Crash of a Cessna 550 Citation II in Manteo

Date & Time: Oct 1, 2010 at 0830 LT
Type of aircraft:
Operator:
Registration:
N262Y
Survivors:
Yes
Schedule:
Tampa - Manteo
MSN:
550-0291
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9527
Captain / Total hours on type:
2025.00
Copilot / Total flying hours:
3193
Copilot / Total hours on type:
150
Aircraft flight hours:
9643
Circumstances:
According to postaccident written statements from both pilots, the pilot-in-command (PIC) was the pilot flying and the copilot was the pilot monitoring. As the airplane approached Dare County Regional Airport (MQI), Manteo, North Carolina, the copilot obtained the current weather information. The automated weather system reported wind as 350 degrees at 4 knots, visibility at 1.5 miles in heavy rain, and a broken ceiling at 400 feet. The copilot stated that the weather had deteriorated from the previous reports at MQI. The PIC stated that they would fly one approach to take a look and that, if the airport conditions did not look good, they would divert to another airport. Both pilots indicated in phone interviews that, although they asked the Washington air route traffic control center controller for the global positioning system (GPS) runway 5 approach, they did not expect it due to airspace restrictions. They expected and received a GPS approach to runway 23 to circle-to-land on runway 5. According to the pilots' statements, the airplane was initially fast on approach to runway 23. As a result, the copilot could not deploy approach flaps when the PIC requested because the airspeed was above the flap operating range. The PIC subsequently slowed the airplane, and the copilot extended flaps to the approach setting. The PIC also overshot an intersection but quickly corrected and was on course about 1 mile prior to the initial approach fix. The airplane crossed the final approach fix on speed (Vref was 104) at the appropriate altitude, with the flaps and landing gear extended. The copilot completed the approach and landing checklist items but did not call out items because the PIC preferred that copilots complete checklists quietly. The PIC then stated that they would not circle-to-land due to the low ceiling. He added that a landing on runway 23 would be suitable because the wind was at a 90-degree angle to the runway, and there was no tailwind factor. Based on the reported weather, a tailwind component of approximately 2 knots existed at the time of the accident, and, in a subsequent statement to the Federal Aviation Administration, the pilot acknowledged there was a tailwind about 20 degrees behind the right wing. The copilot had the runway in sight about 200 feet above the minimum descent altitude, which was 440 feet above the runway. The copilot reported that he mentally prepared for a go around when the PIC stated that the airplane was high about 300 feet above the runway, but neither pilot called for one. The flight crew stated that the airplane touched down at 100 knots between the 1,000-foot marker and the runway intersection-about 1,200 feet beyond the approach end of the 4,305-foot-long runway. The speed brakes, thrust reversers, and brakes were applied immediately after the nose gear touched down and worked properly, but the airplane departed the end of the runway at about 40 knots. According to data extracted from the enhanced ground proximity warning system, the airplane touched down about 1,205 feet beyond the approach end of the 4,305-foot-long wet runway, at a ground speed of 127 knots. Data from the airplane manufacturer indicated that, for the estimated landing weight, the airplane required a landing distance of approximately 2,290 feet on a dry runway, 3,550 feet on a wet runway, or 5,625 feet for a runway with 0.125 inch of standing water. The chart also contained a note that the published limiting maximum tailwind component for the airplane is 10 knots but that landings on precipitation-covered runways with any tailwind component are not recommended. The note also indicates that if a tailwind landing cannot be avoided, the above landing distance data should be multiplied by a factor that increases the wet runway landing distance to 3,798 feet, and the landing distance for .125 inch of standing water to 6,356 feet. All distances in the performance chart are based on flying a normal approach at Vref, assume a touchdown point 840 feet from the runway threshold in no wind conditions, and include distance from the threshold to touchdown. The PIC's statement about the airplane being high at 300 feet above the runway reportedly prompted the copilot to mentally prepare for a go around, but neither pilot called for one. However, the PIC asked the copilot what he thought, and his reply was " it's up to you." The pilots touched down at an excessive airspeed (23 knots above Vref), more than 1,200 feet down a wet 4,305-foot-long runway, leaving about 3,100 feet for the airplane to stop. According to manufacturer calculations, about 2,710 feet of ground roll would be required after the airplane touched down, assuming a touchdown speed at Vref; a longer ground roll would be required at higher touchdown speeds. Although a 2 knot crosswind component existed at the time of the accident, the airplane's excessive airspeed at touchdown (23 knots above Vref) had a much larger effect on the outcome of the landing.
Probable cause:
The pilot-in-command's failure to maintain proper airspeed and his failure to initiate a go-around, which resulted in the airplane touching down too fast on a short, wet runway and a subsequent runway overrun. Contributing to the accident was the copilot's failure to adequately monitor the approach and call for a go around and the flight crew's lack of proper crew resource management.
Final Report:

