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:

Crash of a Beechcraft 1900C-1 off Sand Point: 2 killed

Date & Time: Jan 21, 2010 at 2345 LT
Type of aircraft:
Operator:
Registration:
N112AX
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sand Point - Anchorage
MSN:
UC-45
YOM:
1988
Flight number:
AER22
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3700
Captain / Total hours on type:
3080.00
Copilot / Total flying hours:
1000
Copilot / Total hours on type:
280
Aircraft flight hours:
56184
Aircraft flight cycles:
45158
Circumstances:
The crew departed on a commercial cargo flight during dark night, visual meteorological conditions on an instrument flight rules flight plan. The departure end of the runway is adjacent to an ocean bay, and wind gusts up to 26 knots were reported. Local residents north of the airport reported stronger wind, estimated between 50 and 60 knots. A fuel truck operator, who was familiar with the crew’s normal routine, reported that, before the airplane taxied to the runway, it remained on the ramp for 6 or 8 minutes with both engines operating, which he described as very unusual. There were no reports of radio communications with the flight crew after the airplane departed. The airplane crashed about 1 mile offshore, and the fragmented wreckage sank in ocean water. Because of the fragmented nature of the wreckage and ocean current, the complete wreckage was not recovered. The cockpit area forward of the wings was extensively fragmented, thus the validity of any postaccident cockpit and instrument findings was unreliable. Likewise, structural damage to the airframe precluded determining flight control continuity. Both propellers had witness marks consistent with operating under engine power and within their normal operating range. A postaccident examination of the engines and recovered components did not disclose any evidence of a mechanical malfunction. Due to the lack of mechanical deficiencies of the engines and propellers, and the extensive airframe fragmentation consistent with a high-speed water impact, it is likely that the crew had an in-flight loss of control of an unknown origin before impact.
Probable cause:
An in-flight loss of control for an undetermined reason, which resulted in an uncontrolled descent.
Final Report:

Crash of a De Havilland DHC-3T Turbo Otter off Vomo Island

Date & Time: Dec 29, 2009 at 1800 LT
Type of aircraft:
Operator:
Registration:
DQ-GLL
Survivors:
Yes
Schedule:
Nadi - Vomo Island
MSN:
288
YOM:
1958
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While approaching Vomo Island, near Viti Levu Island, Fiji, the single engine aircraft crashed into the sea few dozen metres offshore. All six occupants were slightly injured while the aircraft was damaged beyond repair.