess of the manufacturer's published weight limitations, and no power setting or performance information was available for climb and cruise operations in excess of these limitations. Furthermore, according to the pilot, before the loss of engine power, the torque was about 937 ft-lbs. According to the pilot-rated passenger, before the failure, the torque gauge was indicating about 980 ft-lbs. Review of the maximum cruise performance chart in the POH and Airplane Flight Manual (AFM) revealed that both of the stated torque settings exceeded the maximum torque setting listed on the chart. Operating the engine beyond the recommended power settings specified in the POH/AFM for a prolonged period will result in accelerated deterioration due to hot section component distress and will affect engine reliability and durability.
Probable cause:
The total loss of engine power during cruise flight for reasons that could not be determined because the airplane was not recovered. Contributing to the accident was the pilot’s failure to comply with the airplane and engine limitations, and his decision to fly over water beyond power-off gliding distance from shore.
Final Report:

Crash of a Casa 212 Aviocar 300DF off Robinson Crusoe Island: 21 killed

Date & Time: Sep 2, 2011 at 1748 LT
Type of aircraft:
Operator:
Registration:
966
Flight Type:
Survivors:
No
Schedule:
Santiago - Robinson Crusoe Island
MSN:
443
YOM:
1994
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
21
Circumstances:
The twin engine aircraft departed Santiago de Chile-Comodoro Arturo Merino Benítez (Pudahuel) Airport on a special flight to Robinson Crusoe Island, carrying 17 passengers and a crew of four. The flight was organized by NGO's in cooperation with the Chilean National Television to see the progress of the reconstruction on the island of Robinson Crusoe following the 2010 earthquake. Among the occupants were members of the National Television and also from the Council of Culture. The famous Chilean television icon Felipe Camiroaga Fernández was among the passengers. Following an almost 3-hour flight, the crew completed a low pass over the runway 14 then started the approach to runway 32 from the sea. At an altitude of about 650 feet, the aircraft entered an uncontrolled descent, rolled to the left to an angle of 90° and impacted the sea. Debris were found floating on water and the main wreckage was later found about one km southeast from the airport. All 21 occupants were killed.

Personnel from the Chilean Air Force:
Lt Carolina Fernández Quinteros,
Lt Juan Pablo Mallea Lagos,
1st Sgt Eduardo Jones San Martín,
1st Cpl Eduardo Estrada Muñoz,
2nd Cpl Flavio Oliva Pino,
2nd Cpl Erwin Núñez Rebolledo,
Cdt Rodrigo Fernández Apablaza,
José Cifuentes Juica.

Council of Culture:
Galia Diaz Riffo,
Romina Irarrázabal Faggiani.

Chilean National Television:
Felipe Camiroaga Fernández,
Roberto Bruce Pruzzo,
Sylvia Slier Munoz,
Caroline Gatica Aburto,
Rodrigo Cabezón de Amesti.

Members of the 'Desafío Levantemos Chile' NGO:
Felipe Cubillos Sigall,
Sebastián Correa Murillo,
Catalina Vela Montero,
Joel Lizama Nahuelhual,
Jorge Palma Calvo,
Joaquín Arnolds Reyes.
Probable cause:
The accident was caused by the loss of control of the airplane while performing the tailwind leg through the channel between the islands of Robinson Crusoe and Santa Clara to an estimated height of 650 feet or less, during the circuit approach to Runway 32 in a very low trajectory (with little height difference above the runway), where very adverse airflow conditions were found, including wind shear, which exposed the crew to extreme flight conditions.
Adverse airflow conditions were the results of a combination of different factors, including:
- Very unstable atmosphere, with strong turbulence and possibly eventually powerful down gusts arising from the presence of open cells after a front passed,
- The presence of the two counter-rotating vortexes in the Santa Clara Island downwind wake,
- The presence of strong and gusty crosswinds that were very variable in strength and direction in a very short time.