Crash of a Beechcraft 65 Queen Air off San Carlos: 3 killed

Date & Time: Sep 2, 2010 at 1151 LT
Type of aircraft:
Operator:
Registration:
N832B
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
San Carlos - Santa Clara
MSN:
LC-112
YOM:
1961
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
18000
Captain / Total hours on type:
6000.00
Circumstances:
Shortly after takeoff for a repositioning flight for the airplane’s upcoming annual inspection, numerous witnesses, including the two air traffic controllers, reported observing the airplane climbing out normally until it was about 1/2 mile beyond the runway. The witnesses stated that the airplane then underwent a short series of attitude excursions, rolled right, and descended steeply into a lagoon. All radio communications between the airplane and the air traffic controllers were normal. Ground-based radar tracking data indicated that the airplane's climb to about 500 feet was normal and that it was airborne for about 40 seconds. Postaccident examination of the airframe, systems, and engines did not reveal any mechanical failures that would have precluded continued normal operation. Damage to both engines’ propeller blades suggested low or moderate power at the time of impact; however, the right propeller blades exhibited less damage than the left. The propeller damage, witness-observed airplane dynamics, and the airplane’s trajectory were consistent with a loss of power in the right engine and a subsequent loss of control due to airspeed decay below the minimum control speed (referred to as VMC). Although required by the Federal Aviation Administration (FAA)-approved Airplane Flight Manual, no evidence of a cockpit placard to designate the single engine operating speeds, including VMC, was found in the wreckage. The underlying reason for the loss of power in the right engine could not be determined. The airplane's certification basis (Civil Air Regulation [CAR] 3) did not require either a red radial line denoting VMC or a blue radial line denoting the single engine climb speed (VYSE) on the airspeed indicators; no such markings were observed on the airspeed indicators in the wreckage. Those markings were only mandated for airplanes certificated under Federal Aviation Regulation Part 23, which became effective about 3 years after the accident airplane was manufactured. Neither the Federal Aviation Administration (FAA) nor the airplane manufacturer mandated or recommended such VMC or VYSE markings on the airspeed indicators of the accident airplane make and model. In addition, a cursory search did not reveal any such retroactive guidance for any twin-engine airplane models certificated under CAR 3. Follow-up communication from the FAA Small Airplane Directorate stated that the FAA has "not discussed this as a possible retroactive action... Our take from the accident studies is that because of the accident record with light/reciprocating engine twins, the insurance industry has restricted them to a select group of pilot/owners…" Toxicology testing revealed evidence consistent with previous use of marijuana by the pilot; however, it was not possible to determine when that usage occurred or whether the pilot might have been impaired by its use during the accident flight.
Probable cause:
A loss of power in the right engine for undetermined reasons and the pilot’s subsequent failure to maintain adequate airspeed, which resulted in a loss of control. Contributing to the loss of control was the regulatory certification basis of the airplane that does not require airspeed indicator markings that are critical to maintaining airplane control with one engine inoperative.
Final Report:

Crash of a De Havilland DHC-2 Beaver in the Kaminshak Bay: 4 killed

Date & Time: Aug 21, 2010 at 1412 LT
Type of aircraft:
Operator:
Registration:
N9313Z
Flight Phase:
Survivors:
No
Schedule:
Swikshak Lagoon - King Salmon
MSN:
441
YOM:
1953
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
4112
Aircraft flight hours:
4946
Circumstances:
The commercial pilot departed a remote, oceanside lagoon in a float-equipped airplane with three passengers on an on-demand air taxi flight in reduced visibility and heavy rain. When the airplane did not reach its destination, the operator reported the airplane overdue. Extensive search-and-rescue efforts along the coast and inland failed to find the wreckage. After the search ended, small portions of the fragmented airplane washed ashore about 28 miles northeast of the departure lagoon. The remainder of wreckage has not been located despite sonar searches of the ocean near where the wreckage was found. A stowed tent and duffel bag, which were reported to be aboard the airplane, were also found ashore near the wreckage location. The tent and duffel bag exhibited evidence of exposure to a high temperature environment, such as a fire. However, there was no evidence indicating that the fire occurred in flight. The lack of soot on the undamaged areas of the items, as well as the very abrupt demarcation line between the damaged portion and the undamaged material, is consistent with these items floating in the water and being exposed to a fuel fire on the surface of the water, rather than having been exposed to a fire in the airplane’s cargo compartment. Due to the fragmentation of the recovered wreckage, it is likely that the airplane collided with ocean’s surface while in flight; however, because the engine and a majority of the wreckage have not been found, the sequence of events leading to the accident could not be determined.
Probable cause:
Undetermined.
Final Report:

Crash of a Learjet 55C Longhorn in Rio de Janeiro

Date & Time: Aug 12, 2010 at 0926 LT
Type of aircraft:
Operator:
Registration:
PT-LXO
Flight Type:
Survivors:
Yes
Schedule:
Rio de Janeiro - Rio de Janeiro
MSN:
55C-135
YOM:
1988
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17000
Captain / Total hours on type:
500.00
Copilot / Total flying hours:
2800
Copilot / Total hours on type:
49
Circumstances:
The aircraft departed Rio de Janeiro-Santos Dumont Airport on a positioning flight to Rio de Janeiro-Galeão-Antonio Carlos Jobim Airport with three crew members on board. Two minutes after takeoff, while in initial climb, the electrical system of the aircraft suffered a voltage power loss. Several instruments lost their functionality such as TCAS, altimeters and airspeed indicator. In good weather conditions, the captain decided to return to Santos Dumont Airport but did not declare any emergency. After being cleared to descend to 3,000 feet, the crew lost all radio communications. On final approach to runway 02R, most of the instruments failed but the crew continued the approach. The aircraft passed over the runway threshold with an excessive speed of 25 knots and after touchdown, the crew started the braking procedure but the spoilers and the reversers could not be activated. Unable to stop within the remaining distance, the aircraft overran and came to rest in the Guanabara Bay. All three crew members escaped uninjured while the aircraft was damaged repair.
Probable cause:
An error in the assembly was detected in the left generator, which interfered with the D+ terminal signal sent to the voltage regulator. Due to a voltage drop, some of the instruments lost their functionality. The following contributing factors were identified:
- The crew did not follow the emergency procedures;
- The crew decided to return to land at Santos Dumont Airport without considering that the runway length was less than the length required for an emergency landing;
- The speed of the aircraft while passing over the runway threshold was 25 knots above the reference speed;
- The pilots were unable to engage the spoilers or the thrust reversers;
- Wrong attitude from the captain;
- Overconfidence of the crew;
- Emotional load due to an emergency situation;
- Poor assessment of the situation due to high stress associated with decreased situational awareness;
- Poor crew coordination;
- Lack of crew resource management;
- Poor judgment;
- Lack of procedures on the part of the operator.
Final Report:

Crash of a Cessna 414A Chancellor off Sydney: 2 killed

Date & Time: Aug 5, 2010 at 2337 LT
Type of aircraft:
Operator:
Registration:
C-GENG
Survivors:
No
Schedule:
Butonville - Sydney
MSN:
414A-0288
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
9677
Circumstances:
The privately owned Cessna 414A departed Toronto/Buttonville Municipal Airport, Ontario, en route to Sydney, Nova Scotia. The flight was operating under an instrument flight rules flight plan with the pilot-in-command and the aircraft owner on board. Nearing Sydney, the aircraft was cleared to conduct an instrument approach. At the final approach waypoint the pilot was advised to discontinue the approach due to conflicting traffic. While manoeuvring for a second approach, the aircraft departed from controlled flight, entered a rapid descent and impacted the water at 2335 Atlantic Daylight Time. The aircraft wreckage was located using a side-scan sonar 11 days later, in 170 feet of water. The aircraft had been destroyed and both occupants were fatally injured. No signal was detected from the emergency locator transmitter.
Probable cause:
Findings as to Causes and Contributing Factors:
1. It is likely that the PIC and the owner were both suffering some degree of spatial disorientation during the final portion of the flight. This resulted in a loss of control of the aircraft and the crew was unable to recover prior to contacting the surface of the water.
2. The PIC did not accept assistance in the form of radar vectors, which contributed to the workload during the approach.
3. Self-imposed pressure likely influenced the crew’s decision to depart Buttonville despite the flight conditions, lengthy day, and lack of experience with the aircraft and the destination airport.
Other Findings:
1. It could not be conclusively determined who was flying the aircraft at the time of the occurrence.
2. The lack of onboard recording devices prevented the investigation from determining the reasons why the aircraft departed controlled flight.
3. The practice of placing aircraft technical records on board aircraft may impede an investigation if the records are lost due to an accident.
Final Report:

Crash of a Cessna 402C off Bequia Island: 1 killed

Date & Time: Aug 5, 2010 at 2216 LT
Type of aircraft:
Operator:
Registration:
J8-SXY
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kingstown - Canouan
MSN:
402C-0519
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The pilot was performing an ambulance flight from Kingstown-E. T. Joshua Airport to Canouan. En route, while cruising off Bequia Island, the twin engine aircraft entered an uncontrolled descent and crashed in the sea. Some debris were found the following day but no trace of the pilot.

Crash of a De Havilland DHC-2 Beaver in Kukaklek Lake

Date & Time: Jun 27, 2010 at 1730 LT
Type of aircraft:
Operator:
Registration:
N9RW
Flight Phase:
Survivors:
Yes
Schedule:
Kukaklek Lake - Kukaklek Lake
MSN:
1095
YOM:
1957
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5000
Captain / Total hours on type:
2000.00
Circumstances:
The commercial pilot was taking off on a passenger flight in conjunction with a remote lodge operation under Title 14, CFR Part 91. The pilot said he picked up passengers in the float-equipped airplane on a beach, and water-taxied out into the lake for takeoff. He said he taxied out about 1,200 feet, reversed course into the wind, and initiated a takeoff. He said when the airplane reached his predetermined abort point, the airplane was still on the water, and might not lift off in time to avoid the terrain ahead. The pilot said rather than abort the takeoff he elected to apply full power and continue the takeoff. He said the airplane collided with the bank, and nosed over. The pilot said there were no preaccident mechanical anomalies with the airplane. The owner of the company said the lake was about 1 mile wide where the pilot elected to takeoff. He said the airplane received substantial damage to the wings and fuselage. He also said the passengers related to him that the engine sounded fine, but they did not think the pilot taxied out very far into the lake.
Probable cause:
The pilot's decision to use only a portion of the available takeoff area, which resulted in a collision with terrain during takeoff.
Final Report:

Crash of a PZL-Mielec AN-2R near Voznesenskoye

Date & Time: Jun 27, 2010 at 1545 LT
Type of aircraft:
Operator:
Registration:
RA-62631
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
1G178-23
YOM:
1978
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2643
Captain / Total hours on type:
2643.00
Copilot / Total flying hours:
645
Copilot / Total hours on type:
645
Aircraft flight hours:
3208
Circumstances:
The crew was performing a survey flight while in a fire fighting program. In flight, the engine failed and the crew elected to make an emergency landing. The aircraft stalled and crashed in the Varnavka River. Both pilots and the passenger were injured while the aircraft sank and was damaged beyond repair.
Probable cause:
The accident was the result of a forced landing on the water surface due to unstable operation of the engine after a loss of power which was caused by the re-enrichment of the fuel-air mixture because of jamming of the needle valve of the left float chamber of the carburetor. The most probable reason for jamming of the needle valve of the left float chamber is its clogging by foreign particles that resulted from failure to comply with section 2.02.01.20 of the rules of maintenance of the AN-2 while performing 100-hour maintenance works due to lack of RTO requirements for mandatory compliance.
Final Report:

Crash of a Grumman E-2C Hawkeye 2000NP in the Oman Sea: 1 killed

Date & Time: Mar 31, 2010 at 1400 LT
Type of aircraft:
Operator:
Registration:
165508
Flight Phase:
Survivors:
Yes
Schedule:
USS Eisenhower - USS Eisenhower
MSN:
A174
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft was engaged in a maritime patrol flight from USS Eisenhower cruising in the Oman Sea. While returning to the ship, the crew encountered technical problems and abandoned the aircraft that crashed in the sea. Three crew members were rescued while the fourth was not recovered.