Crash of an Antonov AN-2 near Choigan-Khole Lake: 1 killed

Date & Time: Aug 22, 2011
Type of aircraft:
Operator:
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Petropavlovka - Toora-Khem
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The single engine aircraft was performing an on-demand flight from Petropavlovka to Toora-Khem with seven fishermen and a pilot who want to go to a remote fish camp located in the natural reserve of Azas. While flying at low altitude, the aircraft went out of control and crashed on the shore of the Choigan-Khole Lake, near the Sorug River. While all seven passengers escaped with minor injuries, the pilot was killed. It appears that the aircraft was not registered and did not have any certificate of airworthiness. Therefore, the flight was considered as illegal and no flight plan was filed.

Crash of a Boeing 747-48EF in the East China Sea: 2 killed

Date & Time: Jul 28, 2011 at 0411 LT
Type of aircraft:
Operator:
Registration:
HL7604
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Seoul - Shanghai
MSN:
29907/1370
YOM:
2006
Flight number:
OZ991
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
14123
Captain / Total hours on type:
6896.00
Copilot / Total flying hours:
5211
Copilot / Total hours on type:
492
Aircraft flight hours:
28752
Aircraft flight cycles:
4799
Circumstances:
On 28 July 2011, about 04:11 Korean Standard Time), Asiana Airlines flight 991, a B747-400F airplane, HL7604 (hereafter referred to as AAR991), a scheduled cargo flight from Incheon, Republic of Korea, to Shanghai, China, crashed into the international waters about 130 km west of Jeju International Airport (hereafter referred to as Jeju Airport after the flight crew reported a cargo fire to SHI ACC near a reporting point SADLI on airway A593 about 03:54 and attempted to divert to Jeju Airport. Due to the crash impact and fire, the captain and the first officer (FO) were fatally injured, the aircraft was destroyed, and the cargo shipments were damaged, incapable of being recovered, or washed away. AAR991 was a scheduled international cargo flight operated at night under the instrument flight rule in accordance with the Aviation Act of the Republic of Korea and the Convention on International Civil Aviation. The captain and the FO showed up at the flight crew ready room of Asiana Airlines in Incheon International Airport (hereafter referred to as Incheon Airport) an hour before the scheduled time of departure) and signed the "show-up log," respectively. The line mechanic stated that on 28 July, about 02:00, the flight crew arrived at the airplane and that the captain performed the ramp inspection. The loadmaster stated that about 02:15, under the guidance with him, the captain inspected the loaded status of dangerous goods and other shipments in the main deck cargo compartment. The transcript) of ATC radio communications shows that at 03:04:28, AAR991 took off from runway 15L in Incheon Airport. From this moment, the captain) took control of radio communications. At 03:05:48, AAR991 made initial contact with Seoul Area Control Center (SEL ACC) after takeoff and was instructed to climb to 34,000 ft and fly direct to MALPA. At 03:12:19, the flight crew were advised to contact Incheon Area Control Center (ICN ACC). At 03:12:35, AAR991 was climbing to 34,000 ft on a permitted route when it made initial contact with ICN ACC, and at 03:13:05, was allowed to fly direct to NIRAT. At 03:26:05, ICN ACC instructed AAR991 to change its radio frequency to 124.52 MHz. From this moment, the FO mainly assumed control of radio communications, but the captain also occasionally made communication. At 03:26:21, the crew were instructed to fly direct to SADLI, and at 03:50:46, ICN ACC advised AAR991 to contact SHI ACC on frequency 134.0 MHz. At 03:51:15, AAR991 stated that it was maintaining at 34,000 ft and flying direct to SADLI when it made initial contact with SHI ACC. At 03:52:39, SHI ACC instructed AAR991, "AAR991 radar contact, off-set 5 miles right of track," and the flight crew carried out this instruction at 03:52:51. The Aircraft Communications Addressing and Reporting System (ACARS) messages) received by the ground station were as follows: about 03:53, "EQUIPMENT SMOKE," "EQUIP COOLING," and "CGO DET 11 MN DK"; and about 03:54, "CGO DET 6 MN DK" and "CGO DET 10 MN DK." At 03:54:23, the FO stated, "Shanghai control, Shanghai control, AAR991 request emergency descent, emergency, declare emergency due to fire main deck. Request descent, and descent to one-zero thousand." At 03:54:37, SHI ACC gave AAR991 a descent clearance and instructed it to turn at its discretion, and the FO acknowledged this instruction. The radar data of ICN ACC shows that AAR991 started descending at 03:54:59. At 03:55:08, the FO requested a diversion to Jeju Airport, stating "We have fire main deck, AAR991, return to Jeju AAR991," and SHI ACC approved the request. At 03:58:03, SHI ACC instructed AAR991 to maintain 10,000 ft, however, followed by no response from AAR991. At 03:58:25, SHI ACC requested KAL886 flying near AAR991 to relay any information from AAR991 to SHI ACC. KAL886 stated that AAR991 was descending to 10,000 ft and flying direct to Jeju. According to the radar data of ICN ACC, AAR991 was flying at 16,000 ft at a ground speed of 452 kt on a heading of 345°. At 03:59:13, AAR991 requested a radar vector to Jeju. At 03:59:50, SHI ACC instructed AAR991 to fly heading 045, and AAR991 acknowledged this instruction. At 03:59:26, according to the ATC transcript, the sound of the FO's breathing through an oxygen mask was recorded four times when he communicated with SHI ACC. The last ACARS messages received by the ground station about 04:00 are as follows: "YAW DAMPER UPR," "RUD RATIO DUAL," and "FLAPS CONTROL." At 04:00:23, SHI ACC instructed AAR991 to contact ICN ACC on 124.52 MHz for a radar vector to Jeju, however, AAR991 stated that it was unable to contact on this frequency. Consequently, SHI ACC instructed the crew to monitor frequency 134.0 MHz. The radar data of ICN ACC shows that at 04:01:43, AAR991 was flying at 8,200 ft at a ground speed of 404 kt on a heading of 033°, and after this, AAR991's altitude, ground speed, and heading changed inconsistently. At 04:02:00, SHI ACC instructed AAR991 to contact Fukuoka Area Control Center (FUK ACC) on 133.6 MHz. At 04:02:10, the FO stated, "AAR991" and 12 seconds later, added, "Fukuoka AAR991 mayday mayday mayday, we have cargo fire, request direct to Jeju please," followed by no response from FUK ACC. At 04:03:01, the FO called SHI ACC and stated that it was unable to contact FUK ACC. Consequently, SHI ACC instructed AAR991 to pass information to KAL886 and let KAL886 relay the information to FUK ACC and ICN ACC. At 04:03:01, the flight track data of the Incheon radar shows that AAR991's transponder code in Mode 3/A was set to 7700 from 6353 when the aircraft was flying at 8,500 ft at a ground speed of 410 kt on a heading of 027°. At 04:03:24, KAL886 advised AAR991 that it would relay its message to ICN ACC, and the FO stated, "Yes, now direct Jeju heading 030." KAL886 informed AAR991 that SHI ACC gave it heading 045, and the FO acknowledged this instruction. At 04:04:14, SHI ACC instructed KAL886 to use another transmitter to contact ICN ACC on 124.52 MHz, to request heading to Jeju from its present position, and to report back to SHI ACC. Regarding this, KAL886 gave an affirmative response. At 04:05:30, the captain called KAL886, and KAL886 responded, "Relay from Incheon Control, from Incheon Control, maintain heading 060, radar vector for final, and you may descend to 7,000 ft." At 04:05:52, KAL886 again relayed the message, "Maintain heading 060, radar vector for final, and descend to 7,000 ft," followed by the captain's response, "Descend 7,000 ft." Beginning 04:06:25, the captain called "Korean Air" twice. At 04:06:30, KAL886 responded, "Stand by, stand by," followed by the captain's statement at 04:06:32, "Ah… we are now that rudder control is not working and seems to be fired… (jamming)." At 04:06:41, SHI ACC instructed KAL886 to contact ICN ACC on 124.52 MHz, and at 04:07:16, instructed AAR991 to try contacting KAL886 on 124.52 MHz, followed by the captain's acknowledgement. At 04:07:34, the captain stated, "We have to open the hatch, hatch." Subsequently, KAL886 instructed AAR991 to change its frequency to ICN ACC frequency 124.52 MHz. At 04:08:52, ICN ACC instructed KAL886 to relay the message to AAR991 that JEJ APP established radar contact with AAR991 and that AAR991 should contact JEJ APP on 121.2 MHz. At 04:09:08, KAL886 relayed this message to AAR991. At 04:09:47, the captain said to JEJ ACC, "Rudder control… flight control, all are not working." The FO said to JEJ ACC, "Did you contact? Uh… do you contact us?" and JEJ ACC responded, "AAR991… yes, I can hear you." At 04:10:06, the FO stated, "We have heavy vibration on the airplane, may need to make an emergency landing, emergency ditching," and JEJ ACC responded, "Yes, say again, please." He stated, "Altitude control is not available due to heavy vibration, going to ditch… ah." At 04:10:26, JEJ ACC asked AAR991, "Can you make approach to Jeju?" and subsequently, tried to contact AAR991 three times, however, followed by no response from AAR991. The aircraft crashed in the East China Sea and both pilots were killed. Debris were found about 130 km west of Jeju.
Probable cause:
The Aviation and Railway Accident Investigation Board (ARAIB) determines the cause of this accident as follows:
A fire developed on or near the pallets containing dangerous goods but no physical evidence of the cause of the fire was found. The fire rapidly escalated into a large uncontained fire, and this caused some portions of the fuselage to separate from the aircraft in midair, thereby resulting in the crash.
Contributing Factors:
1. Flammable materials like photo-resist (Class 3) were loaded in position ML, and flammable materials like paint, photo-resist, corrosive liquid, and lithium-ion batteries (Class 9) were loaded on one pallet in position PR.
2. It was difficult to contain a large scale of fire only by the fire suppression system of a Class E cargo compartment that was not equipped with an active fire suppression system.
Final Report:

Crash of an Antonov AN-24RV in Strezhevoy: 7 killed

Date & Time: Jul 11, 2011 at 1156 LT
Type of aircraft:
Operator:
Registration:
RA-47302
Survivors:
Yes
Schedule:
Tomsk - Surgut
MSN:
5 73 103 02
YOM:
1975
Flight number:
IK9007
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
33
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
4570
Captain / Total hours on type:
4064.00
Copilot / Total flying hours:
9476
Copilot / Total hours on type:
5100
Aircraft flight hours:
48489
Aircraft flight cycles:
32783
Circumstances:
The twin engine aircraft departed Tomsk Airport at 1010LT on a flight (callsign IK9007/SP5007) to Surgut, carrying 33 passengers and a crew of four. About an hour and 26 minutes into the flight, the left engine's 'chips in oil' warning light came on. About eight minutes later, a burning smell was noticed in the cockpit and the captain decided to divert to Nizhnevartovsk Airport. During the descent, the left engine caught fire. Its propeller was feathered and the crew decided to divert to Strezhevoy Airport. But as the fire could not be extinguished, the captain eventually attempted an emergency landing in the Ob River. Upon landing, the aircraft broke in two and came to rest in shallow water. Seven passengers were killed while all other occupants were rescued.
Probable cause:
The Interstate Aviation Committee (MAK) released their final report in Russian concluding the probable causes of the accident were:
The catastrophe of the AN-24 RA-47302 occurred when ditching became necessary due to a fire in the left hand engine's nacelle. The destruction of the aircraft and loss of life was caused by collision with underwater obstacles that the crew could not anticipate or avoid. The fire in the left hand engine nacelle was caused by the fracture of a centrifugal breather releasing an air-fuel emulsion into the engine compartment as well as a delayed reaction to shut the engine down by the crew following an magnetic chip detector indication together with indications of oil pressure fluctuations, a burning smell and a low oil pressure indication. A delay in indicating engine vibrations to the crew as result of degradation of the engine vibration sensoring equipment, most likely caused by changes of the rotor speed of the engine as result of the aft bearing failure of the compressor rotor and/or misalignment of the sensor, which probably influenced the decision of the crew to shut the engine down with a delay. Cause of the fracture of the centrifugal breather was the destruction of the impeller due to prolonged exposure to hot air-fuel emulsion due to the failure of the aft compressor rotor support bearing. It was not possible to determine the cause of the destruction of the aft compressor rotor support bearing due to significant secondary damage. Most likely the destruction was caused by misalignment such as:
- Incorrect assembly of support parts mating with the compressor rotor during on-condition engine repairs,
- Or deviations from required geometry of support parts mating with the compressor rotor.
Contributing factors were:
- Psychological unpreparedness of the captain to shut the engine down due to lack of experience with the aircraft on one engine inoperative
- Late detection of the fire and as a consequence late attempts to extinguish the fire, it was however not possible to establish why the fire was detected late due to lack of objective information about the performance of the fire alarm systems.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 310 in the Maadhiggaru Falhu lagoon

Date & Time: Jul 11, 2011 at 0910 LT
Operator:
Registration:
8Q-TMD
Flight Type:
Survivors:
Yes
Schedule:
Male - Male
MSN:
530
YOM:
1977
Flight number:
TMW201A
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5732
Captain / Total hours on type:
3387.00
Copilot / Total flying hours:
2650
Copilot / Total hours on type:
2650
Aircraft flight hours:
34746
Aircraft flight cycles:
62428
Circumstances:
The 8Q-TMD aircraft took-off from water runway of Male’ International Airport North Bound Left (NL) at 0820 hrs local time on 11 July 2011 for a routine training flight bound to Maadhiggaru Falhu (a lagoon located approximately 15 nautical miles south west of the Male’ International Airport). The sky was clear with good visibility and wind 8-10 knots from west and south west. During the training 5 landings and take-offs were made simulating different conditions of flight. Crew confirmed that all these landings and take-offs were made inside the lagoon except the last landing where the crew decided to land on open water outside the lagoon. Crew were simulating single engine landing with a tail wind. As per the crew, the aircraft initial touch down was smooth. However, they stroke a wave which made the aircraft bounce up for about 20 feet. With the low power the aircraft hit the water again, resulting in multiple float attachments to break. Both front and main spreader bars broke and floats rose up twisted, hitting the engine bottom cowlings. Propeller cut was found on top front of both floats.
Probable cause:
Impact with a high swell during landing followed by a high bounce and hard landing resulting in both float attachments being damaged and detached with a major structural damages. Major contributing factor was higher than normal touch down speed due to abnormal landing configuration.
Contributing factors:
- Selection of inappropriate landing site (channel) and landing direction (tail wind) based on surface conditions present at that time,
- Simulation of multiple emergencies,
- Abnormal landing configuration (flaps at zero) for single engine landing,
- Time pressure to complete the training and return to commercial operations.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Buss Lakes: 5 killed

Date & Time: Jun 30, 2011 at 1111 LT
Type of aircraft:
Registration:
C-GUJX
Flight Phase:
Survivors:
No
Schedule:
Buss Lakes - Southend
MSN:
1132
YOM:
1958
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
4023
Captain / Total hours on type:
3664.00
Aircraft flight hours:
12746
Circumstances:
The Lawrence Bay Airways Ltd. float-equipped de Havilland DHC-2 (registration C-GUJX, serial number 1132) departed from a lake adjacent to a remote fishing cabin near Buss Lakes for a day visual flight rules flight to Southend, Saskatchewan, about 37 nautical miles (nm) southeast. There were 4 passengers and 1 pilot onboard. The aircraft crashed along the shoreline of another lake located about 2 nm southeast of its point of departure. The impact was severe and the 5 occupants were killed on impact. The emergency locator transmitter activated, and the aircraft was found partially submerged in shallow water with the right wing tip resting on the shore. There was no post-crash fire. The accident occurred during daylight hours at about 1111 Central Standard Time.
Probable cause:
Findings as to Causes and Contributing Factors:
While manoeuvring at low level, the aircraft's critical angle of attack was likely exceeded and the aircraft stalled. The stall occurred at an altitude from which recovery was not possible.
Other Findings:
The separation of the propeller blade tip likely resulted from impact forces.
The investigation could not determine whether the fuel pressure warning light was illuminated prior to the accident.
Final Report:

Crash of an Antonov AN-26 off Libreville

Date & Time: Jun 6, 2011 at 1025 LT
Type of aircraft:
Operator:
Registration:
TR-LII
Flight Type:
Survivors:
Yes
Schedule:
Port Gentil - Libreville
MSN:
75 04
YOM:
1978
Flight number:
SLN122A
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew departed Port Gentil on a cargo flight to Libreville on behalf of DHL Airways. On approach to Libreville-Léon Mba Airport, the captain informed ATC about hydraulic problems and initiated a go-around procedure. Shortly later, the aircraft stalled and crashed in the sea some 2,3 km southeast of the airport. All four occupants were rescued while the aircraft was damaged beyond repair. Due to the failure of the hydraulic system, the crew was unable to lower the gear.

Crash of a Xian MA60 off Kaimana: 25 killed

Date & Time: May 7, 2011 at 1405 LT
Type of aircraft:
Operator:
Registration:
PK-MZK
Survivors:
No
Schedule:
Jayapura - Sorong - Kaimana - Nabire - Biak
MSN:
06 03
YOM:
2008
Flight number:
MZ8968
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
25
Captain / Total flying hours:
24470
Captain / Total hours on type:
199.00
Copilot / Total flying hours:
370
Copilot / Total hours on type:
234
Aircraft flight hours:
615
Aircraft flight cycles:
764
Circumstances:
On 7 May 2011, an Xi ’An MA60 aircraft, registered PK-MZK was being operated by PT. Merpati Nusantara Airline as a scheduled passenger flight MZ 8968, from Domine Eduard Osok Airport, Sorong, Papua Barat to Utarom Airport (WASK), Kaimana1, Papua Barat. The accident flight was part of series of flight scheduled for the crew. The aircraft departed from Sorong at 0345 UTC2 and with estimated arrival time in Kaimana at 0454 UTC. In this flight, the Second in Command (SIC) was as Pilot Flying (PF) and the Pilot in Command (PIC) as Pilot Monitoring (PM). On board the flight were 2 pilots, 2 flight attendants, 2 engineers and 19 passengers consisting of 16 adults, 1 child and 2 infants. The flight from Sorong was planned under the Instrument Flight Rules (IFR)3. The destination, Kaimana, had no published instrument approach procedure. Terminal area operations, including approach and landing, were required to be conducted under the Visual Flight Rules (VFR). At about 0425 UTC, after passing waypoint JOLAM the crew of MZ 8968 contacted Kaimana Radio and informed that the weather at Kaimana was raining, horizontal visibility of 3 to 8 kilometers, cloud Cumulonimbus broken at 1500 feet, south westerly wind at a speed of 3 knots, and ground temperature 29°C. The last communication with the crew of MZ 8968 occurred at about 0450 UTC. The flight crew asked whether there were any changes in ground visibility and the AFIS officer informed them that the ground visibility remained at 2 kilometer. The visual flight rules requires a visibility of minimum 5 km and cloud base higher than 1500 feet. The evidence indicates that during the final segment of the flight, both crew member were looking outside the aircraft to sight the runway. During this period the flight path of the aircraft varied between 376 to 585 feet and the bank angle increased from 11 to 38 degree to the left. The rate of descent then increased significantly up to about 3000 feet per minute and finally the aircraft impacted into the sea. The accident site was about 800 meters south west of the beginning of runway 01 or 550 meters from the coastline. Most of the wreckage were submerged in the shallow sea between 7 down to 15 meter deep. All 25 occupants were fatally injured. The aircraft was destroyed and submerged into the sea.
Probable cause:
FINDINGS:
1. The aircraft was airworthy prior the accident. There is no evidence that the aircraft had malfunction during the flight.
2. The crew had valid flight license and medical certificate. There was no evidence of crew incapacitation.
3. In this flight the SIC acted as Pilot Flying until the PIC took control of the aircraft at the last part of the flight.
4. According to company operation manual (COM), in a VMC (Visual Meteorological Condition), a “minimum, minimum” EGPWS alert while the approach was not stabilized should be followed by the action of abandoning the approach.
5. The cockpit crew did not conduct any crew approach briefing and checklist reading.
6. As it was recorded in the CVR during the final segment of the flight, both crews member were looking out-side to look for the runway. It might reduce the situational awareness.
7. At the final segment of the flight, the FDR recorded as follows:
• The approach was discontinued started at 376 feet pressure altitude (250 feet radio altitude) and reached the highest altitude of 585 feet pressure altitude. While climbing the aircraft was banking to the left reaching a roll angle of 38 degree. The torque of both engines was increased reaching 70% and 82% for the left and right engine respectively.
• During the go-around, the flaps were retracted to 5 and subsequently to 0 position, and the landing gears were retracted. The aircraft started to descend, and the pitch angle reached 13 degree nose down.
• The rate of descend increased significantly reaching about 3000 feet per minute, and finally the aircraft crashed into the shallow sea.
8. The rapid descent was mainly a result of a combination of situations such as high bank angle (up to 38 deg to the left) and the flaps retracted to 5 and subsequently to 0 position, and also the combination of other situations: engine torque, airspeed, and nose-down pitch.
9. The ERS button was determined in the CRUISE mode instead of TOGA mode. This had led the torque reached 70% and 82% during discontinuing the approach.
10. The flaps were retracted to 5 and subsequently to 0, while the MA-60 standard go-around procedure is to set the flaps at 15.
11. There was limited communications between the crew along the flight. This type of interaction indicated that there was a steep trans-cockpit authority gradient.
12. The SIC was trained in the first three batches which was conducted by the aircraft manufacturer instructor and syllabus, while the PIC was trained by Merpati instructor using modified syllabus. Inadequacy/ineffectivity in the training program may lead to actions that deviated from the standard procedure and regression to the previous type.
13. The investigation found that the Flight Crew Operation Manual (FCOM) and Aircraft Maintenance Manual (AMM) used non-standard English Aviation Language. This finding was supported by a review performed by the Australian Transport Safety Bureau (ATSB).
OTHER FINDINGS:
1. The DFDR does not have the Lateral and Longitudinal acceleration. These two parameters which were non safety related items were mandatory according to the CASR parts 121.343 and 121.344, and at the time of the MA 60 certification, the CCAR 121 did not require those two parameters.
2. Due to impact forces and immersion in water, the Emergency Locator Transmitter (ELT) did not transmit any signal.
FACTORS:
Factors contributed to the accident are as follows:
1. The flight was conducted in VFR in condition that was not suitable for visual approach when the visibility was 2 km. In such a situation a visual approach should not have been attempted.
2. There was no checklist reading and crew briefing.
3. The flight crew had lack of situation awareness when tried to find the runway, and discontinued the approach.
4. The missed approach was initiated at altitude 376 feet pressure altitude (250 feet radio altitude), the pilot open power to 70% and 82% torque followed by flap retracted to 5 and subsequently to 0. The rapid descent was mainly caused by continuously increase of roll angle up to 38 degree to the left and the retraction of flaps from 15 to 0 position.
5. Both crew had low experience/flying time on type.
6. Inadequacy/ineffectivity in the training program may lead to actions that deviated from the standard procedure and regression to the previous type.
Final Report:

Crash of a BAe 125-700A off Loreto

Date & Time: May 5, 2011 at 1155 LT
Type of aircraft:
Operator:
Registration:
N829SE
Flight Type:
Survivors:
Yes
MSN:
257095
YOM:
1980
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Loreto Airport, the crew encountered technical problems and elected to return. On final approach over the Gulf of California, in a gear up configuration, the aircraft struck the water surface and came to rest into the sea close to the shore, few dozen metres short of runway 34 threshold. Both pilots escaped uninjured while the aircraft was damaged beyond repair.