Crash of a Boeing 737-8AS off Beyrouth: 90 killed

Date & Time: Jan 25, 2010 at 0241 LT
Type of aircraft:
Operator:
Registration:
ET-ANB
Flight Phase:
Survivors:
No
Schedule:
Beirut - Addis Ababa
MSN:
29935/1061
YOM:
2002
Flight number:
ET409
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
82
Pax fatalities:
Other fatalities:
Total fatalities:
90
Captain / Total flying hours:
10233
Captain / Total hours on type:
188.00
Copilot / Total flying hours:
673
Copilot / Total hours on type:
350
Aircraft flight hours:
26459
Aircraft flight cycles:
17823
Circumstances:
On 25 January 2010, at 00:41:30 UTC, Ethiopian Airlines flight ET 409, a Boeing 737-800 registered ET-ANB, crashed into the Mediterranean Sea about 5 NM South West of Beirut Rafic Hariri International Airport (BRHIA), Beirut, Lebanon. ET 409 was being operated under the provisions of the Ethiopian Civil Aviation Regulations (ECAR) and as a scheduled international flight between BRHIA and Addis Ababa Bole International Airport (ADD) - Ethiopia. It departed Beirut with 90 persons on board: 2 flight crew (a Captain and a First Officer), 5 cabin crew, an IFSO and 82 regular passengers. The flight departed at night on an instrument flight plan. Low clouds, isolated cumulonimbus (CB) and thunderstorms were reported in the area. The flight was initially cleared by ATC on a LATEB 1 D departure then the clearance was changed before take-off to an “immediate right turn direct Chekka”. After take-off ATC (Tower) instructed ET 409 to turn right on a heading of 315°. ET 409 acknowledged and heading 315° was selected on the Mode Control Panel (MCP). As the aircraft was on a right turn, Control suggested to ET 409 to follow heading 270° “due to weather”. However, ET 409 continued right turn beyond the selected heading of 315° and Control immediately instructed them to “turn left now heading 270°”. ET 409 acknowledged, the crew selected 270° on the MCP and initiated a left turn. ET 409 continued the left turn beyond the instructed/selected heading of 270° despite several calls from ATC to turn right heading 270° and acknowledgment from the crew. ET 409 reached a southerly track before sharply turning left until it disappeared from the radar screen and crashed into the sea 4‟ 59” after the initiation of the take-off roll (4‟17” in the air). The aircraft impacted the water surface around 5 NM South West of BRHIA and all occupants were fatally injured. Search and Rescue (S&R) operations were immediately initiated. The DFDR and CVR were retrieved from the sea bed and were read, as per the Lebanese Government decision, at the BEA facility at Le Bourget, France. The recorders data revealed that ET 409 encountered during flight two stick shakers for a period of 27” and 26”. They also recorded 11 “Bank Angle” aural warnings at different times during the flight and an over-speed clacker towards the end of the flight. The maximum recorded AOA was 32°, maximum recorded bank angle was 118° left, maximum recorded speed was 407.5 knots, maximum recorded G load was 4.76 and maximum recorded nose down pitch value 63.1°. The DFDR recording stopped at 00:41:28 with the aircraft at 1291‟. The last radar screen recording was at 00:41:28 with the aircraft at 1300‟. The last CVR recording was a loud noise just prior to 00:41:30.
Probable cause:
Probable Causes:
1- The flight crew's mismanagement of the aircraft's speed, altitude, headings and attitude through inconsistent flight control inputs resulting in a loss of control.
2- The flight crew failure to abide by CRM principles of mutual support and calling deviations hindered any timely intervention and correction.
Contributing Factors:
1- The manipulation of the flight controls by the flight crew in an ineffective manner resulted in the aircraft undesired behavior and increased the level of stress of the pilots.
2- The aircraft being out of trim for most of the flight directly increased the workload on the pilot and made his control of the aircraft more demanding.
3- The prevailing weather conditions at night most probably resulted in spatial disorientation to the flight crew and lead to loss of situational awareness.
4- The relative inexperience of the Flight Crew on type combined with their unfamiliarity with the airport contributed, most likely, to increase the Flight Crew workload and stress.
5- The consecutive flying (188 hours in 51 days) on a new type with the absolute minimum rest could have likely resulted in a chronic fatigue affecting the captain's performance.
6- The heavy meal discussed by the crew prior to take-off has affected their quality of sleep prior to that flight.
7- The aircraft 11 bank angle aural warnings, 2 stalls and final spiral dive contributed in the increase of the crew workload and stress level.
8- Symptoms similar to those of a subtle incapacitation have been identified and could have resulted from and/or explain most of the causes mentioned above. However, there is no factual evidence to confirm without any doubt such a cause.
9- The F/O reluctance to intervene did not help in confirming a case of captain's subtle incapacitation and/or to take over control of the aircraft as stipulated in the operator's SOP.
Final Report: